Isabella Lopez, 15 years of age, and accompanied by her mother, visits the clinic for a physical examination, which is required by her new high school (this case is a composite based on my experience). Her history reveals that Isabella arrived one month ago from El Salvador and was reunited with her mother after 14 years apart. During the visit, the pediatric NP finds that vital signs, as well as the review of systems and the result of her physical examination, are within normal limits. She explains this to Isabella and her mother and begins to end the encounter. She asks, “Do you have any questions or concerns you would like to ask or discuss before you leave?” A noticeable, unspoken communication occurs between the teenager and her mother, prompting the NP to say, “You seem to be looking at each other for the answer to a question. How can I help?” Hesitantly, the mother shares that she has observed Isabella locking herself in the bathroom at home. Subsequently, she found razor blades in the pockets of her daughter's pants while doing the laundry. The mother is concerned. After initially silent, Isabella confides that she met a girl at school who said she could deal with her emotions by “cutting”—using a razor blade to cut into her skin. After some questioning by the NP, Isabella admits she's very lonely. Everything she knew, including all her friends and relatives besides her mother, is in El Salvador. Isabella admits to having the razor blades, saying she planned to explore possibly using them but hasn't yet done so, fearing it might be painful. She denies attempts to kill herself or suicidal ideation. She said she locked herself in the bathroom because it's one of the few private spaces she has access to. The NP's examination of the integumentary system revealed unremarkable findings—no healed scars or wounds—and she arranges for Isabella and her mother to meet with the clinic's clinical social worker and mental health clinician for further evaluation during the visit.
A GROWING CONCERN
Nonsuicidal self-injury (NSSI) is a growing concern, particularly among adolescents. Reducing ED visits for nonfatal intentional self-harm injuries is one of the Healthy People 2030 objectives.1 According to the Office of Disease Prevention and Health Promotion, as of 2020 there were 146.6 ED visits in the United States for nonfatal intentional self-harm injuries per 100,000 people ages 10 years and older.1 Self-injury among middle and high school students has also been noted in other countries, including China,2 Korea,3 New Zealand,4 and Norway.5 In the literature, common search terms associated with NSSI include self-injury,6, 7self-harm,3, 8, 9 and nonsuicidal self-harm.10 Other terminology related to self-injurious behavior includes cutting, deliberate self-harm, self-mutilation, nonsuicidal self-directed violence, and parasuicide.
Currently available research on NSSI is limited, and more information is needed to better understand and manage this condition. This article provides an overview of what is known about NSSI, and the information presented can be used to raise awareness among nurses and other health care providers about self-harming behaviors. For additional resources for clinicians, patients, and families, see Resources on Nonsuicidal Self-Injury.
WHAT IS NSSI?
Matthew K. Nock compiled the first comprehensive overview of NSSI in his 2009 book Understanding Nonsuicidal Self-Injury: Origins, Assessment, and Treatment.11 In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which was published in 2013, the American Psychiatric Association (APA) listed NSSI in “Section III: Emerging Measures and Models” as a condition for further study, noting that it's an independent disorder that requires further research.12
A revision of the DSM-5 was published in 2022—referred to as the DSM-5 text revision, or DSM-5-TR—and includes proposed criteria for NSSI. It's described as intentional, self-inflicted damage to the skin—cutting, burning, stabbing, or excessive rubbing—that is intended to produce positive feelings or obtain relief.13 A defining criterion that distinguishes NSSI from other self-injurious behaviors is the absence of suicidal intent, either as stated by the person or as inferred by their repeated engagement in a behavior they know will not result in death.12-14
Other NSSI criteria proposed in the DSM-5-TR include:13
- engagement in behaviors on five or more days of the year that inflict mild to moderate damage to the skin that will not result in death
- engagement in behaviors with one or more of the following expectations: obtaining relief, resolving difficult interpersonal situations, and inducing a positive state
- an association between self-injury and at least one of the following: experiencing negative feelings prior to the act, a preoccupation with engaging in the act that is difficult to control, and frequent thoughts of self-injury without action
- the behavior is not socially sanctioned (unlike tattooing or body piercing)
- the behavior interferes with activities of daily living
- the behavior is not explained by a medical condition or an associated mental disorder
