Non-suicidal Self Injury: An Entity in Need of Validation?

What Is NSSI?

The motivation to avoid pain and injury is a fundamental instinct, crucial to the survival of human beings and other living species. However, for the last 1 to 2 decades, there is an increasing number of individuals presenting to clinicians with self-injurious behavior but “without an intent to die.” This phenomenon of harming oneself without the intent to die is referred to as Non-suicidal Self Injury (NSSI). NSSI is defined as “the direct and deliberate destruction of one’s own bodily tissue in the absence of lethal intent and for reasons not socially sanctioned.” ¹ Accidental and indirect self-injurious behaviors such as disordered eating, drug abuse, suicidal behaviors, and socially accepted behaviors (tattooing, piercing, or religious rituals) do not form part of NSSI. The recognition of this behavior led researchers to include NSSI in section III of DSM 5 as a “condition in need of further study.” ICD-10 included NSSI either as a symptom of borderline personality disorder or as “intentional self-injury with a sharp object (X78),” whereas, ICD-11 does not include it as a diagnostic entity. While some researchers criticize the defined dichotomy between NSSI and suicidal behaviors, others are of the view that NSSI and suicide should be understood as lying on a continuum of self-harming behaviors.

Is NSSI Really a Matter of Concern?

Although, initially considered to be a matter of concern for the western world with prevalence rates in adolescents ranging between 7.5% and 46.5%, ~39% in university students and 4% to 23% in adults, ² the rates in developing countries are also alarming. The 12-month prevalence rate seen in low- and middle-income countries (LMIC) is in the range of 15.5% to 31.3% ³ ; additionally general population studies reporting equivalent rates in both men and women contrary to the belief that women more often engage in NSSI. The variation in the prevalence rates from LMIC is in some part due to the methodological limitations of various studies wherein strict adherence to the definition of NSSI has not been maintained and inadvertently also inclusion of cases with self-harm intent with high lethality. The only study from India adhering to the internationally accepted definition of NSSI reported a prevalence of 31%. ⁴ The most common forms of NSSI in western literature are self-cutting (70%) followed by head banging, scratching, hitting, burning, pinching skin, interfering with healing of wounds, or banging or punching objects or self. A study from the southern part of India reported self-hitting to be the commonest form of self-injury in 15.2% followed by cutting or carving of the skin (13.2%). ⁵ Other LMIC report self-cutting to be commonest (22.5%) followed by excoriation (22.3%) and biting (20.3%). ⁶ Although gender differences are not apparent in the prevalence rates of NSSI, these seem to operate regarding the methods of NSSI used; women more commonly engage in self-cutting behaviors and men more commonly indulge in self-hitting behaviors and burning. ² NSSI is the most common among adolescents with a mean age of onset of 12 years, although reports of younger children engaging in NSSI are present. It is even higher among young adults, mostly in university and college students. ² By now, it has been understood that the prevalence rates of NSSI are almost like prevalence rates of depression and anxiety disorders, highlighting it as an important public mental health concern. It is typically associated with emotional and psychological distress, and cross-sectional studies have highlighted the increased risk of suicide attempts in adolescents engaging in NSSI com- pared to those who do not, ⁷ making the occurrence of NSSI a risk factor for future suicide attempts. Also, there have been numerous reports of self-injurious behavior in a wide range of psychiatric disorders, such as post-traumatic stress disorder, dissociative disorders, conduct disorder, obsessive compulsive disorder and eating disorders. ² Children, adolescents, and young adults engage more often in multiple or repetitive NSSI than not, and they tend to employ the same method more often than not. However, multiple types of NSSI behavior are also reported in the same individual. ² Certain vulnerability factors heighten the risk of NSSI. These are female sex, adolescence, family discord, mental health problems in parents, any mental health problem in the individual, abuse, maltreatment, neglect, past history of NSSI/ suicidal thoughts and attempts and experience of NSSI in peers. ⁸

Why Do Individuals Engage in NSSI?

