After reading this article, you should be able to: 

1. Understand nonsuicidal self-injury (NSSI). its prevalence, and the different forms of self-harm, specifically focusing on NSSI.
2. Explore the relationship between NSSI and suicidal thoughts/behaviors. 
3. Assess, manage, and differentiate NSSI from other behaviors seen in developmental disorders.
   

Self-harm can be separated into different forms, including unintentional self-harm, self-injurious behavior, non-suicidal self-injurious behavior, suicide attempts, and completed suicide. Nonsuicidal self-injury (NSSI) is the intent to harm yourself without wanting to die. This includes burning, cutting, head banging, or punching a wall. This is different from unintentional self-harm, where we might see adolescents with developmental challenges bang their heads, slap themselves, or pick at their skin. In this article, we will discuss how to assess, discuss, and treat NSSI in children and adolescents. 

In a 2017 systematic review, the prevalence of NSSI was about 7.5%–46.5% for adolescents, 38.9% for university students, and 4%–23% for adults. The first incident typically occurs around ages 12 to 13. Why is NSSI so common in children and adolescents? Children are drawn to this behavior when they experience emotional pain but cannot control the situation. The opposite also happens: teens experiencing emotional numbness might harm themselves to feel something. In either case, there’s relief with the sensation of pain. Other adolescents use NSSI to communicate pain, and some use it to punish themselves (Cipriano, A., Cella, S., & Cotrufo, P. (2017). Nonsuicidal Self-injury: A Systematic Review. Frontiers in psychology, 8, 1946. https://doi.org/10.3389/fpsyg.2017.01946). 

How is NSSI related to suicidal thoughts and behaviors (STB)? Is one a risk factor for the other? Can they coexist?

A significant number of adults and adolescents report a history of both behaviors, however, the association between the behaviors is complex. NSSI and suicidal thoughts and behaviors have unique risk factors and although NSSI is associated with a myriad of negative consequences, a developing body of research suggests that NSSI may increase the risk for attempted suicide (Andover, M. S., Morris, B. W., Wren, A., & Bruzzese, M. E. (2012). The co-occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child and adolescent psychiatry and mental health, 6, 11. https://doi.org/10.1186/1753-2000-6-11). Mental health professionals need to identify and treat NSSI and we also need empirically supported prevention programs.

What conditions tend to be comorbid with NSSI?

Until recently, NSSI was considered a symptom of borderline personality disorder (BPD) and came with a gender stigma with more females than males diagnosed with BPD and NSSI. In DSM-5, NSSI is also linked to depression and anxiety disorders. We don’t have clear statistics on how many depressed or anxious kids or teens engage in NSSI, but healthy, well-functioning adolescents do not self-harm as a way to cope—instead, they use more adaptive coping strategies like exercise or talking with someone. 

When determining whether a behavior is or is not NSSI, pay attention to the intention behind it. Someone who pierces their ears because of aesthetics or memorializes a loved one with a tattoo is not engaging in NSSI, but someone who pierces their ears because the act and the pain of piercing makes them feel better is. If someone is refusing food because of a distorted body image, that is not NSSI, but if they do it because the hunger pain makes them feel better, we categorize that as NSSI. 

How to differentiate NSSI from behaviors seen in developmental disorders

Behaviors seen in developmental disorders, such as head banging, slapping themselves, or picking at their skin, are termed “unintentional self-harm.” These children are not thinking about it and planning it in the same ritualistic way that we see in self harm. While these behaviors are impulsive, the children may be doing it out of frustration or anxiety, but not seeking to feel the pain. That’s important to differentiate - the cause is very different. Unintentional self-harm can be thought of as non-suicidal self-injurious behavior, which is not as concerning as actual suicide attempts. 

Gender, cultural, and racial differences in NSSI

More females are reported to engage in NSSI, and the nature of the behavior tends to be different depending on gender. Females do tend to cut more than males. Boys may get angry and punch the wall repetitively as a way of managing emotions, until their hands bleed, or they break their knuckles (Ammmerman, B. A., Hong, M., Sorgi, K., Park, Y., Jacobucci, R., & McCloskey, M. S. (2019). An examination of individual forms of nonsuicidal self-injury. Psychiatry research, 278, 268–274. https://doi.org/10.1016/j.psychres.2019.06.029). 

Reports of NSSI are higher in Caucasian and white females, followed by African-American and Hispanic individuals, but very often kids in minority populations are not getting care, and so NSSI does not get reported. 