People who self-injure may be trying to reduce or moderate negative emotions.13, 15 Fox and colleagues examined mood modification among people who engaged in NSSI.16 They found that people who reported being highly self-critical experienced an improvement in mood while experiencing pain, whereas people who reported low self-criticism felt worse during the pain experience, with mood improving only after the removal of pain.16
NSSI often starts in the early to mid-teen years, peaks in late adolescence and the early 20s, and then declines in adulthood.13 Because of a lack of terminological clarity,17 the challenge of accurately distinguishing suicide attempts from nonsuicidal intentional self-harm,18 and the coexistence of NSSI with other psychopathology, it's challenging to establish accurate estimates of NSSI incidence and prevalence.19, 20 In a study using 2015 data from the Centers for Disease Control and Prevention's Youth Risk Behavior Surveillance System, nearly 18% of U.S. adolescent high school students reported having engaged in NSSI behavior in the past year.21 Research data on Nepalese adolescents collected in 2019 revealed that 44.8% of study participants reported a history of NSSI in the past year.22 In a study of NSSI among three cohorts of college freshmen over time, researchers found that half of the 949 participants reported engaging in NSSI behavior at some point in their lives.23
The prevalence of NSSI is higher in girls and women than in boys and men.10, 13 The DSM-5-TR notes that NSSI is “substantially more common among sexual minorities, especially those who identify as bisexual.”13 Speer and colleagues examined NSSI among lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) youth and found that certain groups—such as those who were transgender and LGB and those questioning their gender who were LGB—were more than six times as likely as their cisgender heterosexual peers to engage in NSSI.24
The most common method of NSSI is cutting with a sharp object, such as a knife, needle, or razor.13 Nurses should examine areas that include the front of the thighs and the dorsal side of the forearm to look for evidence of injuries.12, 13 A cutting episode often results in a characteristic pattern of multiple superficial cuts that are usually separated by one or two centimeters in an accessible location.12, 13 Other areas to examine include the patient's nondominant arm and the upper anterior area of the torso.15, 25
Methods of self-harm may also include scratching and picking wounds to prevent healing, burning skin, and biting.12, 13 Other methods reported in the literature include inserting objects under the skin and nails,16, 22 pulling out hair,22 and self-punching.7
Because NSSI is included in the DSM-5-TR as a condition for which future research is needed, no official risk factors are noted.13 However, studies have reported that NSSI may occur more often among people who have certain mental health conditions,23, 26 are younger in age,10 are at a socioeconomic disadvantage,3 and have a history of being bullied because of their perceived sexual identity.24
Although NSSI is associated with damage to one's body without suicidal intent,13 some people who engage in NSSI also attempt suicide, so it's important for nurses to assess suicide risk in all patients who have a history of NSSI. According to the DSM-5-TR, suicide attempts typically occur approximately one to two years after the initiation of NSSI. Thus, the APA recommends that clinicians look into a patient's history of suicidal behavior and seek information from others (parents, teachers, school counselors) about any changes in stress exposure and mood the patient may be experiencing.13 In a longitudinal study, Mars and colleagues found that most adolescents who engaged in NSSI would not attempt suicide; yet, the risk of a future suicide attempt was associated with a history of NSSI, in addition to other factors such as illicit drug use.27
In a pilot study of school-based programs for the prevention of NSSI, researchers found that participants in both the Happyles and HappylesPLUS programs reported a reduced likelihood of future engagement in NSSI.28 Happyles is a stepped-care prevention program focused on mental health and developed for classrooms to enhance social connectedness and mental well-being that includes various validated self-report questionnaires on emotional status, assessment of NSSI behaviors, and qualitative semistructured interviews.28 HappylesPLUS is a combination of this program and a one hour in-classroom psychoeducation module on NSSI.28 After participation in these programs, adolescents who engaged in NSSI reported increased motivation to seek professional help for NSSI, and students without a history of NSSI noted the importance of motivating peers who self-injure to seek professional assistance.28
TOWARD EVIDENCE-BASED CARE
The scenario at the beginning of this article offers multiple factors for consideration: a young female adolescent recently immigrated to the United States (a stress event) starts at a new school (another stress event), where she meets and is exposed to a person who engages in self-harm, an encounter that prompts the adolescent to further investigate self-harm behaviors. Inclusion of NSSI in the DSM-5-TR will hopefully provide a common language to assist researchers in the development of more well-controlled studies investigating NSSI's prevalence, risk factors, and treatment efficacy, with the aim of providing evidence-based care to patients like this one.
