Non-suicidal self-injury (NSSI) has been proposed as a new diagnostic category
The study of suicide and self-injurious behaviour has been plagued by
inconsistent terminology over the years. The concept of self-injury arose from
Kreitman's term ‘parasuicide’ used to label all non-accidental, self-poisoning or
self-injury that did not result in death, regardless of the intention of the act.
Over time the term ‘deliberate self-harm’ replaced parasuicide, however
more recently the word ‘deliberate’ has been dropped because of its pejorative
connotations and lack of favour with patients.
Within the USA ‘attempted suicide’ has been the more commonly used term to
refer to acts of self-injury with or without suicidal intent.
Confusingly, within the USA the phrase ‘deliberate self-harm’ often refers
to repetitive superficial bodily harm without suicidal intent, more frequently
termed ‘self-injury’ in the UK.
This varied nomenclature covers a spectrum of behaviour, from suicide to suicide
attempt to acts of self-injury without suicide intent.
Although some believe these various forms of self-injurious behaviour
merely represent different degrees of lethality of suicide attempt, there is a
growing body of evidence that the motives for NSSI are different.
If NSSI is distinct in intent, function and epidemiology, then separating
it from suicide attempt may be important. Many fundamental aspects of NSSI remain
unknown, and the lack of clear separation and diagnostic clarity between suicide
attempt and NSSI is likely to have hampered the development of a robust evidence
base for NSSI, with an impact on the development of treatment for this
Definition of NSSI
Non-suicidal self-injury is the direct, deliberate destruction of one's own
body tissue in the absence of intent to die. It differs from suicide attempt
with respect to intent, lethality, chronicity, methods, cognitions, reactions,
aftermath, demographics and prevalence. Primarily, the person's intent in NSSI
is not to terminate consciousness but to modify it. Common forms of NSSI
include cutting, burning, scratching, banging, hitting, biting and excessive
rubbing. Preceding the act of self-injury is a psychological experience of
increasing anger, tension, anxiety, dysphoria and general distress or
depersonalisation, which the person feels they cannot escape from or control.
Engaging in NSSI provides a temporary release from these distressing emotions.
Other reasons include: self-punishment; to draw attention so that other people
can see their distress; to make other people feel guilty and change their
behaviour; and to tie in socially with peers who self-injure.
An immediate feeling of relief, gratification and/or release from
depersonalisation follows the act of self-injury. However, despite this
transient response, NSSI leads to longer-term negative consequences.
Emotionally, it can evoke abiding complex feelings of guilt and shame towards
Prevalence of NSSI and associated factors
The difference in nomenclature and the lack of appropriately standardised and
validated assessment tools for NSSI limits our understanding of its true
incidence and prevalence. The majority of work evaluating NSSI has been on
adolescents and young adults as a result of the belief that it is a phenomenon
that declines across the course of a lifetime. One study has attempted to
compare prevalence rates of NSSI in young adults across nations using
comparable groups and study design.
They compared NSSI, suicide attempts, suicide threats and suicidal
ideation in a similar age group of adolescents, 14- to 17-year-olds, using the
same validated assessment tools in both Germany and the USA. Findings revealed
similar rates of adolescent engagement in at least one act of NSSI, with a
prevalence of 25.6% in German adolescents compared with 23.6% in the US
participants. Additional studies that distinguish between self-injury and
suicide attempt in this way will allow clarity on prevalence rates across
Current research findings point towards diagnostic heterogeneity in those
engaging in NSSI. Originally it was viewed as a symptom of borderline
personality disorder; however, we now know that NSSI has been identified in
numerous clinical samples without borderline personality disorder, including
those with mood and anxiety disorders, eating disorders, substance misuse,
conduct disorder and post-traumatic stress disorder.
In the context of established NSSI, the extent of self-injury engaged in
may play an important role in the prediction of more serious outcomes.
Individuals who engage in moderate to severe self-injury are more likely to
report a history of psychiatric treatment, admission to hospital, suicide
attempt and suicidal ideation.
Clarifying the extent of NSSI engaged in may be beneficial in assisting
health professionals assess the level of risk associated with such
NSSI and suicidality
The importance of identifying NSSI lies not only in its associated negative
emotional, physical and social consequences but also in its association with
suicide attempts. It has been found that NSSI is the strongest predictor of
future suicide attempts in adolescents with depression receiving treatment
under randomised controlled trial conditions.
High levels of depression, suicidal ideation and hopelessness
characterise participants who engage in either NSSI or suicide attempt.
These findings suggest that there are common risk factors predisposing
to both NSSI and suicide attempt. Nonetheless, clear differences have been
found in the extent and quality of these common clinical factors, which
supports the hypothesis that NSSI is a distinct entity in its own right. Those
who attempt suicide when compared with those who engage in NSSI have higher
scores on anxiety, depression and suicide ideation measurements.
One theory explaining the association is based on the hypothesis that engaging
in NSSI predisposes to suicidal attempt.
Potentially traumatic experiences such as NSSI, child abuse and combat
exposure may desensitise an individual to pain and fear of self-destruction, so
making suicide attempt more likely.
