Nonsuicidal self-injury disorder (NSSID) is a mental disorder that refers to the deliberate destruction of the surface of ones own body without suicidal intent. These behaviors include cutting, burning, scraping skin, hitting, and biting oneself and are primarily inflicted to cause bleeding, bruising, or pain. Individuals engage in these behaviors with no intent to end their life, but instead with the expectation that the injury will cause minor or moderate physical pain. Studies have found that compared to adults and children, the prevalence of NSSI is highest among adolescents, with an estimation of 14 to 15% in community samples, and 40% in psychiatric samples engaging in NSSI. The prevalence of NSSI among adolescents could be due to the heightened emotional reactivity and lability experienced by adolescents during a period of development in which key neurobiological changes are occurring.
The individual with NSSI engages in self injury in an attempt to obtain relief from a negative emotion or cognitive state, to resolve an interpersonal difficulty, and/or to induce a positive feeling state. Individuals may also self injure to punish the self or to gain attention from others. Due to negative reinforcement, NSSI is functional in that regardless of future negative consequences, the pain instilled by the individual effectively interferes with unwanted emotional states at the time. NSSI may also occur as a symptom of a pre-existing disorder. Specific psychiatric disorders such as borderline personality disorder, dissociation and dissociative disorders, eating disorders, major depressive disorder, and alcohol dependence have been associated with higher rates and risk to self injury.
The relationship between NSSI and suicide is complex. Studies have shown that there is a strong correlation between self injury and suicide indicating that as much as 40% of individuals have suicidal thoughts while self injuring and about 50-80% of people who self injure have attempted suicide at some point in their lifetime. Unlike those that engage in nonsuicidal self injury, those that attempt suicide through self injury have longer histories of self injury and experiment with more methods of self injury. Those exhibiting suicidal behavior differ from those who engage in self injury in their level of intent, method, and psychological impact. However, it is important to look for signs of worsening self injury and be able to identify when it becomes a risk for suicide. Clinically speaking, it is important that a physician understand their patient's outlook on suicide and remaining alive in order to identify when NSSI is a potential risk for suicidal behavior.
Treatment for NSSI is hard to identify in that the positive and negative reinforcement experienced by individuals with NSSI disorder makes successful management of self injury challenging. Nonetheless, treatment plans do exist, including pharmacologic treatment and psychosocial interventions. Studies researching pharmacologic treatment have shown that distributing naltrexone to participants engaged in self injury resulted in complete abstinence from self injury. In regards to psychosocial interventions there are a multitude of approaches to treatment such as psychodynamic psychotherapies and cognitive-behavioral psychotherapies. Across all research studies investigating the effectiveness of treatment for self injury, consistent contact with a therapist has been found to be the most helpful tool in overcoming NSSI.
Video Nonsuicidal self-injury disorder
Signs and Symptoms
Nonsuicidal Self Injury Disorder may be characterized by the following signs and symptoms:
- Intentional self-inflicted damage to the surface of one's body in the past year for 5 or more days, likely to cause bleeding, bruising, or pain
- Cutting, burning, stabbing, hitting, and excessive rubbing on the surface of the body with no suicidal intent
- Performed with the expectancy of retrieving relief from a negative feeling or cognitive state, to resolve an interpersonal difficulty, or to induce a positive feeling state
- Interpersonal difficulties or negative thoughts or feelings such as anxiety, depression, tension, anger, generalized distress, or self-criticism occurring immediately prior to self injuring
- A period of preoccupation with the intended behavior that is difficult to control prior to engaging in the self injury
- Thoughts about self injury that occur frequently
- The behavior causes distress or interference with academic, interpersonal, or other areas of daily life
- The behavior is not specific to psychotic episodes, intoxication, or delirium
The most distinguishing symptoms of NSSI are damage to the surface of the body by cutting, burning, hitting, punching, picking, or rubbing that inflict pain, but are performed with no suicidal intent. Overall people with NSSI use self injury to reduce negative emotions, such as tension, anxiety, and self-reproach and/or to resolve an interpersonal conflict.