Resources on Nonsuicidal Self-Injury
Cornell University's Self-Injury and Recovery Resources
Institute for Non-Suicidal Self-Injury
Mental Health America's Self-Harm Information and Support
National Alliance on Mental Illness, Self-Harm
2. Lang J, Yao Y. Prevalence of nonsuicidal self-injury
in Chinese middle school and high school students: a meta-analysis. Medicine (Baltimore)
3. Park H, et al. Association of socioeconomic status with nonsuicidal self-injury
and suicidal ideation in young Korean adults. Int J Soc Psychiatry
4. Fitzgerald J, Curtis C. Non-suicidal self-injury
in a New Zealand student population; demographic and self-harm characterizations. NZ J Psychol
5. Tørmoen AJ, et al. Change in prevalence of self-harm from 2002 to 2018 among Norwegian adolescents. Eur J Public Health
6. Fox KR, et al. Self-injurious thoughts and behaviors may be more common and severe among people identifying as a sexual minority. Behav Ther
7. Giordano A, et al. Clinical work with clients who self-injure: a descriptive study. The Professional Counselor
8. Flaherty HB. Treating adolescent nonsuicidal self-injury
: a review of psychosocial interventions to guide clinical practice. Child Adolesc Social Work J
9. Sveticic J, et al. Suicidal and self-harm presentations to emergency departments: the challenges of identification through diagnostic codes and presenting complaints. Health Inf Manag
10. McManus S, et al. Prevalence of non-suicidal self-harm and service contact in England, 2000-14: repeated cross-sectional surveys of the general population. Lancet Psychiatry
11. Nock MK, editor. Understanding nonsuicidal self-injury: origins, assessment, and treatment
. Washington, DC: American Psychological Association; 2009.
12. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5
. 5th ed. Washington, DC; 2013.
13. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5-TR
. 5th ed, text revision. Washington, DC; 2022.
14. International Society for the Study of Self-Injury
. What is self-injury?
15. Glenn C, Nock MK. Nonsuicidal self-injury
in children and adolescents: assessment. UpToDate
16. Fox KR, et al. Why does nonsuicidal self-injury
improve mood? A preliminary test of three hypotheses. Clin Psychol Sci
17. Hooley JM, et al. Nonsuicidal self-injury
: diagnostic challenges and current perspectives. Neuropsychiatr Dis Treat
18. Gabella BA, et al. Multi-site medical record review for validation of intentional self-harm coding in emergency departments. Inj Epidemiol
19. Bauer RN, et al. Helping patients who harm themselves. Am Nurse Today
20. Ghinea D, et al. Non-suicidal self-injury
disorder as a stand-alone diagnosis in a consecutive help-seeking sample of adolescents. J Affect Disord
21. Monto MA, et al. Nonsuicidal self-injury
among a representative sample of US adolescents, 2015. Am J Public Health
22. Poudel A, et al. Non suicidal self injury and suicidal behavior among adolescents: co-occurrence and associated risk factors. BMC Psychiatry
23. Wester K, et al. Nonsuicidal self-injury
: increased prevalence in engagement. Suicide Life Threat Behav
24. Speer SR, et al. An intersectional modeling of risk for nonsuicidal self-injury
among LGBTQ adolescents. J Child Fam Stud
25. Southard EP, et al. Non-suicidal self-injury
: the nurse practitioner's role in identification and treatment. Womens Healthc (Doylestown)
26. Masi G, et al. A comparison between severe suicidality and nonsuicidal self-injury
behaviors in bipolar adolescents referred to a psychiatric emergency unit. Brain Sci
27. Mars B, et al. Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study. Lancet Psychiatry
28. Baetens I, et al. School-based prevention targeting non-suicidal self-injury
: a pilot study. Front Psychiatry