To date there are no known empirical trials of treatments specifically addressing nonsuicidal self-injury. Treatments that do address this behavior have historically done so in the context of concomitant suicidal behaviors or other related forms of psychopathology (eg, BPD). Therefore, the treatments discussed in this section are specific to BPD. Data from trials of these therapies pertaining to their effects on self-injury are highlighted. Although a detailed description of the theoretical basis for all treatments is beyond the scope of this manuscript, a basic description of each treatment is provided below, followed by outcome data.
Transference-Focused Psychotherapy. Transference-focused psychotherapy (TFP) was developed as an intensive treatment for patients with BPD.100 This treatment shares the common goals of all BPD treatments: reduction of suicidal behavior, self-injury, and interpersonal chaos; and improvement of affective regulation and behavioral control.
In general terms, TFP aims to help patients change their affective and behavioral responses to stress, especially in interpersonal contexts, by providing extensive opportunities for discussion of the patient-therapist relationship during regular therapy sessions twice per week for 1 year. This relationship is conceptualized as both a microcosmic representation of how the patient approaches other relationships in his or her life and as a “holding environment” in which the patient can safely express themselves without fear of losing the therapist (unless they violate the treatment contract established at the beginning of treatment). Through intensive focus on the therapy relationship as a primary content of sessions, the patient can learn new understandings of and responses to interpersonal relationships, as well as the necessary affective and behavioral control techniques required for fostering healthier interpersonal relationships.101,102
Thus far, TFP has shown some promise as a psychosocial treatment for self-injury, but more so for BPD as a whole. An initial effectiveness study103 of 23 outpatients with BPD found that the severity of self-injury and the level of medical care required after self-injury were reduced after 1 year of TFP. However, the frequency of self-injury was not significantly changed (P = .45). Subsequent randomized clinical trials of the efficacy of TFP104,105 compared this treatment to dialectical behavior therapy (DBT)29 and an active placebo. Levy et al104 reported data pertaining to changes in “attachment patterns” and “reflective function” (both TFP-related constructs), but failed to discuss the effect of TFP on self-injury. Similarly, Clarkin et al105 reported improvements in impulsivity, social functioning, depression, anxiety, and suicidality in their controlled trial (finding treatment equivalence between DBT and TFP on this latter variable), but no data on self-injury was reported.
It is logical to conclude (and proponents of TFP contend) that a treatment that treats the crux of a psychopathology will result in changes to the myriad manifestations of that psychopathology, such as self-injury. However, as it pertains to self-injury specifically, the data about TFP published to date are relatively weak. Moreover, Clarkin et al's103 original findings of the potential effects of TFP in reducing the severity of self-injury have not been replicated in (or at least have not been reported in) subsequent trials. Currently, the data supporting TFP as a treatment for self-injury is level 2 evidence and SORT recommendation rating of C for the use of (or referral for) this treatment, owing primarily to a lack of replication (or, at least, a lack of publication) of findings about the effectiveness of TFP for reducing self-injury. Further research on this treatment is needed to determine its effectiveness in modifying self-injury.
Mentalization-Based Therapy. Mentalization-based therapy (MBT) is another treatment for BPD that is derived from psychodynamic attachment theory.106 This therapy was originally developed by Bateman and Fonagy106 as part of a day treatment program for severely and chronically dysfunctional patients with BPD. The general theoretical premise of MBT is that BPD results from a patient's lack of awareness of the relationships between thoughts and emotions, which adversely impacts interpersonal attachments. MBT is aimed at increasing the patient's ability to “mentalize,” that is, to focus attention on and understand thoughts and emotions in an attempt to more accurately interpret one's own and others’ behavior, thereby improving interpersonal functioning.106,107 This is accomplished through an intensive 18-month partial hospitalization program with a weekly treatment program consisting of a 1-hour individual psychoanalytic psychotherapy session; 3, 1-hour group analytic psychotherapy sessions; a 1-hour psychotherapy session aimed at teaching psychodrama techniques; a 1-hour weekly “community meeting”; a monthly meeting with a case worker; and a monthly medication management meeting with a psychiatrist.
The initial effectiveness study107 was a nonrandomized trial comparing MBT (administered by psychiatric nurses and supervised by clinical psychologists) to general milieu psychiatric treatment (treatment-as-usual [TAU]) for 19 patients with BPD. Bateman and Fonagy98 reported significantly fewer episodes of self-injury and suicide attempts in the MBT group than the TAU group at the 12-month assessment, and a significantly lower proportion of self-injuring patients in the MBT group than the TAU group was observed at the 18-month assessment despite no significant differences in proportions at baseline.106 A subsequent 8-year follow-up study108 found significantly fewer suicide attempts in the MBT group versus the TAU group, among other maintained improvements (eg, psychosocial functioning, days in the hospital). However, no data about self-injury was presented by the authors for this follow-up.
Similar to TFP, the data pertaining to the effectiveness of MBT in treating self-injury is promising. However, the data for MBT as a treatment for self-injury remains as level 2 evidence at best. This is largely because of a lack of an active treatment comparison group, a lack of randomization, and a lack of replication thus far. Furthermore, although potential mechanisms of change in MBT have been articulated,107 the setting in which MBT was conducted (a partial hospitalization program) also provided for a multitude of other therapeutic interactions. It may be reasonably argued that 18 months of structured, intensive therapeutic contact (5 hours per week in the case of MBT) in a partial hospitalization program of any kind may yield similar effects. Therefore, the active component of MBT that produces change remains unclear. When considering the outcome data for MBT, the evidence for this therapy as an intervention for self-injury is level 3, with a SORT recommendation rating of C.
