Nonsuicidal self-injury

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sunita Kumawat, M.B.B.S[2]

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

Classification

Non Suicidal Self Injury

The NSSI also known as Self Harm, Self Injury, Self-inflicted violence, Self Injurious Behavior. 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

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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.

Common causes of Non Suicidal Self Injury

• Psychological factors: Abuse during childhood, troubled relationships with parents or partner, bereavement. Lack of belonging, considering oneself as a burden, feelings of entrapment,defeat, with the onset of pubertal period and sexual activity because of neurodevelopmental vulnerability. Associated with autism spectrum disorders, borderline personality disorder. As an experience of dissociative state and depersonalisation. Unemployment, war and poverty are other contributing factors.

• Mental disorder:The mental illnesses which have an increased associated risk of self-injury are depression, dissociative disorders, borderline personality disorder, autism spectrum disorders, bipolar disorder, conduct disorders and phobias. OCD, PTSD, Schizophrenia, Substance abuse, poor problem-solving skills and impulsivity, Münchausen syndrome. Eating disoreds and anxiety disorders.

• Genetics: The rare genetic condition, Lesch–Nyhan syndrome is characterised by self harm which includes biting and head-banging. Genetics is involved in the development of psychological conditions such as anxiety and depression which may contribute to self-injuring behaviour.

• Drugs and alcohol: Self-harm is linked to chronic substance abuse, dependency, and withdrawal.
• Benzodiazepine dependence as well as benzodiazepine withdrawal.
• Alcohol addiction.
• Cannabis use and intentional self-injury.
• Smoking

Differentiating Nonsuicidal self-injury from other Diseases

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Epidemiology and Demographics

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Risk Factors

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Screening

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Natural History, Complications, and Prognosis

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Diagnosis

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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:

• Self-poisoning, self-embedding of objects, hair pulling, burning, alcohol abuse, bruising/hitting one's self,
• Fresh cuts, bruises, scratches, bite marks or other wounds.
• Knowingly abusing over the counter or prescription drugs,
• Scars, often in patterns
• Excessive rubbing of an area to create a burn
• Self-harm related to anorexia and bulimia.
• Frequent reports of accidental injury
• Keeping sharp objects close by or on hand
• Wearing long sleeves or long pants, even in hot weather
• Statements of helplessness, worthlessness or hopelessness
• Emotional and behavioral instability, unpredictability and impulsivity
• Difficulties in interpersonal relationships

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Physical Examination

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Laboratory Findings

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Electrocardiogram

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X-ray

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Echocardiography or Ultrasound

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CT scan

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MRI

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Other Imaging Findings

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Other Diagnostic Studies

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Treatment

Medical Therapy

For 6 kinds of psychotherapy empirical evidence was available:

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.

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.

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.

TFP- 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.

DDP- DDP is a manualized psychodynamic treatment for BPD patients with challenging co-occurring conditions that uses weekly individual sessions to increase clients’ capacity to describe affective and interpersonal experiences in coherent narratives. the frequency of NSSI within the final 3 months of DDP treatment was significantly less than the frequency in the 3 months prior to treatment.

VMT- VMT is an integrated expressive arts therapy that aims to reduce emotion dysregulation and increase self-awareness via sound-making, singing, expressive writing, massage, movement, and drama activities. female young adults engaged in less frequent NSSI while receiving 10 weeks of VMT, compared with during the 10-week pretreatment period.

Psychotherapy for Nonsuicidal Self-Injury Empirical evidence was available for 6 types of psychotherapy: We excluded several studies of well-known, manualized treatments (for example, MBT and SFT) owing to consistent use of operational definitions or outcome measures that failed to clearly differentiate between NSSI and SSI. ERGT

