Non-Suicidal Self-Injury

Non-suicidal self-injury (NSSI) is recognized in DSM-5-TR as a condition for further study, defined as deliberate, self-inflicted destruction of body tissue (cutting, burning, hitting, scratching, severe scratching, biting, head banging) without suicidal intent. Lifetime prevalence is 17-23% in adolescents, 6% in young adults, and 5% in adults, with onset typically in early adolescence (12-14 years). Despite its non-suicidal nature, NSSI is associated with substantially elevated risk of suicide attempts and suicide, requiring serious clinical attention.

Pathogenesis involves emotional regulation deficits (most common function — to escape, reduce, or manage overwhelming negative emotions), self-punishment, anti-dissociation, anti-suicide function, interpersonal communication, sensation seeking, social bonding (peer-related), genetic vulnerability, neurobiological factors (HPA axis dysregulation, opioid system involvement), childhood trauma (especially sexual abuse), invalidating environments, family conflict, and emerging body image concerns. Most common methods include cutting (most common, 65-75%), severe scratching, burning, self-hitting, interfering with wound healing.

Diagnosis includes detailed clinical interview about behaviors (frequency, methods, body locations, severity, triggers, functions), psychiatric assessment for comorbid conditions (depression, anxiety, eating disorders, borderline personality disorder, post-traumatic stress disorder, substance use disorders), trauma history, suicide risk assessment, and family functioning evaluation. Treatment combines evidence-based psychotherapies including dialectical behavior therapy (DBT, gold standard for NSSI especially in BPD), cognitive behavioral therapy (CBT), mentalization-based therapy, family-based therapy for adolescents, interpersonal therapy, and emotion regulation skills training. Pharmacotherapy targets comorbid conditions but no specific medication for NSSI. Hospitalization considered for severe self-injury, suicidal ideation, or treatment failure. Family involvement, school coordination for adolescents, and long-term monitoring are essential. Prognosis improves with comprehensive treatment, but NSSI may persist for years and indicates need for ongoing mental health care.