Cognitive and Cognitive-Behavioral Psychotherapies
Manual Assisted Cognitive-Behavioral Therapy. Manual assisted cognitive behavioral therapy (MACT)109 was developed as a brief, cost-effective intervention for the reduction of self-injury in patients with a history of repeated self-injurious behaviors. This treatment combines 2 to 6 sessions of individual cognitive-behavioral and solution-focused psychotherapy with self-directed bibliotherapy. The bibliotherapy component employs 6 short book chapters that focus on teaching patients emotion management skills, ways to cope with negative thought patterns, and skills to prevent relapse into self-injury. Both therapy sessions and bibliotherapy components focus on problem solving. This is accomplished in part by helping the patient understand the origins and triggers for their self-injury through use of a behavioral chain analysis form, as well as via thought and behavior monitoring forms.
Evans et al.109 compared MACT to a TAU condition in a randomized controlled pilot trial that included 32 patients who were habitually self-injuring. Results indicated that the MACT group had lower monthly rates of self-injury and longer times until the next episode of self-injury than the TAU group, but neither of these differences reached statistical significance. A larger randomized controlled trial110 compared MACT to a TAU condition in 480 outpatients. Patients receiving MACT had up to 7 sessions of individual, solution-focused therapy along with a 6-chapter, 70-page book (described above). Results of this larger trial revealed that MACT was not associated with a significantly greater reduction in self-injury at either 6- or 12-month assessment than was TAU, and that MACT was not associated with a significant change in self-injury from pre- to posttreatment assessment. Nonetheless, a nonsignificantly smaller proportion of MACT participants (39%) than TAU participants (46%) reported ongoing self-injury at the 12-month assessment. In addition, survival analyses revealed that MACT participants went for a longer period of time (222 days) than TAU participants (169 days) before their repeat episode of self-injury, although this difference was also not statistically significant. Similar to the study by Evans et al,109 this second trial110 was also characterized by substantial heterogeneity in the way treatment actually occurred within each group, which may account for a lack of group differences. For example, 5 MACT participants reported that they never received a booklet, and 90 participants (almost 40%) never attended an individual psychotherapy session. Likewise, TAU included individual problem-solving therapy, seeing a general practitioner for treatment, group therapy, psychodynamic psychotherapy, or brief counseling. Thus, the failure to find any differences between groups is perhaps not surprising because the design and execution of the study was not conducive to comparing the effects of discrete treatment conditions on a unitary outcome measure. Both Tryer et al110 and Evans et al109 note the cost-effectiveness of MACT as a brief treatment. However, the extant data do not support this as a rationale for recommending MACT as an intervention for self-injury given the nonsignificant differences noted between MACT and TAU groups. Additional research is needed to more rigorously evaluate this treatment and further refine the treatment components.
Dialectical Behavior Therapy. DBT30 was developed as a cognitive-behavioral treatment for chronically suicidal and self-injuring patients diagnosed with BPD. DBT is considered to be an acceptance-based treatment because of its focus on both developing patients’ self-acceptance and its strategic utilization of an accepting and nonjudgmental stance by the therapist. DBT is based on Linehan's30 biosocial model of BPD. This model postulates that BPD is a pervasive disorder of the emotion regulation system, which develops as a result of a transactional relationship between caustic and abusive conditions in one's developmental environment and a genetic predisposition toward rapid and frequent fluctuations between emotional extremities and intensities.111–115 Thus, this model conceptualizes self-injury as a maladaptive emotional regulation strategy that originates from deficits in emotion regulation skills.30 DBT is a comprehensive cognitive-behavioral treatment that is designed to address these skills deficits as a way of reducing suicidality and self-injury among people with BPD.
There are 4 modes of treatment involved in standard, adult DBT: (1) 12 months of weekly individual therapy; (2) 12 months of weekly group psychosocial skills training; (3) skills coaching and consultation to patients between sessions; and (4) the therapist's participation in a consultation team. The 4 modes of treatment are structured around the 4 stages of treatment: (1) learning to control uncontrolled behaviors; (2) increasing awareness and experience of emotions; (3) decreasing general problems with life; and (4) increasing quality of life. Patients who enter a DBT program commit to 1 year of treatment and to working toward the goal of reducing all self-injurious behaviors (including suicidal behaviors) as the primary goal of treatment. Secondarily, patients agree to address any behaviors that are obstacles to the first goal. In this way, behaviors that sabotage treatment are reduced and the potential for therapy to be effective is increased. Group psychosocial skills training also takes place weekly and serves as a required didactic supplement to the weekly individual therapy session.30,116 Through skills training, patients develop and learn how to apply skills in 4 domains: (1) emotional regulation, (2) distress tolerance, (3) interpersonal effectiveness, and (4) self-awareness (“mindfulness”) skills.116
DBT was first evaluated by Linehan and her colleagues117 in a randomized, controlled trial that compared DBT (n = 24) to a TAU (n = 23) condition. This initial effectiveness study randomly assigned female patients with BPD and a history of at least 2 suicide attempts or 2 episodes of self-injury during the past year to either 1 year of DBT or 1 year of treatment by a mental health service provider in the community. DBT patients received the treatment package described above, whereas the TAU patients received a diverse array of other treatments that may or may not have included individual therapy sessions. Initial results revealed that patients who received DBT had significantly fewer episodes of self-injury at each 4-month assessment interval point, including posttreatment. In addition, during the course of the 1-year follow-up,118 DBT patients were significantly less likely to resume self-injurious behavior during the first 6 months than were the TAU patients (26% vs 60%, respectively). However, this difference was not significant at the 12-month follow-up assessment.
Koons et al119 evaluated the effectiveness of DBT for female veterans diagnosed with BPD (n = 10) compared with a weekly 1-hour therapy TAU condition (n = 10). Analyses combined suicide attempts and nonsuicidal self-injury, making specificity of treatment effects hard to identify. Nonetheless, this study revealed a significant decrease in aggregated self-harming behaviors across all 3 assessment periods for patients with DBT (P = .04) but not for TAU patients (P = .98), as well as a trend for differences in self-harm episodes before and after treatment for patients receiving DBT (P = .06) but not for TAU patients (P = .25). Additionally, a trend toward significance (P = .07) was found for the between-group differences in the proportions of participants reporting self-harming behaviors; the proportion of patients reporting any self-harming behaviors decreased from 50% to 10% for patients with DBT versus 30% to 20% for TAU patients.