NSSI and social exposure

If an adolescent self-harms, people in their circle are more likely to self-harm. That also goes for substance use and for sexual acting-out behaviors. They are most likely to engage in NSSI if they have pre-existing conditions, feeling upset or depressed. They are at a low point, feeling out of control, and emotional: “I know this works for someone else. I’m going to try it.”

Does NSSI lead to more serious self-harm? 

While individuals who engage in NSSI behavior do not do so with the intention to die, continued behavior poses physical risks. For some, the self-harming behaviors will dissipate on their own, but for others it can increase in severity like other addictive behaviors. There is a theory that NSSI releases endogenous opioids, reducing pain sensitivity, which can result in more episodes and increased severity to feel relief from the behaviors (Sher, L., & Stanley, B. H. (2008). The role of endogenous opioids in the pathophysiology of self-injurious and suicidal behavior. Archives of suicide research : official journal of the International Academy for Suicide Research, 12(4), 299–308. https://doi.org/10.1080/13811110802324748). There is always a risk that the self-harm can result in infection or unintended death if the injuries are severe.

How to assess for possible NSSI

It’s important to ask patients about NSSI. Asking screening questions is seven times more likely to discover NSSI as well as suicidal thought (Bernet W. (2001). Introduction: new format for executive summary of practice parameters. Journal of the American Academy of Child and Adolescent Psychiatry, 40(7 Suppl), 1S–3S. https://doi.org/10.1097/00004583-200107001-00001). Some mental health providers worry that asking about NSSI will put the thought in the client’s head, but that is not true. They’re more likely to feel understood. It’s when you don’t ask the questions that they don’t feel safe talking to you. Ask the questions in a caring way, and you’ve opened the door to say, “this is a safe place to talk.”

When asking about such a sensitive topic, it’s important to build up to it gradually. Start with depressive symptoms, stress, and distress: “How have things been going for you? Are there any increased difficulties for you right now? How do you normally manage these things?” Then normalize NSSI and ask, “When people are experiencing distress, sometimes they’ll harm themselves. Have you ever done that?” Reassure them that this a safe place to talk about things.

Manage confidentiality and conversations with parents

It’s important to address this topic at the very beginning, eg, “What you say here stays here unless you’re harming yourself or others. If you’re harming yourself, I am going to tell your mom. I’m going to do whatever I can to keep you safe. It’s my job and I care about you. But let’s finish talking about what’s going on and then you and I can talk about if or what we’re going to tell your mom. We can talk about why you are worried about telling your mom and if she needs to know, we can tell your mom together. 

When you are helping a patient talk to their parents, validate the teen’s concerns and use it as a therapeutic moment. You might say things like, “We need to tell your parents about this because we need their help to support you in finding better ways to manage the challenges in your life.” This includes all the details of the self-harming, what it is, and how often they do it. You should prepare the adolescent ahead of time so they know exactly what you will say.

When you talk with parents about NSSI, try not to be too alarmist, and use normalization to help parents deal with the situation. For example, you can approach the conversation saying something along the lines of, “Riley brought some heavy stuff to session this week, and as she was talking about her anxiety and her depression, she mentioned to me that one of the ways she copes is to self-harm. Now, I know that sounds scary, but unfortunately, it’s common with this age group and we want to tell you what’s going on and what we can do to support her.”

When we take these steps, parents feel engaged with us, and the adolescent doesn’t feel like we’ve betrayed them by breaking confidentiality. We need a long-term working relationship with both the parents and the adolescent.

How to distinguish NSSI from suicidality

It’s crucial to distinguish suicidal vs nonsuicidal intent in any episode of self-harm. If a patient confirms they are engaging in NSSI, ask: “How are you self-harming?” Now is when you need to do a suicide assessment: “Have you thought about harming yourself so severely that you would end your life?” or,“ Have you thought about ending your life?”

Assuming that the child is not acutely suicidal, move on to specific questions about how and when they self-harm. Patients commonly will describe ritualistic behavior around the self- harm episodes. For example, they might keep everything in a certain place, turn on music, and sit down in the same spot. This helps you understand how dangerous the behavior actually is and helps later with intervention. For example, impulsively taking a kitchen knife to their wrist is more dangerous than using a safety pin on their leg. Ask about how they feel before and after they self-harm. How often are they thinking about it during the day? Do they only think about it when they’re angry, sad, or are they constantly thinking about self-harming?