NSSI is a complex and multifactorial phenomenon; however, a tendency to act impulsively under stressful situations for temporary relief of overwhelming negative emotions seems to be the most common reason. NSSI seems to serve different functions that can be divided into two categories: (1) intrapersonal/self-focused, that is, emotional regulation difficulties, avoiding negative/aversive effects, and self-punishment; and (2) interpersonal/other focused, for example, influencing other person’s behavior, seeking support, and communicating distress. Intrapersonal motives account for 63% to 78% with emotional regulation difficulties being the majority compared to 33% to 56% being interpersonal motives leading to NSSI. A study in a large sample of high school students identified three functions:- affective regulation (most common) followed by social influence and social avoidance. ⁹ In an Indian sample of young adults, emotional regulation, and influencing others were reported. ⁴ Persons engaging in NSSI however report that they engaged in NSSI “to feel relaxed” and “to take control of the situation.” ⁵ Both intrapersonal and interpersonal motives can be pos- itively and negatively reinforce the behavior. For example, in the line of automatic negative reinforcement, NSSI serves the function of diminishing negative feelings or thoughts (i.e., anger, tension), while automatic positive reinforcement describes the experience of pleasant or positive feelings or thoughts during or after engaging in NSSI (i.e., feeling alive). Social positive reinforcement describes reinforcing social interaction (i.e., getting attention or sending a message to others), while social negative reinforcement describes NSSI to escape unpleasant social interactions (i.e., ending an argument, not attending sports class), increased feelings of loneliness, sadness, and feeling overwhelmed before engaging in NSSI. ¹⁰ Easy accessibility to technological advancements, internet, and social media platforms may promote NSSI in vulnerable adolescents. One such phenomenon is growing youth subcultures that promote self-injury (gothic, emo), sexuality. Media influence, fan pages, and cyberspace, which can give way to an imaginary world where everything is possible, every limit is pushed, and actions may not lead to real consequences that can promote behavioral experiments of pushing limits and testing thresholds. Modelling behaviors, that is, observation/knowledge of NSSI among peers and sharing on social media are an important and essential factor to NSSI. ¹¹

NSSI increases the risk of suicide in individuals who involve in NSSI for more than a year, have used higher number of different methods of NSSI and engaged more frequently in behaviors, such as, cutting, cutting body parts other than arms or wrists, reporting absence of physical pain during NSSI, leading to severe physical damage, and attempting to conceal NSSI. ¹² Overall, NSSI has wide ranging negative emotional, physical, and social consequences.

What Can Be Done?

Since, it is known that NSSI has adverse outcomes both in the short term and long term, treatment needs to be considered in its own right. While, appropriate management of any existing mental health condition is to be instituted, ongoing evaluation for NSSI should be considered because the assumption that NSSI will stop once mental health is better may not always be the case. Evidence for treatment of NSSI is limited. However, working on emotional regulation difficulties may prove to be beneficial. Building a strong and protective therapeutic alliance should be the first step. In the therapy, client’s experience of a holding space for discomforting feelings and shame, therapeutic presence, non-critical stance, not showing disappointment on failing to adhere to behavioral contracts of avoiding NSSI can play a crucial role. Urge surfing, support of abstinence, acknow- ledging, and reinforcing small wins, catching them when they are good lead to developing motivation to change. Managing burnout of parents is also crucial to avoid criticism, hostility, or disappointment toward adolescents, thus building sup- portive environment and promoting healthy body rhythms for both adolescents and parents. It may be helpful for the clinician to acknowledge the client’s emotional pain and the purposes that the NSSI serves, thereby communicating a willingness to join. ¹³ Moving away from client–therapist relationship to having a collaborative relationship should be the focus of therapy.

To Conclude!

NSSI is a fairly common occurrence not only in developed countries but also in developing countries. The “intent to die” differentiates it from suicide and suicide attempts. Nevertheless, the position of NSSI in the broader spectrum of suicidal behavior remains to be fully ascertained. ¹⁴ Children as young as 12 years engage in such behaviors due to a variety of personal and familial predisposing factors. Managing NSSI in its own right is the call of the hour. Although evidence base for the treatment of NSSI is scarce, however, establishing a strong therapeutic alliance and working on the affective regulation can be helpful. As research (including that from India) has reported higher NSSI and its association with increased hospitalization and suicide, it is a potential entity that requires proper validation.