Separating fact from fiction
Reprinted from "Young People: Self-Injury" issue of Visions Journal, 2017, 13 (2), p. 8
Nonsuicidal self-injury (NSSI) is the intentional damaging of one’s own body tissue (for example, cutting or burning the skin) without suicidal intent. Nonsuicidal self-injury does not include suicide attempts (that is, behaviours undertaken with the intent to die) and does not include intentional activities that are socially accepted, such as tattoos or body piercings.1
For those who know little about the behaviour, NSSI seems counterintuitive. After all, people usually go to great lengths to avoid pain and injury. We take Tylenol when we have a headache, for example, and we heed “slippery when wet” signs. Many other forms of pain and injury control are a pervasive part of our lives.
Yet a significant percentage of the population has intentionally injured themselves at least once. More importantly, those who self-injure more frequently are at increased risk for emotional distress, mental illness and even suicide.2 It is important that people in a position to recognize NSSI and provide help—including health professionals, school officials and parents—have an accurate understanding of the behaviour.
Nonsuicidal self-injury is often misunderstood and even stigmatized. This article provides clear, accurate, evidence-based information about NSSI and also dispels some common misconceptions.
What is NSSI?
NSSI can take many forms. Common examples of NSSI include cutting, burning or scratching one’s own skin, as well as banging or hitting one’s body parts. Behaviours that may seem like forms of self-injury, such as substance abuse, alcohol abuse or eating disordered behaviours (binging, purging, over-exercising), are not considered by experts to be NSSI because the tissue damage in these cases is indirect and not part of the individual’s intent. While NSSI often results in light bleeding or bruising and can leave scars, it rarely causes injuries severe enough to require professional medical attention.3
Youth report NSSI more often than adults (although NSSI can be found in any age bracket in the population). The lifetime rates among youth and young adults are 15-20%, whereas about 6% of adults report lifetime occurrence of NSSI.3,4 It is unclear if the lower lifetime rate in adults is due to a reporting bias (for example, a 45-year-old may not remember one or two instances of NSSI when he or she was 14) or to increases in NSSI for newer generations (for example, NSSI may be more common in youth now than it was more than 20 years ago). Typically, NSSI in youth begins around age 13 or 14, though approximately one-third of cases of NSSI begin after age 18.1,3 Generally, rates of NSSI are similar around the globe.4
Nonsuicidal self-injury is slightly more common in women than men, but the form of NSSI is the most obvious gender difference. Women more often use cutting, whereas men may be more likely to use hitting, banging or burning.5 Rates of NSSI are noticeably higher in people who report non-heterosexual orientations (for example, homosexual, bisexual, transgender, gender-nonconforming or questioning). Rates of NSSI are also higher among Caucasians than among non-Caucasians.3
NSSI is especially common among people receiving mental health treatment.1 Perhaps the most common characteristic of those who engage in NSSI is emotional distress. Those who self-injure experience more frequent and intense negative emotions than others, especially negative emotions that are high-arousal (for example, anger) and self-directed (like self-hate and self-criticism). Perhaps for this reason, diagnoses associated with negative emotions, such as mood disorders, anxiety disorders, borderline personality disorder (BPD) and eating disorders, are strongly associated with NSSI.3
It is important not to equate NSSI with any particular mental illness or condition, however. There is a misconception, for example, that NSSI is first and foremost a symptom of BPD. This belief has been reinforced in part by the Diagnostic and Statistical Manual of Mental Disorders (DSM), which for decades has included NSSI only on the symptom list for BPD.6 But BPD is a severe personality disorder and a stigmatized one, so it can be quite harmful for a young person with NSSI to be automatically labelled as having BPD.
In fact, there is overwhelming evidence that NSSI is distinct from BPD. For example, rates of NSSI are much higher than rates of BPD, and there are many cases of NSSI in the absence of BPD, as well as many cases of BPD in the absence of NSSI.7 For these reasons, the most recent version of the DSM proposes a definition for an independent NSSI diagnosis.8
Why do people self-injure?
There are many theories for why people self-injure. Careful research has helped separate fact from fiction, and more accurate theories from less accurate ones.9 By far, the most common motivation for NSSI is emotion regulation. In other words, people use NSSI to reduce intense negative emotions and achieve a sense of calm and relief.10 We do not yet completely understand the mechanisms behind this effect, but researchers have suggested both physiological and psychological explanations.
Many people who self-injure also describe additional motivations.9 For example, some use NSSI as a way to express self-directed anger or punishment. Others use NSSI to interrupt dissociative experiences (for example, feeling “unreal”) or stop suicidal urges. Less often, NSSI can be used to influence or bring out reactions from others.