Should you examine the patient’s injury?

This can be a complicated decision. If the injury is in a location that doesn’t require removing clothing, try to see it. In part, this is important because you have to decide whether this person should go to the ER for immediate treatment of the injury. For example, a patient may tell you that they don’t cut “deep” but when you look on the arm you see it is deep and looks infected—that patient should go to the ER, not because they’re suicidal, but because they need medical treatment.

How should clinicians approach the conversation regarding the disposal of sharp objects?

For someone who’s suicidal, you need to prioritize safety. Secure dangerous items such as knives and other sharp objects; medications, including over-the-counter meds like acetaminophen (Tylenol), ibuprofen (Motrin) and aspirin; other poisonous household products; ropes and cords; and of course, firearms, preferably out of the house and off the premises.  Hospitalize the person if necessary. By contract, when someone is not suicidal, empower them to dispose of their self-harming instruments on their own, in front of the parent, rather than having the parent do a sweep of the room. This not only empowers the adolescent but also helps the parent understand the adolescent’s ritual and see things better from their teen’s perspective. This in turn can lead to better communication and problem-solving as a team. 

In some situations, body checks may become necessary, but overall, they can complicate treatment. Self-harm doesn’t stop just because the teen has acknowledged it, and if it is set up as a bad behavior that needs policing, the teen is likely to try harder to hide it. So it’s better to involve parents in a plan of what they can do instead if there is an urge to self-harm rather than checking for potential injuries.

Treatment for NSSI 

As with any high-risk behavior, teach some harm-reduction techniques. The three most common for NSSI are the rubber band technique, the ice cube technique, and tearing paper. Have them wear rubber bands around their wrist, ankle, etc. if that’s where they’re self-harming, and snap the rubber band instead of self-harming. Holding an ice cube also feels painful but isn’t as dangerous as cutting or burning. Tearing paper can feel quite cathartic in the same way depending on what their self-harming behavior was.

It is important to note that all three methods are intended to reduce harm as you explore the root causes of the intense emotions through talk therapy. These methods are not meant to be used in lieu of more definitive treatment and need to be monitored as some patients will use them to continue self-harm (Wadman, R., Nielsen, E., O'Raw, L., Brown, K., Williams, A. J., Sayal, K., & Townsend, E. (2020). "These Things Don't Work." Young People's Views on Harm Minimization Strategies as a Proxy for Self-Harm: A Mixed Methods Approach. Archives of suicide research : official journal of the International Academy for Suicide Research, 24(3), 384–401. https://doi.org/10.1080/13811118.2019.1624669).

There are several talk therapies to address NSSI, including Developmental Group Therapy (DGT), Mentalization Based Treatment for Adolescents (MBT-A), Dialectical Behavior Therapy for Adolescents (DBT-A), or Therapeutic Assessment and Brief Intervention (TA). You can get training in these techniques to treat the patient yourself or refer out to someone else in your community (Witt, K. G., Hetrick, S. E., Rajaram, G., Hazell, P., Taylor Salisbury, T. L., Townsend, E., & Hawton, K. (2021). Interventions for self-harm in children and adolescents. The Cochrane database of systematic reviews, 3(3), CD013667. https://doi.org/10.1002/14651858.CD013667.pub2). DGT is for kids 12–18 and includes behavioral, dialectical, social skills, and interpersonal aspects. MBT-A helps teens and families understand the role of feelings in behavior. DBT-A focuses on building skills and reducing maladaptive behavior. TA is a 30-minute treatment where the teen identifies the challenge, clarifies the motivation for change, and creates a letter with a plan for change.

While there are no definitive medications for NSSI, there are small studies that suggest that medication is an option to treat co-occurring conditions such as depression, anxiety,  PTSD, BPD, and others in conjunction with psychotherapy (Turner BJ, Austin SB, Chapman AL. Treating nonsuicidal self-injury: a systematic review of psychological and pharmacological interventions. Can J Psychiatry. 2014;59(11):576-585. doi:10.1177/070674371405901103).

[Note: For more information, see the Q&A with Hanni Flaherty, PhD, LCSW, published in The Carlat Child Psychiatry Report, published on January 30: https://www.thecarlatreport.com/articles/4288-assessment-of-non-suicidal-self-injury-in-children-and-adolescents-hanni-flaherty-lcswr-phd-casac]