In a more recent randomized, controlled trial among patients receiving DBT, Linehan et al120 randomly assigned female patients with BPD to 1 year of either DBT (n = 52) or community treatment by experts (n = 49). Community treatment by experts consisted of individual therapy by 25 therapists who identified the treatment they provided to patients as either “nonbehavioral” or “psychodynamic.” Results of this trial indicated significantly lower rates of self-injury at posttreatment for patients receiving DBT but no significant differences between groups. Thus, DBT was equally as effective at reducing self-injury as nonbehavioral treatment by experts. However, during the course of this 2-year trial, patients receiving DBT had significantly lower mean medical severity across all self-harming (self-injurious and suicidal) behaviors and significantly fewer suicide attempts than did the TAU participants.
DBT has also been adapted, modified, and evaluated for inpatient and adolescent populations. Thus far, no randomized controlled trials have been conducted; however, evidence with lower strength is available. Barley and colleagues121 reported the effects of integrating skills training onto an inpatient personality disorders unit. This study evaluated, among other variables, self-injury outcomes in 130 patients admitted to an inpatient facility. Compared with self-injury data from the general psychiatry inpatient unit in the same hospital, patients on the personality disorders unit evidenced significantly fewer episodes of self-injury after DBT was implemented. More recently, Bohus et al122 adapted DBT for an inpatient setting. The treatment used a standard DBT protocol of individual therapy, skills training, and skills coaching fitted into a 4-week program. In their evaluation of the effectiveness of 24 female inpatients diagnosed with BPD and who reported a history of at least 2 episodes of self-injury during the last 2 years, DBT was effective in significantly reducing the frequency of self-injury (P = .004). That 19 of the 24 inpatients were medication-free throughout the latter study is a noteworthy consideration.
Finally, Rathus, Miller, and colleagues,123–125 and Katz and colleagues126 have adapted DBT for adolescent populations. Rathus et al125 originally adapted DBT by reducing treatment length to 12 weeks, reducing the skills taught, and including the family in skills training. In a quasi-experimental effectiveness study, Rathus and Miller123 found that, among suicidal adolescent outpatients with BPD features, the group receiving DBT (n = 29) had significantly fewer hospitalizations during treatment than a TAU group (n = 82), and there were no significant differences in suicide attempts between groups. However, there was a significant decrease in suicidal ideations in the DBT group at posttreatment. No data about self-injury specifically was reported. Katz et al126 adapted inpatient DBT for adolescents, implementing a 2-week program that consisted of daily skills training and individual DBT. Results of a quasi-experimental study found that this adaptation of DBT significantly reduced self-harm behavior in aggregate, including self-injury, during a 1-year follow-up period. In addition, significant reductions in suicidal ideations were found at discharge and 1-year follow-up.
DBT has been subjected to more scrutiny than any other treatment for self-injury. However, the data about the actual effectiveness of DBT are mixed and suggest a modest effect of this treatment on self-injury. In aggregate, the literature indicates that DBT is likely to reduce self-injury (as well as risk of suicide attempts) during the course of treatment and that these effects are likely to last for up to 6 months without further treatment and for ≥1 year with further intermittent treatment contact.117–120 Based on the quality of research about DBT, the evidence for DBT as an intervention for self-injury is level 1; however, the SORT recommendation rating for DBT is B because of the inconsistency of demonstrated effects on this behavior specifically.
The studies discussed above were generally well-designed randomized, controlled trials. However, there are some notable shortcomings of DBT research. First, compared with other treatments, DBT has only been systematically evaluated in women. This is a substantial limitation of the generalizability of DBT to the populations it purports to treat. Although approximately 75% of individuals with BDP are women, the DBT literature says nothing about its effectiveness with the remaining 25% that consists of men.
Second, from a design perspective, research about DBT is limited by a lack of comparison with specific alternative treatments. Thus far, research about DBT has used poorly defined TAU conditions. The original studies117,118 compared DBT to a condition in which patients received an indeterminate level of therapeutic contact. Perhaps any patient with BPD who receives 3 hours of structured, goal-directed contact weekly would improve to a greater degree than would patients who may only receive 30 or 60 minutes of group or individual treatment. Although the degree of change evidenced in this first trial was significant, the most recent trial of DBT120 did not find significant between-group differences for self-injury. The comparison condition was slightly better defined (and ostensibly consisted of greater expertise) in this latest study, but it was still lacking a clear description of the alternative treatment.
Another problem with DBT, as with other treatments, is an inadequate or inconsistent definition of outcome measures for self-harm behaviors. The use of the term “parasuicide” by Linehan,30 Linehan et al,117 and many others has contributed to this definitional problem. In Koons and colleagues’119 study, for example, there were notable decreases in aggregated self-harm behaviors, but these behaviors included both suicidal and nonsuicidal self-injury. In Linehan et al's120 recent clinical trial, medical severity of self-harm behaviors was examined across types of self-harm.
The data from the DBT literature are promising and clearly suggest treatment effects. Thus far these data give more hope for suicide prevention and self-injury reduction than any other treatment. However, the current data leave us with unanswered questions: For whom is DBT best suited (eg, only white women)? What is DBT best suited for treating? and To which treatments is DBT a superior intervention? Research on DBT could be greatly enhanced by including well-defined comparison treatments. Finally, one oft-cited concern about DBT is the considerable startup cost involved in implementing a program because of the extensive training required.119 Although modified approaches have been found to be at least somewhat effective,122–127 DBT is still typically viewed as a necessarily comprehensive treatment approach for a complex clinical problem (ie, BPD).