Maps Nonsuicidal self-injury disorder
Functions of NSSI
A functional approach to NSSI indicates that the behavior is engaged and maintained by multiple reinforcement processes, such as:
- intrapersonal negative reinforcement: NSSI decreases or distracts from aversive thoughts or feelings
- intrapersonal positive reinforcement: Desired feelings or stimulation are acquired through NSSI
- interpersonal positive reinforcement: A help seeking behavior conducted by NSSI
- interpersonal negative reinforcement: Escape from undesired social situations is facilitated by NSSI
Individuals who engage in NSSI mainly report doing so to calm themselves down, to punish themselves, or to receive attention from others. A study by Glenn and Klonsky found that affect regulation (calming oneself down) was the most common function of NSSI, endorsed by 98% of the sample participants as either somewhat relevant or very relevant to the experience of NSSI. Other frequently used functions were marking distress (making it evident to others that the individual is struggling), upheld by 89% of the sample, self punishment (punishing oneself) endorsed by 88% of the sample, and anti-dissociation (causing pain to relieve the feeling of numbness), endorsed by 88% of the sample.
Positive reinforcement might occur from punishing oneself in a manner that the individual feels is deserved. In this case the behavior induces a pleasant or relaxed state, generates attention from others, or expresses anger in a clearly visible and intense way.
Negative reinforcement on the other hand is used to regulate affect and reduce unpleasant emotions and avoid distressing thoughts (such as suicide).
Self punishment is engaged in when the individual feels that they did something to deserve the self injury. Individuals that engage in NSSI for this reason mainly do it to make up for acts that may have caused distress or harm to others.
Why Use NSSI to Serve These Functions?
There are many non-injurious ways to combat negative affect or to gain attention, so why is it that some individuals decide to engage in NSSI and others do not? Empirical research has led to multiple different hypothesized processes that would lead an individual to engage in NSSI to serve these functions.
Social Learning Hypothesis
Observing others engage in self injury influences the likelihood that an individual will also engage in NSSI. Most self injurers learn about the behavior from friends, family, and the media. Over the past decade, references to NSSI have begun to appear more frequently in movies, music, print media, and the internet. This could explain the increase in prevalence of NSSI over the same time period.
Self Punishment Hypothesis
NSSI may also be motivated by self punishment and self-depreciation. Repeated criticism or abuse by others may cause individuals to interpret their behaviors and adopt them to as self-directed abuse in the form of NSSI. Evidence showing that those who have suffered childhood abuse are likely to engage in NSSI, which supports this hypothesis in that the abuse is then adapted as self-criticism later on in adolescence.
Social Signaling Hypothesis
Individuals may use NSSI as a communication method because it elicits more attention than just verbal communication. Because NSSI is harmful and costly it is more likely to be believed by others as some sort of intent to communicate felt issues. Compares to low intensity cost behaviors, high intensity or high cost behaviors are more likely to gain desired responses from others. If other communication efforts have failed due to low quality or clarity in the past the individual may be more likely to engage in NSSI since less costly behaviors have not produced the desired effect because of an unresponsive or invalidating environment in the past.
Pain Analgesia/Opiate Hypothesis
Others may be resistant to engaging in NSSI due to the pure fact that it is painful and they do not have the tolerance for it. However, self injurers report little or no pain during NSSI and lab tests of pain tolerance have shown pain analgesia in individuals who engage in NSSI. It is unclear whether analgesia could be due to elevated levels of endorphins in the body, habituation to pain as a result to childhood abuse, or is a result of the release of endogenous opiates resulting from repeated NSSI.
Implicit Identification Hypothesis
Individuals who have performed NSSI before may come to identify with its methods and its effectiveness for completing the respective function. This identification may be incentive to continue engaging in NSSI over other forms of relief. For example, a runner may run to de-stress instead of smoking a cigarette because they identify themself as a runner and not a smoker. The same type of identification occurs with those who exhibit NSSI.
Psychiatric Disorders and Self Injury
Prior to its classification in the DSM 5 as a condition requiring further study, NSSI has been continuously listed as a criterion for other psychiatric disorders. Although NSSI is most commonly associated as a symptom of borderline personality disorder (BPD), NSSI is not unique to BPD. NSSI is also related to dissociative disorders as well as many Axis I disorders including major depressive disorder, anxiety disorders, substance abuse disorders, and eating disorders.
Borderline Personality Disorder
NSSI is one of the nine criterion for individuals with BPD. Individuals suffering from BPD have been found to experience intense states of aversive tension and negative emotions. NSSI is used as a dysfunctional coping strategy to regulate these states and provide relief from negative emotions. Approximately 70-75% of individuals with BPD engage in self injury. Motives for engaging in NSSI for BPD patients include self punishment, feeling physical pain, reducing anxiety, controlling others, distraction, and emotion generation. Individuals with BPD also experience dissociative states such as derealization and depersonalization, and have reported ending dissociative states as an additional motive fore engaging in NSSI.