DBT involves a combination of individual and group treatment, in addition to a therapist consultation team and the availability of therapists between sessions for coaching and assistance with effective skill use.55,56 DBT prioritizes reducing life-threatening behaviours, and several studies have demonstrated that DBT leads to greater reductions in NSSI and SSI (considered together), compared with TAU.57–60 We identified several empirical investigations of DBT (including 4 RCTs, 2 non-RCTs, and 10 uncontrolled trials) that distinguished NSSI from SSI in their outcome measures. However, results regarding the efficacy of DBT in treating NSSI have been mixed. Although uncontrolled trials generally suggest that DBT reduces rates, frequency, and urges to engage in NSSI,34,61–66 2 RCTs found that reductions in NSSI frequency were not statistically greater than those achieved in active control conditions.67,68 Conversely, however, 2 other RCTs demonstrated that DBT led to greater reductions in NSSI frequency than TAU.69,70 Regarding NSSI rates, whereas one RCT70 noted greater reductions in rates of NSSI in DBT, compared with TAU, another study did not detect any such differences.69 When reductions in NSSI are achieved during DBT, they are often sustained 6 to 12 months after treatment.67,69,70 Although we identified several uncontrolled studies investigating adaptations of DBT across various populations (for example, adolescents and patients with eating disorders) and settings (for example, inpatient and forensic), RCTs have thus far been limited to predominantly female adult outpatients with BPD. Thus it is unclear at this time whether the promising results achieved in uncontrolled trials of DBT are related to differences in the efficacy of DBT for NSSI across populations, or to differences in research designs, particularly given that controlled studies have used active treatment rather than wait-list control conditions. Investigations regarding potential mediators and moderators of treatment outcome for NSSI may help to clarify these contradictory findings. Currently, the available evidence suggests that while DBT confers considerable benefits in reducing BPD symptoms and associated psychopathology, findings are mixed on whether DBT outperforms active control conditions in the reduction of NSSI specifically.

ERGT is the only other psychotherapy that has been evaluated for its effects on NSSI in more than one controlled trial. Administered in a 14-week group format, ERGT focuses on the development of emotion regulation and acceptance skills, as well as on strategies to identify and pursue important goals and values.71 We identified 2 RCTs indicating that ERGT resulted in significantly greater reductions in NSSI frequency, compared with TAU.71,72 Further, 47% of the patients who received ERGT abstained from NSSI throughout a 9-month follow-up, supporting the durability of treatment effects.72 An uncontrolled ERGT trial also demonstrated significant reductions in NSSI frequency and increased rates of NSSI abstinence from pre- to posttreatment.73 All of the women in these clinical samples had a history of NSSI, and most (74% to 100%) met criteria for BPD.

Investigations of the other 4 psychotherapies reviewed (MACT, VMT, DDP, and TFP) are each limited to a single study; as such, confidence in their findings is contingent on further replication.

MACT is a brief (typically 6 sessions), structured, problem-solving treatment, including individual therapy and bibliotherapy.74 Although MACT has been evaluated in 2 major RCTs,74,75 the outcome measures did not differentiate NSSI from SSI, and thus the studies were not included in our review. However, a smaller RCT indicated a significant advantage of MACT, compared with TAU, in reducing NSSI frequency among female adults with BPD.76

VMT is an integrated expressive arts therapy that aims to reduce emotion dysregulation and increase self-awareness via sound-making, singing, expressive writing, massage, movement, and drama activities.77 An uncontrolled, within-group, time-controlled trial suggested that female young adults engaged in less frequent NSSI while receiving 10 weeks of VMT, compared with during the 10-week pretreatment period.78 The diagnostic characteristics of this sample were not reported.

DDP is a manualized psychodynamic treatment for BPD patients with challenging co-occurring conditions that uses weekly individual sessions to increase clients’ capacity to describe affective and interpersonal experiences in coherent narratives.79 In a small RCT of adults with BPD and cooccurring substance disorders, in which only 7 participants reported engaging in NSSI prior to treatment, 3 (57.1%) reported abstaining from NSSI during the final 3 months of DDP.80 Moreover, among these participants, the frequency of NSSI within the final 3 months of DDP treatment was significantly less than the frequency in the 3 months prior to treatment.80 Unfortunately, comparisons of NSSI-related outcomes in the DDP and the control group were not carried out.