Citation: Whitlock J (2010) Self-Injurious Behavior in Adolescents. PLoS Med 7(5): e1000240. https://doi.org/10.1371/journal.pmed.1000240
Published: May 25, 2010
Copyright: © 2010 Janis Whitlock. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No specific funding was received for this piece.
Competing interests: The author has declared that no competing interests exist.
Provenance: Commissioned; externally peer reviewed.
What constitutes non-suicidal self-injury (NSSI) is a matter of some debate, but its growing presence in mainstream and popular media as well as the growing number of anecdotal reports by physicians, therapists, and junior and senior high school counselors suggest that it may be, as some have called it, “the next teen disorder” . Referred to in the literature and media as “self-injurious behavior,” “self-injury,” “self-harm,” “self-mutilation,” or “cutting,” self-injury is typically defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned . Although most often not a suicidal gesture, it is statistically associated with suicide and can result in unanticipated severe harm or fatality ,,.
What Do We Know about NSSI Prevalence and Characteristics in Adolescents?
Although study of NSSI in adolescence is relatively new, empirical advances in NSSI research over the past several years have resulted in a solid foundation of knowledge about basic epidemiological parameters. Many normally developing youth practice what is typically referred to as common NSSI . This form of self-injury includes NSSI that is (a) compulsive (ritualistic and rarely premeditated such as hair pulling or trichotillomania), (b) episodic (every so often and with no identification as someone who self-injures), and (c) repetitive (performed on a regular basis and with ego identification as someone who self-injures). Common NSSI can be mild, moderate, or severe depending on the lethality of the injuries. Although common NSSI can and does co-occur with other DSM classifiable mental illnesses, such as depression or anxiety, it is also increasingly evident that it presents independently of other mental illness .
In general, U.S. studies tend to find that lifetime prevalence of common NSSI ranges from 12% to 37.2% in secondary school populations  and 12% to 20% , in late adolescent and young adult populations. NSSI scholarship consistently shows an average age of onset between 11 and 15 y ,,,, with a normally distributed age of onset ranging from about 10–24 . Of all youth reporting any NSSI, over three quarters report repeat NSSI (>1 episode)  and an estimated 6%–7% of adolescents report current repetitive NSSI (NSSI in the past year) ,,. Overall, about a quarter of all adolescents and young adults with NSSI history report practicing NSSI only once in their lives ,, but since even a single NSSI episode is significantly correlated with a history of abuse and comorbid conditions such as suicidality and psychiatric distress, there may be a group of adolescents in which a single incident of NSSI serves as a risk indicator for other risk behaviors or pathology . Duration of NSSI is understudied, but available evidence suggests that among individuals with a history of repeat NSSI, the majority (79.8%) reported stopping NSSI within 5 y of starting and 40% reported stopping within 1 y of starting .
NSSI differs from culturally sanctioned self-injury, such as piercing or tattooing, by intention rather than form as well as by injurious agent (piercing and tattooing are most commonly performed by someone other than oneself, while the reverse is usually true for NSSI). Although most often associated with the term “cutting,” the most common forms among youth include scratching, cutting, punching, or banging objects with the conscious intention of self-injury; punching or banging oneself; biting, ripping, or tearing the skin; carving on the self; and burning ,,,,. Where on the body one injures may be important as well. Injuries inflicted on the face, eyes, neck in the jugular region, breast, or genitals, for instance, may be clinically indicative of greater psychological disturbance than when injuries are inflicted elsewhere ,. The majority of young people reporting repeat self-injury also report using multiple methods and multiple body locations .
Most studies show females slightly more likely to practice NSSI than males (unpublished data) ,. Recent work suggests that there may be different self-injury groups or “classes,” one of which consists largely of men who use self-injury forms that can be described as “self-battery” and/or who practice NSSI in social settings . Findings with regard to race and NSSI are mixed, with some studies suggesting that it may be more common among Caucasians  and others showing similarly high rates in minority samples ,. There is also evidence linking NSSI to sexual orientation such that incidence of NSSI is slightly elevated among those who report exclusive homosexual attraction and some same-sex attraction, and it is very elevated among individuals with bisexual and questioning sexual orientation status (unpublished data) .
Although empirical attention devoted to NSSI varies dramatically around the world, it is clear that NSSI is globally present and prevalent. The U.K., for example, has dedicated national resources to investigation and reduction of “self-harm” among youth , and scholars from both Canada and Europe , have documented alarmingly high rates of self-harm in their countries. Although most widely investigated in industrialized regions such as Europe, North America, Australia, and New Zealand, NSSI also occurs with some regularity in other industrialized and non-industrialized countries as well ,,. However, comparing rates and characteristics of NSSI internationally is complicated by the fact that many measures of NSSI outside of the U.S. (most commonly referred to as “self-harm”) include behaviors undertaken with suicidal intent and may also capture socially sanctioned self-injurious behaviors, such as those used as part of religious or ritualistic practices .
Why Do Youth Self-Injure?
In general, reasons for self-injuring break down into three general categories: psychological, social, and biological. Of these, psychological functions are most commonly cited and center around reducing psychological pain, expressing and alleviating psychological distress, and refocusing one's attention away from negative stimulus ,,. Much less common but sometimes cited are reasons such as “so someone would pay attention” and “to get a rush or surge of energy.” Both underscore the role of both social and biological roles in maintaining NSSI. Social function models point to the importance of viewing NSSI as a behavior undertaken to fulfill multiple functions simultaneously, most of which are intrapersonal (emotion regulation) but some of which are fundamentally interpersonal in nature. In addition to being identified as factors that predispose or place at-risk adolescents who ultimately adopt NSSI as a release for negative emotion ,, research finds interpersonal factors also make significant contributions to NSSI maintenance ,,. Biological models of function tend to focus primarily on the role of NSSI in regulation of endogenous opioids. The homeostasis model of NSSI, for example, suggests that individuals who self-injure may have chronically lower than normal levels of endogenous opioids. In this model, NSSI is fundamentally remedial—it represents an attempt to restore opioids to normal levels. Low levels of opioids may result from a history of abuse, trauma, or neglect or may be biologically endowed through other processes . These models are very helpful in deepening understanding about how and why some individuals perceive that they are dependent on NSSI behavior for emotion regulation.