Dissociative Disorders
Individuals experiencing dissociation have the perception of being disengaged from the real world psychologically and in some cases physically. Research has found that approximately 69% of people with dissociative disorders have a history of engaging in self injury.
Major Depressive Disorder (MDD)
MDD is a medical condition that includes abnormalities of affect or mood, loss of sleep and appetite, and feelings of worthlessness and hopelessness. The relationship between depression and self injury is unclear. Although some studies indicate that those who have engaged in NSSI before are more likely to experience depression and symptoms of depression, other findings have failed to find any correlation between self injury and MDD. However specific symptoms of depression have been found in NSSI such as a negative cognitive schema, suicidal ideation, lower self-worth, and dysphoria.
Anxiety Disorders
Anxiety plays a major role in NSSI. Anxiety causes individuals to look for tension reducing behaviors which consequentially manifest as self injury. Studies have found increased levels of anxiety in individuals who self injure. In a study by Brain, Haines, and Williams (1995) found that self-injuring individuals had decreases in heart rate, respiration, and skin conductancy level in response to self-harm imagery scripts. Another study by Andover et al. (2005) found that individuals with a history of self-mutilation were more likely to report feelings of anxiety than those with no history of self-harm.
Substance Abuse Disorders
Similarly to substance abuse, self injury is argued to be an addictive behavior in that it is "relieving" and "coercive". In a sample of general psychiatric outpatients substance abuse was directly related to NSSI without pre-existing disorders such as BPD and antisocial personality disorder.
Eating Disorders
Eating disorders include bulimia nervosa, anorexia nervosa binge purge subtype, and anorexia nervosa restricting subtype. Research has found that those with eating disorders are somewhat inclined to engage in self injury. Prevalence studies have shown that those diagnosed with bulimia nervosa have rates of self injury ranging from 27% to 55%, 27% to 61% for those diagnosed with anorexia nervosa binge-purge subtype, and 13% to 42% for those with anorexia nervosa restricting subtype. The prevalence of self injury among individuals with eating disorders may be attributed to their shared similar correlate that result in risk for the behavior.
NSSI and Suicide
Although NSSI and suicidal ideations or attempts have two very distinct classifications, they have been found to be significantly related. According to Turner et al. between 55% and 85% of individuals that engage in NSSI also have suicidal thoughts. Furthermore, higher frequencies of NSSI behaviors have been related to an increased risk of suicide attempts. There is a potential morbidity that can be found for those that engage in NSSI as well as suicide attempts such as childhood sexual abuse, depression, interpersonal or family conflict, isolation or loneliness, impulsivity, borderline personality disorder, and psychiatric illness.
Treatment of NSSI Disorder
To date the standard treatment approach for NSSI disorder has been hospitalization, but this treatment method is expensive and has not been found to reveal effective outcomes. Furthermore, many that engage in NSSI are unlikely to be admitted because they do not express the intent to die. Because non-suicidal self-injury is mainly categorized as a tool for emotion regulation and is considered a behavior mainly maintained through positive and negative reinforcements (as well as self punishment), treatments using cognitive-behavioral therapy (CBT) show the most effectiveness in reducing NSSI behaviors. Two types of treatments using cognitive behavioral therapy that focus specifically on NSSI are Problem-Solving Therapy and Dialectical Behavior Therapy. These treatments share commonalities including being time-limited, and a focus on immediately targeting NSSI and improving skills. Other treatments for NSSI disorder include Emotion-Regulation Group Therapy, Voice Movement Therapy, and Transference Focused Psychotherapy. Although relatively limited information exists on Pharmacotherapy for NSSI, empirical evidence has been found for 5 different drug classes: SSRI's, atypical antipsychotics, SNRI's, opioids, and opioid antagonists.
Problem-Solving Therapy (PST)
Individuals that engage in NSSI lack strong problem-solving skills and therefore rely on self injury as a way of coping. The main goal surrounding the use of PST in patients engaging in NSSI is to help the client identify and resolve the problems they face in their lives as well as teach them coping and problem-solving skills they can use in the future to effectively deal with their problems. This goal is usually obtained by teaching the client how to use a step-by-step process to solve life's problems. The process can be broken down into two parts: 1) using a problem-solving orientation in life and 2) using rational problem-solving skills.
