Nonsuicidal self-injury

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Synonyms and Keywords: Self-harm (SH), Self-inflicted violence (SIV), self-injury (SI), Non suicidal self injury (NSSI) or self-injurious behavior (SIB),

Overview

Non-suicidal Self Injury means the intentional or conscious effort by someone to destruct his or her own body tissues with out having any intent for suicidality. The most common examples associated with NSSI includes cutting, scratching, burning, banging, self hitting. Mostly the people who self injure themselves are having the history of using two or more methods out of what described before. Because NSSI is frequently connected with emotional and psychiatric discomfort, as well as an increased risk of suicide, correct establishment of conceptual and clinical models of this behavior are critical.

The Non suicidal Self Injury is most commonly seen in young adults and adolescents age groups of around 13-14 years with a lifetime rates of 15-20%. But when the stats studied adult population the rate is 6%. Psychiatric groups, particularly those who report features linked with emotional distress, such as negative emotionality, depression, anxiety, and emotion dysregulation, have the highest incidence of NSSI in both adolescents and adult age group. In addition People who are prone to self-directed negative emotions and self-criticism are more likely to develop NSSI. Although it is typical for people to believe that NSSI is more common in women, general population surveys show that men and women have similar rates. However the sex difference makes the contribution when its comes to the point of methods used for NSSI. The women's are more found to be using cutting whereas the men's more often use the method of hitting and burning.

Historical Perspective

  • In early 1844 Bethlem Royal Hospital asylum made clear distinction between "self injury or disposition to suicide"[1][2][3]
  • In 20th century, Karl Menninger was the first to decribe self harm as a clinical entity.
  • In 1871, G. Fielding Blandford, MD, differentiated between, "will harm or mutilate portion of their bodies" and those who "attempt in every manner to put an end to themselves". He defined self mutilations as nail biting, face or hand picking, and hair plucking are common in nervous people.
  • In 1896, George Gould and Walter Pyle, divided self mutilation cases into those committed:

In a period of temporary insanity from melancholia or hallucinations

With suicidal purpose, and

In a religious frenzy or passion.

  • In 1883, 1892 James Adam distinguished between self injury with and without psychotic symptoms.
  • In 1878, Walter Channing, published a case report of Helen Miller, who was possessed with urges to cut. She resided in an asylum and cut repetitively for 3 years.[4]

Classification

Non Suicidal Self Injury

The Non Suicidal Self Injury also known as Self-harm, Self Injury, Self-inflicted violence, Self Injurious Behavior. [5] These are the common term used interchangeably by various authors and practioners to name the disease. The behavior entails intentional tissue injury that is usually carried out without a suicidal motive. Cutting the skin with a sharp item, such as a knife or razor blade, is the most prevalent type of self-harm. The word "self-mutilation" is also occasionally used, albeit it has connotations that some people find alarming, inaccurate, or unpleasant.

Soldiers use the term "self-inflicted wounds" to describe non-lethal injuries they cause in order to be released from combat sooner. But this damage is inflicted for a defined secondary aim, which differs from the standard definition of self-harm. We can also say the people who injure their bodies through disordered eating may be included in the definition of self-harm when broader aspect of the disease is considered.

NSSI has been proposed as a disorder in the DSM-5's "Conditions for Further Study" category. It should be noted that this proposed diagnostic criteria for a future diagnosis is not an officially approved diagnosis and should not be utilized in clinical practice; rather, it is intended solely for research purposes. The NSSI is classified as deliberate self-inflicted harm without the intent to commit suicide. The criteria for diagnosing and identifying NSSI includes 5 or more days of self inflicted harm over the duration of one year without having any intention to commit the suicide and along with that the person must have been having a motivation to relief from the negative state or to achieve a positive state.

Self-harm is commonly misunderstood as an attention-seeking behavior; however, this is not always the case. Many self-harmers are self-conscious about their scars and wounds, and they feel bad about their actions, therefore they go to great measures to hide their actions from others. They try to give the alternate reasoning for their scars or try to hide them with clothing. Self-harmers aren't usually trying to take their own lives; instead, it's thought that they're using it as a coping method to ease emotional anguish or discomfort, or as a way to communicate their distress.

Self-harm is dependent on environmental circumstances such as receiving attention or escaping expectations, according to studies of people with developmental disabilities (such as intellectual disability). Some people suffer from dissociation because they want to feel authentic or fit to society's rules.

Pathophysiology

Causes

Self-injury is a complicated condition without any simple explanation. Most people use it as a coping mechanism to deal with the feelings of unreality or numbness, to express distressful emotions, to punish themselves, to stop flashbacks and to relieve tension.[12][13][14][15][16]

Common causes of Non Suicidal Self Injury

Differentiating Nonsuicidal self-injury from other Diseases

Differential diagnosis of Nonsuicidal self-injury[17][18][19]
Name of the condition Characteristic features
Post-traumatic Stress disorder Reliving the incident with distressing recollections, flashbacks, dreams, and/or physical and psychological distress, avoidance of events that might trigger experiences or memories of the trauma, and increased arousal.
Dissociative disorder An unintentional escape from reality characterized by separation between identity, thoughts, memory and awareness.
Obsessive-compulsive disorder Obsessions which are repetitive and persistent urges, thoughts or images followed by compulsions which are repetitive behaviors or mental acts that the individual feels driven to perform.
Conduct disorder Deceitfulness and theft, destruction of property, aggression against people and animals, and serious violations of rules.
Intermittent explosive disorder Unable to stop impulses which leads to physical and verbal aggression. These are out of proportion to the provocation, unplanned and cause subjective and psychosocial distress.
Substance use disorder Use of tobacco, alcohol, and/or legal and illegal drugs causes disability, health problems,or failure to meet major responsibilities at work, school or home. Leads to problems with social interactions, impaired control, and risky behaviors.
Bulimia Consuming huge amounts of food while losing control of one's appetite and then attempting to burn off the excess calories in an unhealthy manner.
Dissociative identity disorder The existence of two or more distinct personality states, as well as repeated gaps in recollection of personal information or experiences, characterizes identity disruption.