Identifying unique antecedents to NSSI is more difficult since it shares with many adolescent risk behaviors predisposing factors such as emotion dysregulation, self-derogation, childhood adversity, and comorbid or antecedent psychiatric disorders . In clinical populations, self-injury is strongly linked to childhood abuse, especially childhood sexual abuse ,. Self-injury is also linked to eating disorders, substance abuse, post-traumatic stress disorder, borderline personality disorder, depression, and anxiety disorders . While much of this research reflects comorbidity in clinical populations, more recent studies of these relationships in community populations of youth document similar patterns, though at significantly lower levels of association ,,. Indeed, one study found that 44% of respondents with current NSSI behavior evidenced no existing comorbid clinical conditions .
What Is the Relationship between NSSI and Suicide?
That NSSI and suicide behaviors are related is well documented –, but the nature of its relationship remains somewhat ambiguous. Most NSSI treatment specialists and scholars agree that in the vast majority of cases NSSI is utilized to temporarily alleviate distress rather than to signal the intention to end one's life ,,. Indeed, some see it as a means of avoiding suicide ,. Thus, in its relation to suicide, NSSI possesses an ambiguous, seemingly paradoxical, status as both a temporarily functional means of sustaining life by reducing and regulating strong negative emotion while simultaneously serving as a potential harbinger for suicidal intent and attempts. This dual status suggests that efforts to discern variations in motivation and intent may be the most productive means of generating information useful in tailoring treatment guidelines, materials, and services. While Walsh  has argued that NSSI and suicide are entirely distinct psychological and behavioral phenomenon, Joiner theorizes that some suicidal individuals acquire the capacity to engage in high lethality behavior (i.e., suicide) by engaging in increasingly severe NSSI over time . Assuming that suicide behavior is a consequence of NSSI behavior assumes a temporal relationship that has yet to be documented. If this assumption proves true, then the data would suggest that for some NSSI serves as a harbinger of distress that, if left unmitigated, may lead some individuals to consider or attempt suicide later.
Is NSSI Contagious?
It is widely assumed that NSSI is contagious, although lack of empirical data necessarily limits our capacity to test this assumption. Nevertheless, studies of contagion among adolescents in clinical settings demonstrate the tendency for NSSI to spread in a population – and the presence of self-injury in media, such as in music, movies, and newspapers, has increased dramatically in the past several years . The Internet, as well, has proven to be a popular avenue for the gathering of individuals who practice NSSI . Studies of the social contexts of behavior consistently show that positive and negative behaviors are socially patterned and often clustered  and that the primary mechanism of spread tends to be through (a) the shaping of norms, (b) providing social reinforcement of behaviors, (c) providing (or limiting) opportunities to engage in the behavior, and (d) facilitating or inhibiting the antecedents for the behavior . Considered together, these mechanisms provide a useful framework for understanding how self-injury might spread in community populations of youth and point to the need for prevention and intervention approaches that address each of these areas.
How Is NSSI Best Treated?
Although NSSI treatment specialists can offer advice based on experience, few studies that actually test treatment strategies have been conducted. In a systematic review of 23 randomized controlled trials related to Deliberate Self Harm (a U.K.-based term that includes NSSI and suicide-related behavior), reviewers concluded that the most promising approaches include problem-solving therapy, provision of emergency service contact information, long-term psychological therapy, and depot flupenthixol (for those with repeat self-harm experience). They caution, however, that current knowledge is insufficient and more trials are sorely needed . In a systematic review of NSSI-specific treatment strategies, Muehlenkamp concludes that approaches utilizing largely cognitive-behavioral therapy (CBT) may prove most efficacious in NSSI treatment . Because of the time-limited and structured coping skill-building nature of the technique, she specifically identifies problem-solving therapy and dialectical behavioral therapy as the most promising CBT-based candidates but suggests that while both may be efficacious under the right treatment conditions, neither has emerged as efficacious in the limited study available. Although dialectical behavior therapy has been used with significant success in borderline personality disordered patients with suicide and NSSI as well , there is significant need for well-designed and rigorous trials of NSSI treatment strategies among community populations.
How Do We Detect NSSI?
Although common among adolescents, NSSI is often undetected. Medical providers are uniquely positioned to assess for NSSI behavior during intake assessments and during examination since wounds or scars may be visible. Arms, fists, and forearms opposite the dominant hand are common areas for injury. However, evidence of self-injurious acts can and do appear anywhere on the body. Other signs include inappropriate dress for season (consistently wearing long sleeves or pants in summer), constant use of wrist bands/coverings, unwillingness to participate in events/activities that require less body coverage (such as swimming or gym class), and frequent bandages and odd/unexplainable paraphernalia (e.g., razor blades or other implements that could be used to cut or pound). It is important that questions about the marks be non-threatening and emotionally neutral. Treatment veteran Barent Walsh indicates that he has the most success making patients comfortable and gleaning clinically useful information by demonstrating “respectful curiosity” toward individuals with NSSI history .
If NSSI is detected, health professionals should investigate and address:
- Immediate risk of infection: Open wounds should be assessed for likelihood of infection. Even in cases where wounds are healed, a discussion of how to care for wounds is warranted. This is particularly important since a significant number of those with NSSI experience indicate inflicting wounds of unintended severity ,.
- NSSI severity: In general, lifetime frequency of NSSI in combination with the number of methods used and the likelihood that the methods used will cause severe tissue damage (i.e., cutting, burning, bone breaking, etc.) is directly and positively correlated with risk of other adverse outcomes, such as suicide-related behaviors and global psychological distress. High-severity cases (high lifetime frequency, injury in the past 6 mo, use of forms likely to inflict high tissue damage, and/or use of multiple forms) warrant thorough assessment of existing therapeutic support and referral if found inadequate or lacking.