In the past decade, researchers have developed ways to assess the functions of NSSI.12,13 It can be useful to think of the different NSSI functions as falling into one of two larger categories: self-focused (for example, emotion regulation, self-punishment) and social/other-focused (for example, influencing others, help-seeking).11 Contrary to the common misconception that people who use NSSI are usually seeking attention from others, self-focused functions are far more common than social/other-focused functions.12
Some early theories about NSSI have led to the misconception that NSSI is caused by childhood sexual abuse. While there is a correlation between childhood sexual abuse and NSSI, it is a modest one.14 For some, the abuse can contribute to the negative emotions that drive NSSI, but many individuals with a history of abuse do not use NSSI, and many who use NSSI do not have any history of childhood sexual abuse.
NSSI and suicidal behaviour
The relationship between NSSI and suicide is frequently misunderstood.15 Some practitioners and researchers view NSSI as a form of suicidal behaviour, and others assert there is little overlap. The truth is somewhere in the middle. On the one hand, NSSI is
more common than suicidal behaviours
used with greater frequency than suicidal behaviours
likely to involve different methods (e.g., cutting rather than purposely overdosing)
results in less medically severe damage3
most often used in the absence of suicidal thoughts16
When NSSI is mistaken for attempted suicide or suicidal behaviour, self-injurers can feel misunderstood, invalidated and mistrustful of those who might otherwise be able to provide help.
On the other hand, NSSI more strongly predicts suicide attempts than other suicide risk factors (such as depression, anxiety and personality disorders).15,17 Contemporary suicide theories suggest that both suicidal wishes and the capability to act on such wishes are necessary for potentially lethal suicide attempts.15,17 Even among people with high distress and strong suicidal wishes, fears of pain, injury and death may be barriers to suicide attempts. A person can become more or less capable of overcoming these barriers and attempting suicide through various life experiences that get them accustomed to pain, injury and death.
Not only is NSSI associated with emotional distress, which increases risk for suicidal intent, but NSSI represents experience and practice with self-inflicted injury, which increases the capability for attempting suicide. People who use multiple methods of NSSI or engage in NSSI frequently are at especially high risk for suicide attempts. In short, although NSSI is distinct from a suicide attempt, it represents “double trouble” for suicide risk because NSSI increases risk both for suicidal desire and for the capability to act on that desire.15
NSSI is an important mental health concern. Fortunately, research over the past 15 years has greatly improved our understanding of who self-injures and why. Research has also increased our understanding of the relationship between NSSI and suicidal behaviour, where the two types of behaviour overlap and where they do not. Armed with this knowledge, health providers are in a much better position to help those in need.
About the author
E. David Klonsky is a professor of psychology at the University of British Columbia. He is the lead author of Nonsuicidal Self-injury as well as many scientific papers on self-injury, suicide and related topics. Dr. Klonsky’s Three-Step Theory (3ST) explains the development of suicidal ideation and the transition from suicide ideation to attempts
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Klonsky, E.D., Victor, S.E. & Saffer, B.Y. (2014). Nonsuicidal self-injury: What we know and what we need to know. Canadian Journal of Psychiatry, 59(11), 565-568.
Muehlenkamp, J.J., Claes, L., Havertape, L. & Plener, P.L. (2012). International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child and Adolescent Psychiatry and Mental Health, 6(1), 10.
Bresin, K. & Schoenleber, M. (2015). Gender differences in the prevalence of nonsuicidal self-injury: A meta-analysis. Clinical Psychology Review, 38, 55-64.
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Glenn, C.R. & Klonsky, E.D. (2013). Non-suicidal self-injury disorder: An empirical investigation in adolescent psychiatric inpatients. Journal of Clinical Child & Adolescent Psychology, 42(4), 496-507.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226-239.
Klonsky, E.D. (2009). The functions of self-injury in young adults who cut themselves: Clarifying the evidence for affect-regulation. Psychiatry Research, 166(2-3), 260-268.
Klonsky, E.D., Glenn, C.R., Styer, D.M., Olino, T.M. & Washburn, J.J. (2015). The functions of nonsuicidal self-injury: Converging evidence for a two-factor structure. Child and Adolescent Psychiatry and Mental Health, 9(1), 1-9.
Klonsky, E.D. & Glenn, C.R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31(3), 215-219.
Klonsky, E.D. & Lewis, S.R. (2014). Assessment of non-suicidal self-injury. In M.K. Nock (Ed.), Oxford Handbook of Suicide and Self-Injury, 337-351. Oxford: Oxford Press.
Klonsky, E.D. & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis. British Journal of Psychiatry, 192, 166-170.
Klonsky, E.D., May, A.M. & Glenn, C.R. (2013). The relationship between nonsuicidal self-injury and attempted suicide: Converging evidence from four samples. Journal of Abnormal Psychology, 122(1), 231-237.
Klonsky, E.D. (2011). Non-suicidal self-injury in United States adults: Prevalence, sociodemographics, topography, and functions. Psychological Medicine, 41(9), 1981-1986.
Hamza, C.A., Stewart, S.L. & Willoughby, T. (2012). Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clinical Psychology Review, 32, 482-495.