TFP is a psychodynamic treatment involving twice-weekly individual treatment using transference in relationships (therapeutic and other) as a vehicle for therapeutic change.81 Results from one uncontrolled trial of TFP for females with BPD indicated significant pre- to posttreatment reductions in the severity, but not frequency, of NSSI.82 Unfortunately, controlled studies of TFP83,84 did not meet our inclusion criteria, as NSSI was not clearly differentiated from SSI in these trials.

Pharmacotherapy for Nonsuicidal Self-Injury

Empirical evidence regarding psychopharmacological effects on NSSI was available for 5 drug classes: SSRIs (for example, fluoxetine), atypical antipsychotics (for example, aripiprazole and ziprasidone), SNRIs (venlafaxine), opioids (buprenorphine), and opioid antagonists (naltrexone).

Only 1 RCT has evaluated the efficacy of medication for reducing NSSI specifically, demonstrating that, among adults with BPD, more participants abstained from NSSI during treatment with aripiprazole and at the 18-month follow-up, compared with those receiving a placebo.85,86 Specifically, only 2 of the 26 patients engaged in NSSI during 8 weeks of aripiprazole treatment, and 4 engaged in NSSI during the 18-month follow-up (compared with 5 from the placebo group who engaged in NSSI during treatment, and 11 reporting NSSI during follow-up). Similarly, a non-RCT87 found that another atypical antipsychotic (ziprasidone) resulted in lower rates and frequency of NSSI in self-injuring adolescents, compared with alternative neuroleptic medications (for example, risperidone, olanzapine, chlorproxithen, and promethazine).

Regarding nonantipsychotics, a case-controlled, multiple-baseline trial showed that the rates and frequency of NSSI decreased significantly during augmentive naltrexone treatment in adults with BPD, compared with at baseline.88 Several uncontrolled trials have also reported benefits for venlafaxine, buprenorphine, fluoxetine, and naltrexone in reducing NSSI frequency and (or) increasing rates of NSSI abstinence,89–92 but replication with controlled designs is necessary to support these findings.

Combination Treatments for Nonsuicidal Self-Injury Two RCTs have evaluated the incremental benefit of adding CBT to antidepressants (SSRI or SNRI) in treating adolescent major depressive disorder. Both studies concluded that adjunctive CBT did not reduce the likelihood of engaging in NSSI, compared with antidepressants alone,25,93,94 and may even increase risk for engaging in NSSI.93 Regarding the supplementation of CBT-oriented treatment with medication, one RCT evaluating DBT + olanzapine, compared with DBT + placebo, for women with BPD identified no incremental benefit of medication for reducing NSSI frequency.95

Comprehensive Therapeutic Programs for Nonsuicidal Self-Injury Two uncontrolled studies have examined the effects of comprehensive treatment programs for adults with BPD or mixed personality disorders.96,97 These specialized programs included psychoeducation, pharmacotherapy, and group and individual therapy, and both incorporated DBT skills training as a component of treatment. Both studies detected significant reductions in rates of NSSI, postintervention (more than 50% and 17% to 25%, respectively).

Other Interventions for Nonsuicidal Self-Injury Numerous studies have evaluated the effects of treatments that are not formalized as psychotherapy or pharmacotherapy. One recent RCT found that a structured postcard intervention following deliberate self-poisoning significantly reduced suicide-related outcomes; however, it did not reduce the rate or frequency of self-cutting.98 Likewise, one naturalistic follow-up study investigated brief (8 to 15 minutes), biweekly psychiatrist-facilitated assertiveness training sessions aimed at helping patients increase their self-acceptance and ability to calmly express their needs and desires. Among the 13 patients with BPD who were treated, 4 (30.7%) reported no NSSI during the final week following 1 to 4 years of treatment.99 Finally, one naturalistic, uncontrolled study reported that auricular acupuncture was associated with significant decreases in NSSI frequency among 9 depressed adolescents.100 Importantly, however, both of these uncontrolled studies were based on very small samples (n < 15).

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

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Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

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Surgery

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References

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