A further possibility is that with a lower combination of risk factors
only NSSI may be apparent. However, with a greater loading of psychopathology
and environmental difficulties, one sees more frequent and persistent NSSI and
eventually suicide attempt. This would suggest that although NSSI may not
directly lead to suicide attempt, if the needs and deficits reflected in NSSI
are not addressed it may ensue.
Notwithstanding the important association between NSSI and suicide attempt or
the hypothesis that it lies along a spectrum of self-destructive actions, it is
essential to remember that NSSI does not necessarily represent a less lethal
attempt at suicide. The clear distinction is that whereas NSSI represents a
maladaptive coping mechanism to regulate overwhelming emotions and to endure
life, a suicide attempt reflects a desire to escape and to end one's life.
Non-suicidal self-injury can be understood as a signal of psychological
distress, which could increase risk for suicide.
Non-suicidal self-injury and suicide attempt can occur in isolation yet
they may also co-occur, there may even be alternation between NSSI and suicide
attempt in the same individual.
Yet, this does not mean that NSSI and suicide attempt are the same;
essential qualitative and phenomenological differences do distinguish suicide
attempt from NSSI so continuing to differentiate self-injury with and without
suicidal intent is essential to building precise understandings of these behaviours.
NSSI as a separate category in DSM-5
Given the lack of intent to die we believe to be inherent in NSSI it is
certainly feasible to separate suicide attempt from NSSI. At present, there is
nowhere in the current classification of Axis I disorders to record NSSI,
implying that mental health professionals need not consider it abnormal. Given
the intense feelings of psychological distress, the adverse consequences
associated with NSSI and its potential relationship with future suicide
attempts, the importance of classifying it along with other mental health
disorders is clear. At present the occurrence of NSSI may lead clinicians to
make an automatic assumption that there is an underlying diagnosis of
borderline personality disorder. Yet, the individual in question may actually
meet diagnostic criteria for another mental health disorder. Assigning a
specific category to NSSI in DSM-5 allows for improved diagnostic clarity. This
may reduce the opportunity for clinician bias that NSSI merely indexes
borderline personality disorder. Furthermore, NSSI may have important
prognostic implications. That NSSI is likely to be a predictor of suicide
attempt, as detailed earlier, adds to the evidence that it is clinically
important and warrants identification. A further factor to consider is
treatment of NSSI. The short- and long-term adverse consequences of NSSI
suggest that treatment needs to be considered in its own right. Assigning NSSI
as a separate disorder is likely to increase the chance that specific treatment
will be offered. Research to date on specific treatment options for NSSI has
been hampered by the lack of precision in its definition and measurement.
Adding NSSI as a separate category in the new DSM-5 classification system will
hopefully enhance our ability to build an evidence base for treatment
Future directions for NSSI research
There is mounting evidence that NSSI and suicide attempt appear to be separate
entities. The proposed classification of NSSI as a separate category in DSM-5
will allow the development and validation of adequate assessment tools specific
to this behaviour. Accurately distinguishing NSSI from suicide attempt will
provide more information on its prevalence and allow a correct assessment of
both public health implications and treatment needs. Further research using the
clarified diagnostic criteria could then delineate the true aetiological,
motivating and maintaining factors associated with NSSI and its real prognostic
implications. This will inform the design of specific treatments and facilitate
methodologically sound treatment studies testing specific interventions for
NSSI in the presence and absence of other psychopathologies.
American Psychiatric Association.
Non-suicidal self injury. In
American Psychiatric Association DSM-5 Development.
APA, 2012 (http://www.dsm5.org).
O'Connor, R, Platt, S, Gordon, J. International Handbook of Suicide Prevention. Research,
Policy and Practice.
2005; 366: 1471–83.
Nock, MK, Kessler, RC. Prevalence of and risk factors for suicide attempts
versus suicide gestures: analysis of the National Comorbidity
Survey. J Abnorm Psychol
2006; 115: 616–23.
Wilkinson, P, Goodyer, I.
Non-suicidal self-injury. Eur Child
2011; 20: 103–8.
Plener, PL, Libal, G, Keller, F, Ferget, JM, Muehlenkamp, JJ. An international comparison of adolescent
non-suicidal self-injury (NSSI) and suicide attempts: Germany and the
USA. Psychol Med
2009; 39: 1549–58.
Jacobson, CM, Muehlenkamp, JJ, Miller, AL, Turner, JB. Psychiatric impairment among adolescents engaging in
different types of deliberate self-harm. J Clin
Child Adolesc Psychol
2008; 37: 363–75.
Wilkinson, P, Kelvin, R, Roberts, C, Dubicka, B, Goodyer, I. Clinical and psychosocial predictors of suicide
attempts and nonsuicidal self-injury in the Adolescent Depression
Antidepressants and Psychotherapy Trial (ADAPT).
Am J Psychiatry
Nonsuicidal self-injury as a predictor of suicidal behavior
in depressed adolescents. Am J
2011; 168: 452–4.
Muehlenkamp, JJ, Claes, L, Havertape, L, Plener, PL. International prevalence of adolescent non-suicidal
self-injury and deliberate self-harm. Child
Adolesc Psychiatry Ment Health
2012; 6: 10.