The Psychology of Nonsuicidal Self-Harm Behavior
Self-harm behavior refers to intentionally harming and injuring oneself. The more specific term nonsuicidal self-injury (NSSI) describes acts that cause only superficial tissue damage (e.g., skin-deep cuts). Unlike suicidal behavior (e.g., slashing one’s wrists), NSSI is not intended to result in death.
There are no agreed-upon criteria for diagnosing NSSI. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists nonsuicidal self-injury in the category of “Conditions for Further Study.” The proposed criteria for NSSI include:
- On at least five days, the patient has intentionally caused minor or moderate self-harm (i.e. superficial self-injury).
- The purpose of the self-harm behavior has been to obtain relief from unpleasant feelings and thoughts, experience positive feelings, or resolve a relationship conflict.
- The self-injurious behavior has been linked with one or more of the following: Frequently thinking about self-injury, interpersonal problems, negative feelings/thoughts, or hard-to-control preoccupation with self-injury.
The onset of NSSI is usually in early adolescence, though hospital admissions are more common for people in their 20s.
Common forms of NSSI include scratching, cutting, pinching, rubbing, piercing, burning, self-hitting, and excessive rubbing. Injuries are usually inflicted on the arms and legs, though any part of the body may be involved. Rates of NSSI are similar for men and women; however, one study found gender differences when examining different forms of self-injury (e.g., burning is more common among men than women).
Nonsuicidal Self-Harm Treatment
It is essential to seek treatment as soon as possible because not only is self-harm usually a sign of major issues in a person’s life, but self-harm can also result in serious injuries or even death.
DSM-5 notes most people who engage in NSSI do not seek treatment. The reasons are not clear but might be related to the stigma associated with self-injury or having a positive view of self-injury.
So the first step is admitting to self-injury. Then an assessment is needed. The treatment cannot begin until the treating therapist has obtained a full medical and psychiatric history and has formed a proper diagnosis. Why? Because self-injurious behavior can have many causes.
For instance, some goals of self-harm, as summarized in a recent review of NSSI in adolescents, include the following:
- Coping with intensely unpleasant emotions and thoughts (e.g., thoughts of hopelessness)
- Self-punishment and attempts to escape feelings of guilt
- Drawing attention to one’s distress
- Changing other people’s behaviors
- Fitting in with friends or other individuals who also injure themselves
- Attempting to feel something (i.e. to counter feelings of emptiness)
- Experiencing positive emotions (e.g., perhaps due to the release of endogenous opiates)
After a full assessment, the therapist might conclude that self-harm is a symptom of a mental health condition. Indeed, self-injury is sometimes seen in various psychological disorders, like mood disorders, borderline personality disorder, eating disorders, and substance use disorders. The therapist will use information about the motivations for self-harm and the person’s diagnosis to suggest a treatment, such as psychotherapy.
During therapy, patients learn about what triggers their self-harm behavior, how to communicate their needs or their distress effectively, ways to build a support system, and healthier ways of coping with triggers—e.g., engaging in problem-solving or mindfulness practices instead of self-harm.
Aside from various types of psychological therapy—family therapy, cognitive-behavioral therapy, dialectical behavior therapy—medications like antidepressants (e.g., SSRIs) may also be used as part of the treatment. And for younger individuals, particularly children, expressive therapies (e.g., music therapy, art therapy) may be of benefit.