Epidemiology and Demographics

  • The prevalence of NSSI varies between 7.5 and 46.5 percent in teenagers, rising to 38.9 percent among students and 4–23% among adults. Despite the fact that self-injurious behaviour is a common occurrence, results from different studies differ significantly.[8][20][8][21][22][23][24]
  • The beginning of NSSI is most common in early adolescence, between the ages of 12 and 14, however NSSI behavior has also been seen in children under the age of 12.
  • Self-cutting is the most prevalent method, followed by burning, head banging, hitting, and sctratching. Most people who engage in NSSI, use a combination of methods to affect their wrists, arms, stomach and legs.
  • The findings of several research studies showed that women exhibited more NSSI behaviors than men.
  • Self-cutting is the most prevalent way among women, who are more prone than males to participate in NSSI methods that typically entail blood, whereas burning, hitting and banging are the most common means among men. Among college students, adolescents and adults equal incidence of NSSI has been reported.
  • No differences in the race have been seen in the university and adolescent population.
  • Multiracial college students have the highest incidence rates in the ethnically varied sample, followed by Caucasian (16.8), and Hispanic (17%). Prevalence rates in Chinese students for NSSI is in the range of 24.9-29.2%. In the Turkish adolescent group it is 21.4%.

Risk Factors

The common risk factors involved in Non Suicidal Self Injury are as follows:[25][17]

Screening

The screening for Non Suicidal Self Injury is done by using the The Functional Assessment of Self-Mutilation (FASM). It gives us an assessment if the person was involved in self harming behaviour in the past one year. The person answers a set of questionnaire in terms of yes, no, how many times if its a positive response and if received any treatment.[26][27][28]


Diagnosis

Diagnostic Study of Choice

Most of the people who show self-harming behaviour meet the DSM-5 criteria for Non Suicidal Self Injury.

Non Suicidal Self Injury
DSM-5 Criteria for diagnosis of Non Suicidal Self Injury

History and Symptoms

Eighty percent of self-injury includes stabbing or cutting the skin with a sharp tool, sometimes completely piercing the skin. Self-harm is frequently committed in regions of the body that are readily hidden and undetectable to others. Most often it is a symptom of an underlying disorder and these people look for help to get out of this.
Common signs and symptoms that a person may be engaging in self-harm include the following:[29][30]

Physical Examination

During physical examination special attention must be given to orientation and level of consciousness, vital signs and toxidrome manifestations. In addition to this physicians should check for the following: [31]

Laboratory Findings

The laboratory evaluation of a suicidal child or adolescent should be tailored to the circumstances of the ideation or attempt, as well as the clinical risk assessment for illicit drug use and complicating medical issues, such as pregnancy and the presence of sexually transmitted diseases.[32] Screening laboratory tests that are often conducted and typically needed by hospitals before they consider patients for admission are.

MRI

Non suicidal self injury
fMRI in Non suicidal self injury

Resting state fMRI (rsfMRI or R-fMRI) is a method of functional magnetic resonance imaging (fMRI). When fMRI was done on a patient with NSSI, the findings were:[33]

Treatment

Short term psychotherapy and pharmacotherapy are effective in decreasing NSSI.[34][35][36][37][38][39][40] It is important to manage comorbid disorders before giving a trial of medications for self injury. Always those interventions are tried first which have greater evidence based effectiveness


Psychotherapy for Nonsuicidal Self-Injury.
Type of Psychotherapy Description
Dialectical behavioral therapy (DBT) It's a combination of individual and group therapy, as well as a therapist consultation team. DBT causes larger decreases in NSSI and SSI, which last for 6 to 12 months following therapy. DBT lowers the frequency, rate, and desire to participate in NSSI.
Emotion Regulation Group Therapy (ERGT) ERGT is a 14-week group therapy program that focuses on developing emotion control and acceptance skills, as well as identifying and pursuing significant objectives and values. In comparison to treatment as usual (TAU) , there were considerably larger decreases in NSSI frequency. Studies involving a follow up period indicated that therapy effects are long-lasting.
Manual-assisted cognitive-behaviour therapy (MACT) MACT is a systematic, problem-solving treatment that includes individual counseling and bibliotherapy and is generally completed in six sessions. MACT has a substantial benefit over TAU (treatment as usaul) in lowering the frequency of NSSI in female adults with BPD.
Transference–Focused Therapy(TPF) TFP is a psychodynamic therapy that involves twice-weekly individual sessions that use relationship transference for therapeutic change. TFP for females with BPD found substantial decreases in severity from pre- to posttreatment.
Dyadic developmental psychotherapy (DDP) DDP is a manualized psychodynamic therapy that employs weekly individual sessions for BPD patients with difficult co-occurring disorders to help hem explain affective and interpersonal experiences in coherent narratives. The frequency of NSSI in the last three months of DDP therapy was considerably lower than before the treatment.
Voice movement therapy (VMT) VMT is an and expressive arts therapy that integrates sound-making, expressive writing, singing, movement, massage, and drama activities to minimize emotion dysregulation and enhance self-awareness. When compared to the 10-week pretreatment period, young females engaged in less frequent NSSI while receiving 10 weeks of VMT.

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