- Extent of informal and formal support system: Has the patient disclosed injury to anyone, and if so, how supportive are those who know? Does the patient currently receive therapy in which presence of NSSI has been disclosed? If not, referral is warranted—particularly for high-severity cases.
- Presence of comorbid mental health conditions, such as disordered eating, depression, anxiety, borderline personality disorder, and generalized psychological distress. Presence of one or more of these conditions in NSSI patients is common and may heighten risk of suicide ,,.
- Suicide assessment: Although NSSI is not a suicidal gesture, it can indicate the presence of suicidal thoughts and feelings and should trigger suicide assessment in individuals who have self-injured in the previous year. A variety of assessment tools are available to do this, including but not limited to the SI-IAT  and the Beck Suicide Intent Scale .
NSSI is a common practice among adolescents, and medical providers are uniquely positioned to detect its presence, to assess its lethality, and to assist patients in caring for wounds and in seeking psychological treatment. NSSI assessment should be standard practice in medical settings. Randomized control trials of effective treatment and prevention strategies are warranted. Because NSSI research is nascent, unanswered research questions abound. Those most pressing for clinicians and allied medical health professionals include (a) discerning individuals with NSSI history at elevated risk for suicide from those not at elevated risk, (b) effective treatment regimes, (c) effective prevention strategies in school and community settings, and (d) assessment and referral protocols likely to result in effective treatment and abatement of NSSI behavior.
Five Key Studies in the Field
1. Ross S, Heath N (2002) A study of the frequency of self-mutilation in a community sample of adolescents. J Youth Adolesc 31: 66–77.
This is one of the first descriptive studies of NSSI in a high school sample of adolescents. It paved the way for study of NSSI in community populations by documenting a high prevalence rate and providing novel descriptive details .
2. Nock MK, Prinstein MJ (2004) A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol 72: 885–890.
This is the first study to document a functional model of NSSI that moved beyond the pejorative manipulation function and provided empirical support for a multi-functional conceptualization of NSSI in adolescents .
3. Whitlock J, Eckenrode J, Silverman D (2006) Self-injurious behaviors in a college population. Pediatrics 117: 1939–1948.
This was the first large-scale epidemiological study to document the phenomena of NSSI in college students and to provide detailed epidemiological portraits of the phenomenon .
4. Muehlenkamp J, Gutierrez PM (2007) Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res 11: 69–82.
This was among the very first empirical papers to document the distinctions between NSSI and suicide beyond the intent of the behavior, and did so within a community sample of high school students, expanding research on NSSI to nonclinical settings .
5. Rossow I, Ystgaard M, Hawton K, Madge N, van Heeringen K, et al. (2007) Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents. Suicide Life Threat Behav 37: 605–615.
This was the first large-scale international study of NSSI prevalence (called “deliberate self harm” in Europe). It also paved the way for looking at the relationship between NSSI and common adolescent risk behaviors such as alcohol use .
ICMJE criteria for authorship read and met: JW. Wrote the first draft of the paper: JW. Contributed to the writing of the paper: JW.
- 1. Welsh P (June 2004) P. WelshJune 2004Students' scars point to emotional pain. USA Today Editorials: 11A. Available: http://findarticles.com/p/articles/mi_kmusa/is_200406/ai_n6875652/. Accessed 06 November 2009. Students' scars point to emotional pain. USA Today Editorials: 11A. Available: http://findarticles.com/p/articles/mi_kmusa/is_200406/ai_n6875652/. Accessed 06 November 2009.
- 2. International Society for the Study of Self-injury (2007) Definitional issues surrounding our understanding of self-injury. Conference proceedings from the annual meeting. International Society for the Study of Self-injury2007Definitional issues surrounding our understanding of self-injury.Conference proceedings from the annual meeting
- 3. Whitlock J, Knox KL (2007) The relationship between self-injurious behavior and suicide in a young adult population. Arch Pediatr Adolesc Med 161: 634–640.J. WhitlockKL Knox2007The relationship between self-injurious behavior and suicide in a young adult population.Arch Pediatr Adolesc Med161634640
- 4. Muehlenkamp J, Gutierrez PM (2007) Risk for suicide attempts among adolescents who engage in non-suicidal self-injury. Arch Suicide Res 11: 69–82.J. MuehlenkampPM Gutierrez2007Risk for suicide attempts among adolescents who engage in non-suicidal self-injury.Arch Suicide Res116982
- 5. Nock MK, Joiner TE, Gordon KH, Lloyd-Richardson E, Prinstein MJ (2006) Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res 144: 65–72.MK NockTE JoinerKH GordonE. Lloyd-RichardsonMJ Prinstein2006Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts.Psychiatry Res1446572
- 6. Nock M, Favazza AR (2009) Non-suicidal self-injury: definition and classification. In: Nock M, editor. Understanding non-suicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association. M. NockAR Favazza2009Non-suicidal self-injury: definition and classification.M. NockUnderstanding non-suicidal self-injury: origins, assessment, and treatmentWashington, DCAmerican Psychological Association
- 7. Gollust SE, Eisenberg D, Golberstein E (2008) Prevalence and correlates of self-injury among university students. J Am Coll Health 56: 491–498.SE GollustD. EisenbergE. Golberstein2008Prevalence and correlates of self-injury among university students.J Am Coll Health56491498
