What is Nonsuicidal Self-Injury?

The International Society for the Study of Self-Injury defines non-suicidal self-injury as the deliberate, self-inflicted damage of body tissue without suicidal intent and for purposes not socially or culturally sanctioned.

This definition has several important parts:

  1. First, the harm that results from self-injury is an intentional or expected consequence of the behavior. Risky behaviors that could result in harm, such as not wearing a seatbelt while driving, or accidental harm, that may occur when playing extreme sports, are typically excluded in our definition.
  2. Second, self-injury usually results in some sort of immediate physical injury, including cuts, bruises, scratches, or marks on the skin. Behaviors that do not directly result in injuries are usually excluded, even though they may be harmful or dangerous. For instance, food restriction is typically not considered a form of self-injury since the associated physical damage tends to build up over time instead of happening all at once when the behavior occurs.
  3. Third, self-injury is separate from suicidal thoughts or behaviors, in which individuals want to end their lives. People usually report that they have no expectation or intention to cause death when they engage in self-injury. In fact, in some cases, self-injury may be used to manage intense distress that may associate with suicidal thinking 1.
  4. Finally, behaviors that might cause physical damage but are acceptable in our society, or part of a recognized cultural, spiritual or religious ritual, are not considered self-injury. For this reason, body modification, body piercing or tattooing are not usually considered forms of self-injury.

Non-suicidal self-injury (NSSI) is often used interchangeably with self-injury, though it is important to bear in mind that self-injury may carry lethal and non-lethal intent. Sometimes, NSSI is also referred to deliberate self-harm; however, this term is typically much broader in scope and encompasses any self-inflicted injury, regardless of intent. Though less frequent, NSSI is sometimes referred to by focusing on particular methods (e.g., self-cutting). While cutting is among the most widely recognized forms of self-injury, the behavior can take many other forms, including burning, hitting, or scratching oneself. Furthermore, many people who self-injure report using more than method during their lives 2 3.

 

Want to cite this definition? Our recommended format is:

International Society for the Study of Self-injury. (2018, May). What is self-injury? Retrieved from: https://itriples.org/about-self-injury/what-is-self-injury.

Who Engages in Nonsuicidal Self-Injury?

People of all ages, genders, ethnicities, and social classes self-injure. Research has shown that self-injury is most common in adolescence and young adulthood, with about 17-18% of young people reporting that they have engaged in self-injury at least once in their lives 4, 2. Current research suggests that self-injury most commonly begins between ages 12 and 15, although some people first start to self-injure before the age of 12 and some first self-injure much later in life; an age of onset before 12 is associated with more severe self-injury over a longer period of time [6]3. Typically rates of self-injury increase through early-mid adolescence and decline in later adolescence 4. However, recent research suggests a second peak in age of onset at around 20 years 5. A recent meta-analytic review showed that girls and women are slightly more likely to self-injure than boys and men, with this gender difference particularly evident in clinical samples.  6 Self-injury is more common among people who experience mental health challenges such as depression, anxiety, and eating or substance problems 7 8 9. However, not everyone who engages in self-injury has a mental disorder; some studies show about 15-20% of adolescents who engage in self-injury do not meet criteria for any disorder. 10 11 People who engage in self-injury report being more sensitive to interpersonal stress or conflict, and more difficulty expressing and regulating their emotions 12 13 14. Self-injury is also more common among adolescents and young adults who identify as bisexual or transgender 15 16

Why Do People Engage in Nonsuicidal Self-Injury?

People engage in self-injury for many different reasons. One of the most commonly reported reasons is to cope with negative emotions, such as sadness or anger, or negative thoughts, such as self-criticism 17. Some people also use self-injury as a way to punish themselves, to gain a sense of control, to communicate their pain, to reconnect with themselves or others, or to alleviate numbness 2. Most people report that they engage in self-injury for multiple reasons 3 , and these reasons can change over time 4.

How Does Nonsuicidal Self-Injury Affect People?

Self-injury can have varied short- and long-term impacts on individuals, as well as their friends, partners, and families 5. In the short-term, many people report that they feel a sense of calm or relief right after they engage in self-injury. 2 However, some people also feel guilty or ashamed of this behavior and may worry that others will judge them if they found out about the self-injury. Understandably, this, can contribute to feelings of anxiety, shame, and isolation. Furthermore, such feelings can make it hard to reach out for help.