Applying a problem solving orientation usually means:
- looking at problems as challenges
- understanding that the problems can be solved
- realizing that time and effort are required for effective problem solving
Rational problem-solving skills include:
- problem identification as it occurs
- defining a problem
- attempting to understand the problem
- setting problem related goals
- brainstorming and assessing possible solutions
- selecting and implementing the best solution
- evaluating the success of the chosen solution
PST normally involves oral as well as written presentation of the steps by the therapist, plus guided practice both in sessions and as homework. It is recommended that clients receive 8-16 sessions of 1.5-2 hours each.
A variety of studies found potential for PST to significantly reduce NSSI. They found that the PST's that incorporated additional cognitive, interpersonal, or behavioral elements into the standard problem-solving protocol showed greater promise for long-term efficacy in reducing NSSI. Overall, PST can show signs of effectively reducing NSSI when combined with other CBT skills.
Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT) was first developed to treat those with borderline personality disorder, for which NSSI is a common symptom. DBT combines therapeutic elements from Zen Buddhism, problem-solving, cognitive-behavioral interventions, and skills training. The application of DBT consists of a balance between encouraging the client to change and accept him or herself simultaneously. DBT aims to reduce NSSI behavior by helping clients with a variety of goals, such as:
- Develop new coping skill sets
- Confront motivational obstacles during treatment
- Generalize skills learned outside the therapy setting
A hierarchical stage model that provides a guiding structure to the behavioral therapy is used to help the client gradually master the skills needed to improve. This is done through a number of platforms including individual therapy, group skills training, phone coaching, and supervision as well as consultation for the counselor. There are three stages in total focused on reducing NSSI behaviors, processing traumatic experiences, and emphasizing the importance of maintaining self-respect.
Pretreatment: Pre-treatment consists of orienting the client to the therapy process and receiving a confirmation of agreement to therapy.
Stage 1: Focuses on reducing NSSI behaviors, maintaining therapy compliance from the client, and reducing distress related to Axis I disorders. Strategies used to encourage the fulfillment of these goals include:
- Validating the clients experiences
- "Problem solving techniques, including behavioral analysis of the NSSI as well as teaching of adaptive coping skills"
- "Behavioral skills training in mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance"
- "Contingency management strategies"
Stage 2: Addresses mechanisms for dealing with traumatic experiences as well as invalidating environments.
Stage 3: Encourages the patient to develop and maintain self-respect while trying to master the skills learned.
According to Muehlenkamp four randomized clinical trials as well as a number of other studies have proved DBT to be an effective treatment for NSSI. Each of the clinical trials showed a high rate in reductions of self-harming behavior using DBT compared to treatment-as-usual controls for up to 6 months post treatment. DBT was also found to be more effective in reducing suicide attempts. DBT has been used in multiple different settings including both inpatient and partial hospitalization programs and has been found to be effective at reducing NSSI behavior in both. DBT is normally recommended as a year long treatment for the initial stage of skill development and control of NSSI behavior, however the main effects of the treatment occur during the first four months. The other eight months are seen as a period of skill consolidation. A study by Stanley et al. researched the effectiveness of Brief Dialectical Behavior Therapy, a shorter course of DBT only lasting six months. The participants were twenty patients with borderline personality disorder who received six months of DBT in the standard manner except for the shorter duration of time. All variables were measured at baseline and then again at six months. Results revealed a 95% retention rate and significant reductions in NSSI urges, engagement in NSSI, and suicidal ideation, distress, and hopelessness. Overall, the use of DBT has been found to be extremely effective in reducing or even eliminating NSSI engagement.
Emotion-Regulation Group Therapy (ERGT)
ERGT is a 14-week group therapy program that focuses on the development of emotion regulation and acceptance skills, as well as strategies to identify and pursue certain goals. A review by... found that ERGT was extremely effective in reducing NSSI behavior compared to that of TAU. Of the participants involved in the study, 47% abstained from NSSI throughout a 9-month follow-up.
Voice Movement Therapy (VMT)
VMT is an expressive arts therapy that combines the act of sound making, singing, expressive writing, massage, movement, and drama activities to reduce emotion dysregulation and increase self-awareness. There are not many studies that have investigated this treatment thus far, but it has been implemented in various settings such as partial hospitalization programs, inpatient hospital programs as well as other centers.
References
Source of the article : Wikipedia