- 8. Jacobson CM, Gould M (2007) The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res 11: 129–147.CM JacobsonM. Gould2007The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature.Arch Suicide Res11129147
- 9. Whitlock J, Eckenrode J, Silverman D (2006) Self-injurious behaviors in a college population. Pediatrics 117: 1939–1948.J. WhitlockJ. EckenrodeD. Silverman2006Self-injurious behaviors in a college population.Pediatrics11719391948
- 10. Muehlenkamp JJ, Gutierrez PM (2004) An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav 34: 12–24.JJ MuehlenkampPM Gutierrez2004An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents.Suicide Life Threat Behav341224
- 11. Kumar G, Pepe D, Steer RA (2004) Adolescent psychiatric inpatients' self-reported reasons for cutting themselves. J Nerv Ment Dis 192: 830–836.G. KumarD. PepeRA Steer2004Adolescent psychiatric inpatients' self-reported reasons for cutting themselves.J Nerv Ment Dis192830836
- 12. Nock MK, Prinstein MJ (2004) A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol 72: 885–890.MK NockMJ Prinstein2004A functional approach to the assessment of self-mutilative behavior.J Consult Clin Psychol72885890
- 13. Heath NL, Toste JR, Nedecheva T, Charlebois A (2008) An examination of nonsuicidal self-injury among college students. J Ment Health Counsel 30: 137–156.NL HeathJR TosteT. NedechevaA. Charlebois2008An examination of nonsuicidal self-injury among college students.J Ment Health Counsel30137156
- 14. Laye-Gindhu A, Schonert-Reichl KA (2005) Nonsuicidal self-harm among community adolescents: understanding the “whats” and “whys” of self-harm. J Youth Adolesc 34: 447–457.A. Laye-GindhuKA Schonert-Reichl2005Nonsuicidal self-harm among community adolescents: understanding the “whats” and “whys” of self-harm.J Youth Adolesc34447457
- 15. Briere J, Gil E (1998) Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry 68: 609–620.J. BriereE. Gil1998Self-mutilation in clinical and general population samples: prevalence, correlates, and functions.Am J Orthopsychiatry68609620
- 16. Klonsky ED (2007) Non-suicidal self-injury: an introduction. J Clin Psychol 63: 1039–1043.ED Klonsky2007Non-suicidal self-injury: an introduction.J Clin Psychol6310391043
- 17. Walsh B (2006) Treating self-injury: a practical guide. New York: Guilford Press. B. Walsh2006Treating self-injury: a practical guide.New YorkGuilford Press
- 18. Young People and Self-Harm: A National Inquiry (2004) Young People and Self-Harm: A National Inquiry2004What do we already know? prevalence, risk factors & models of intervention. Available: http://www.selfharmuk.org/inform.asp. Accessed 15 September 2004. What do we already know? prevalence, risk factors & models of intervention. Available: http://www.selfharmuk.org/inform.asp. Accessed 15 September 2004.
- 19. Conterio K, Lader W (1998) Bodily harm: the breakthrough healing program for self-injurers. New York: Hyperion. K. ConterioW. Lader1998Bodily harm: the breakthrough healing program for self-injurers.New YorkHyperion
- 20. Whitlock JL, Muehlenkamp J, Eckenrode J (2008) Variation in non-suicidal self-injury: identification of latent classes in a community population of young adults. J Clin Child Adolesc Psychol 37: 725–735.JL WhitlockJ. MuehlenkampJ. Eckenrode2008Variation in non-suicidal self-injury: identification of latent classes in a community population of young adults.J Clin Child Adolesc Psychol37725735
- 21. Bhugra D, Singh J, Fellow-Smith E, Bayliss C (2002) Deliberate self-harm in adolescents. A case study among two ethnic groups. Eur J Psych 16: 145–151.D. BhugraJ. SinghE. Fellow-SmithC. Bayliss2002Deliberate self-harm in adolescents. A case study among two ethnic groups.Eur J Psych16145151
- 22. Marshall H, Yazdani A (1999) Locating culture in accounting for self-harm amongst Asian young women. J Community Appl Soc Psychol 9: 413–433.H. MarshallA. Yazdani1999Locating culture in accounting for self-harm amongst Asian young women.J Community Appl Soc Psychol9413433
- 23. Ross S, Heath N (2002) A study of the frequency of self-mutilation in a community sample of adolescents. J Youth Adolesc 31: 66–77.S. RossN. Heath2002A study of the frequency of self-mutilation in a community sample of adolescents.J Youth Adolesc316677
- 24. Rossow I, Ystgaard M, Hawton K, Madge N, van Heeringen K, et al. (2007) Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents. Suicide Life Threat Behav 37: 605–615.I. RossowM. YstgaardK. HawtonN. MadgeK. van Heeringen2007Cross-national comparisons of the association between alcohol consumption and deliberate self-harm in adolescents.Suicide Life Threat Behav37605615
- 25. Favazza AR (1998) The coming of age of self-mutilation. J Nerv Ment Dis 186: 259–268.AR Favazza1998The coming of age of self-mutilation.J Nerv Ment Dis186259268
- 26. Klonsky ED (2007) The functions of deliberate self-injury: a review of the empirical evidence. Clin Psych Rev 27: 226–239.ED Klonsky2007The functions of deliberate self-injury: a review of the empirical evidence.Clin Psych Rev27226239
- 27. Yates TM (2004) The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation. Clin Psychol Rev 24: 35–74.TM Yates2004The developmental psychopathology of self-injurious behavior: compensatory regulation in posttraumatic adaptation.Clin Psychol Rev243574
- 28. Prinstein MJ, Guerry JD, Browne CB, Rancourt D (2009) Interpersonal models of nonsuicidal self-injury. In: Nock MK, editor. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association. MJ PrinsteinJD GuerryCB BrowneD. Rancourt2009Interpersonal models of nonsuicidal self-injury.MK NockUnderstanding nonsuicidal self-injury: origins, assessment, and treatmentWashington, DCAmerican Psychological Association