 

Over the long-term, people who engage in self-injury may report worsening depression or anxiety, physical consequences such as scarring, and difficulties in their close relationships. 3 45 Parents and caregivers, teachers, and mental health professionals often feel frightened or confused when they find out a young person is engaging in self-injury.6 7 Although self-injury is often associated with emotional and social strain, some studies show that the process of addressing, and healing from, self-injury can bring some relationships closer and enhance self-understanding, especially when the person feels well-supported. 8 9


The relationship between self-injury and suicidal behaviors is complex. While most acts of self-injury are not accompanied by suicidal thoughts, evidence suggests people who have self-injured are more likely to attempt suicide than those who have never self-injured. 10 Importantly, engaging in self-injury is associated with two important risk-factors for suicide: the experience of emotional distress, and the experience of inflicting pain and injury on oneself 11. The experience of inflicting pain can reduce the inhibition to suicide if someone is thinking about ending their life. In short, although self-injury is not a suicide attempt, the presence of self-injury may indicate someone is thinking about suicide or may do so in the future. As such, self-injury should be considered as an important risk-factor for suicidal thoughts and behaviors 12

Is ‘Self-injury’ an Official Diagnosis?

As of 2018, there is no official diagnosis for non-suicidal self-injury. In 2013, however, the American Psychiatric Association published the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), which included Non-Suicidal Self-Injury Disorder as a condition for further study [28]. ISSS was consulted on the development of proposed criteria for this disorder, and ISSS members continue to be involved in research to study and improve the reliability and validity of these diagnostic criteria.

Are there Treatments for Self-Injury?

Until recently, few treatments were developed specifically for self-injury. Although there is currently no “gold-standard” treatment for self-injury, several treatments show promise in helping people decrease or stop these behaviors.

Dialectical Behavior Therapy (DBT) is one of the most well-known treatments for people engaging in self-injury. DBT is a psychotherapeutic treatment designed to treat Borderline Personality Disorder, of which non-suicidal self-injury is a common symptom [28]. DBT integrates behavioral strategies (e.g., behavior analysis, problem-solving strategies, skills training in emotion regulation and interpersonal effectiveness, contingency management) with mindfulness (e.g., nonjudgmental, present-focused attention), and dialectical strategies (e.g., balancing acceptance and change) [30]. DBT addresses self-injury by targeting instability in one’s emotions and sense of self, as well as increasing control over one’s behavior. DBT is an intensive treatment, which typically involves weekly individual therapy and group-based skills training, as well as coaching between sessions, for one to two years.

Several well-designed studies have shown DBT to be effective in treating borderline personality disorder, including reducing non-suicidal self-injury [29, 31,32]. It is important to note, however, that some research shows that DBT is not superior to other treatments in reducing self-injury [33]. Further, DBT is designed to treat self-injury in the context of Borderline Personality Disorder; it is not clear how effective DBT may be for treating self-injury among individuals who do not have Borderline Personality Disorder.

 

Emotion Regulation Group Therapy (ERGT) is another treatment that was designed for people with Borderline Personality Disorder; however, unlike DBT, ERGT is intended specifically to treat non-suicidal self-injury [34]. ERGT was intended as a briefer alternative to DBT that includes 14 weeks of group-based psychotherapy integrating components of DBT and Acceptance and Commitment Therapy. Further, ERGT was designed as an adjunctive treatment, meaning it is best used in conjunction with, rather than instead of, other types of treatment (such as individual psychotherapy). ERGT specifically addresses emotion dysregulation and the use of self-injury to manage emotions by increasing emotional awareness, understanding, and acceptance, facilitating goal-directed behaviors, inhibiting impulsive behaviors in response to negative emotions, modulating emotional intensity and duration, and tolerating and experiencing negative emotions.

Several well-designed studies have shown that ERGT is effective in reducing self-injury in adult women with Borderline Personality Disorder [34-35]. A recent feasibility study also suggests that ERGT may be effective in adolescent girls engaging in non-suicidal self-injury [36]. Importantly, research on ERGT has been limited to studies on women; more research is needed to determine whether ERGT is equally effective for men.

Treatment for Self-Injurious Behaviors (T-SIB) is a brief (9 session) intervention conducted during weekly individual therapy designed for young adults engaging in non-suicidal self-injury [37]. T-SIB is a behavioral intervention which uses motivational enhancement strategies, functional analysis, and skills training for problem-solving, distress tolerance, cognitive distortions, and interpersonal communication to address self-injury. An initial pilot study of T-SIB found decreased self-injury over the course of treatment [38]; however, further research is needed to see if T-SIB will be effective in other groups of people and to compare T-SIB to other treatments that address self-injury.