- 29. Sher L, Stanley B (2009) Biological models of nonsuicidal self-injury. In: Nock MK, editor. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association. L. SherB. Stanley2009Biological models of nonsuicidal self-injury.MK NockUnderstanding nonsuicidal self-injury: origins, assessment, and treatmentWashington, DCAmerican Psychological Association
- 30. Klonsky ED, Glenn CR (2009) Assessing the functions of non-suicidal self-injury: psychometric properties of the inventory of statements about self-injury (ISAS). J Psychopathol Behav Assess 31: 215–219.ED KlonskyCR Glenn2009Assessing the functions of non-suicidal self-injury: psychometric properties of the inventory of statements about self-injury (ISAS).J Psychopathol Behav Assess31215219
- 31. Brodsky BS, Cloitre M, Dulit RA (1995) Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatr 152: 1788–1792.BS BrodskyM. CloitreRA Dulit1995Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder.Am J Psychiatr15217881792
- 32. Ogle RL, Clements CM (2008) Deliberate self-harm and alcohol involvement in college-aged females: a controlled comparison in a nonclinical sample. Am J Orthopsychiatry 78: 442–448.RL OgleCM Clements2008Deliberate self-harm and alcohol involvement in college-aged females: a controlled comparison in a nonclinical sample.Am J Orthopsychiatry78442448
- 33. Conterio K, Lader W (1998) Bodily harm: the breakthrough healing program for self injurers. New York: Hyperion Press. K. ConterioW. Lader1998Bodily harm: the breakthrough healing program for self injurers.New YorkHyperion Press
- 34. Alderman T (1997) The scarred soul: understanding and ending self-inflicted violence. Oakland, CA: New Harbinger. T. Alderman1997The scarred soul: understanding and ending self-inflicted violence.Oakland, CANew Harbinger
- 35. Strong MA (1998) Bright red scream: self-mutilation and the language of pain. New York: Viking. MA Strong1998Bright red scream: self-mutilation and the language of pain.New YorkViking
- 36. Joiner TE (2006) Why people die by suicide. Cambridge, MA: Harvard University Press. TE Joiner2006Why people die by suicide.Cambridge, MAHarvard University Press
- 37. Walsh B, Doerfler LA (2009) Residential treatment of self-injury. Washington, DC: American Psychological Association. B. WalshLA Doerfler2009Residential treatment of self-injury.Washington, DCAmerican Psychological AssociationIn:Understanding non-suicidal self-injury: origins, assessment, and treatment.
- 38. Taiminen TJ, Kallio-Soukainen K, Nokso-Koivisto H, Kaljonen A, Helenius H (1998) Contagion of deliberate self-harm among adolescent inpatients. J Am Acad Child Adolesc Psychiatry 37: 211–217.TJ TaiminenK. Kallio-SoukainenH. Nokso-KoivistoA. KaljonenH. Helenius1998Contagion of deliberate self-harm among adolescent inpatients.J Am Acad Child Adolesc Psychiatry37211217
- 39. Matthews PC (1968) Epidemic self-injury in an adolescent unit. Int J Soc Psychiatry 14: 125–133.PC Matthews1968Epidemic self-injury in an adolescent unit.Int J Soc Psychiatry14125133
- 40. Whitlock J, Purington A, Gershkovich M (2009) Media, the internet, and nonsuicidal self-injury. In: Nock MK, editor. Understanding nonsuicidal self-injury. Washington, DC: American Psychological Association. J. WhitlockA. PuringtonM. Gershkovich2009Media, the internet, and nonsuicidal self-injury.MK NockUnderstanding nonsuicidal self-injuryWashington, DCAmerican Psychological Association
- 41. Whitlock JL, Powers JL, Eckenrode J (2006) The cutting edge: the internet and adolescent self-injury. Dev Psychol 42: 407–417.JL WhitlockJL PowersJ. Eckenrode2006The cutting edge: the internet and adolescent self-injury.Dev Psychol42407417
- 42. Berkman LF, Kawachi I (2000) A historical framework for social epidemiology. In: Berkman LF, Kawachi I, editors. Social epidemiology. Oxford: Oxford University Press. LF BerkmanI. Kawachi2000A historical framework for social epidemiology.LF BerkmanI. KawachiSocial epidemiologyOxfordOxford University Press
- 43. Hawton KKE, Townsend E, Arensman E, Gunnell D, Hazell P, et al. (1999) Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews 3 Art. No.: CD001764.KKE HawtonE. TownsendE. ArensmanD. GunnellP. Hazell1999Psychosocial and pharmacological treatments for deliberate self harm.Cochrane Database of Systematic Reviews 3Art. No.CD001764DOI:10.1002/14651858.CD001764. DOI:10.1002/14651858.CD001764.
- 44. Muehlenkamp J (2006) Empirically supported treatments and general therapy guidelines for non-suicidal self-injury. J Ment Health Counsel 28: 166–185.J. Muehlenkamp2006Empirically supported treatments and general therapy guidelines for non-suicidal self-injury.J Ment Health Counsel28166185
- 45. Linehan M, Comtois KA, Murray A, Brown M, Gallop R, et al. (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 63: 757–766.M. LinehanKA ComtoisA. MurrayM. BrownR. Gallop2006Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder.Arch Gen Psychiatry63757766
- 46. Haw C, Hawton K, Houston K, Townsend E (2001) Psychiatric and personality disorders indeliberate self-harm patients. Br J Psychiatry 178: 48–54.C. HawK. HawtonK. HoustonE. Townsend2001Psychiatric and personality disorders indeliberate self-harm patients.Br J Psychiatry1784854
- 47. Nock M, Banaji MR (2007) Prediction of suicide ideation and attempts among adolescents using a brief performance-based test. J Consult Clin Psychol 75: 707–715.M. NockMR Banaji2007Prediction of suicide ideation and attempts among adolescents using a brief performance-based test.J Consult Clin Psychol75707715
- 48. Beck AT, Kovack M, Weissman A (1979) Assessment of suicidal intention: the scale for suicide ideation. J Consult Clin Psychol 47: 343–352.AT BeckM. KovackA. Weissman1979Assessment of suicidal intention: the scale for suicide ideation.J Consult Clin Psychol47343352