(p. 328) Assessing and Treating Nonsuicidal Self-Injury
Nonsuicidal self-injury (NSSI) refers to the intentional destruction of one’s body tissue without suicidal intent and for purposes not socially sanctioned. Other terms sometimes used synonymously with NSSI include self-mutilation and deliberate self-harm; however, because the former is often considered pejorative and the latter does not specify nonsuicidal intent, they have come to be used less frequently.
In clinical populations, the most common forms of NSSI are skin cutting, followed by burning and banging/hitting body parts (Klonsky & Muehlenkamp, 2007). Additional methods include needle sticking, interfering with wound healing, scratching, and rubbing against rough surfaces; most self-injurers have utilized more than one method.
However, not all types of self-damaging behaviors are regarded as NSSI. Behaviors associated with substance disorders (e.g., drug and alcohol abuse) and eating disorders (e.g., binging and purging) are not typically regarded as NSSI because the resulting tissue damage is not intentional. Body piercings and tattoos are also not typically regarded as NSSI when they are socially sanctioned forms of artistic or self-expression.
In The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), NSSI appears only once, as a symptom of a larger disorder (i.e., borderline personality disorder [BPD]). But as of the date of this writing, the American Psychiatric Association has proposed that NSSI be classified as its own diagnostic entity in the DSM-5 appendix for future study and consideration (www.DSM5.org, retrieved November 1, 2011). The rationale for this potential change is that NSSI has been documented to frequently occur outside a diagnosis of BPD and to be independently associated with clinically significant distress and impairment. A further aim is to help clinicians better distinguish between NSSI and attempted suicide.
Prevalence, Demographics, and Characteristics
NSSI occurs most often among adolescents. Age of onset is typically between the ages of 12 and 14 years, although NSSI begins after age 18 in about one-third of cases. Whereas approximately 6% of adults report having self-injured at least once (Klonsky, 2011), this rate is higher, about 14%–17%, among adolescents and young adults. This pattern suggests that NSSI has become more common in recent years.
Although it is commonly believed that NSSI is more common among women/girls than men/boys, large studies of community populations do not find gender differences in rates of NSSI. However, there do appear to be gender differences regarding forms of NSSI. Specifically, women more often engaged in (p. 329) skin cutting, whereas men more often engaged in burning and self-hitting. There may also be a relationship between NSSI and ethnicity. In some (but not all studies) Caucasians appear more likely to self-injure than non-Caucasians. Finally, rates of NSSI appear to be disproportionately high among those who identify as bisexual or report being unsure about their sexual orientation.
There is considerable diagnostic heterogeneity among those who self-injure, and the presence of NSSI does not imply the presence of any particular mental disorder. At the same time, two psychological features appear to characterize those who repeatedly engage in the behavior.
1. Negative emotionality. People who self-injure tend to experience more frequent and intense negative emotions—including depression, anxiety, and anger—than noninjurers. Self-injurers also have difficulty being aware of and expressing their emotions. For these individuals, NSSI temporarily alleviates and provides relief from overwhelming negative emotions.
2. Self-criticism (or self-derogation). Studies often find that measures of self-criticism, self-derogation, and low self-esteem are elevated among individuals who engage in NSSI. Slightly more than half of self-injurers report that the act of self-injuring is, in part, an act of self-directed anger or punishment.
Assessment and Treatment
• Understand the motivations. The most common motivation for NSSI is affect regulation (Klonsky, 2007). Typically, episodes of NSSI are preceded by overwhelming negative emotions such as anxiety, anger, depression, and self-derogation, and the performance of NSSI is associated with reduced negative affect and an increased sense of calm and relief. Next to affect regulation, the most commonly reported motivation is self-punishment. Across numerous studies, approximately half of self-injurers endorse reasons such as “to express anger at myself” and “to punish myself.” Less common motivations for NSSI include influencing others, coping with suicidal thoughts, ending episodes of dissociation/derealization, and excitement seeking.
• Ensure good rapport. Although the topic of NSSI can be private and sensitive, psychologists should not shy away from discussing and asking questions about NSSI, particularly given its high and perhaps increasing prevalence. It is important that psychologists manage reactions, such as disgust or disdain, that could damage rapport and client trust. Adopting a stance of “respectful curiosity” may help psychologists inquire about NSSI in a manner that maximizes rapport and client comfort.
• Assess thoroughly. Treatment planning should include thorough and systematic assessment of the NSSI, including the behavior’s onset, frequency, medical severity, motivations, antecedents, consequences, and relation (if any) to suicidal ideation, plans, and attempts. Many valid and comprehensive instruments have been developed to assess the topography of NSSI (e.g., Nock et al., 2007) and motivations for NSSI (e.g., Klonsky & Glenn, 2009).
• Consider the level of care. A key choice that therapists must make is the level of treatment (e.g., outpatient vs. inpatient vs. no treatment with careful monitoring). NSSI confers increased risk for suicidal thoughts and behaviors. In cases where suicidal ideation is severe, inpatient treatment may be warranted to ensure client safety. If suicidal intent is absent or minimal, less aggressive approaches such as outpatient treatment are likely to be most appropriate and therapeutic. Notably, because most of the 14% to17% of adolescents and young adults reporting NSSI have engaged in the behavior only once or twice, some who self-injure may not require formal treatment as long as a parent or guardian can monitor for future instances of NSSI and related psychological distress.
• Treat carefully. There are no research-supported treatments for NSSI yet. However, much has been learned from treatment studies of populations in which NSSI is common. (p. 330) In general, treatments emphasizing functional assessment, problem solving, and emotion regulation appear to be most effective for treating NSSI (Klonsky, Muehlenkamp, Lewis, & Walsh, 2011). Specific approaches that appear to be well suited to the treatment of NSSI include dialectical behavior therapy, motivational interviewing, problem-solving therapy, cognitive-behavioral therapy, and functional assessment.
• Distinguish between NSSI and suicide attempt. It was not uncommon for NSSI to be mistaken for or regarded as a failed suicide attempt. However, NSSI and suicide attempts have different motivations, and NSSI does not typically result in life-threatening tissue damage (Klonsky & Muehlenkamp, 2007; Klonsky et al., 2011). Confusing NSSI for a suicide attempt can have a number of harmful consequences, including inappropriate hospitalization. Involuntary or inappropriate hospitalization can severely damage a client’s ability to trust his or her parents, loved ones, and therapist. Therefore, when NSSI does not result in medically severe tissue damage and is not accompanied by severe suicidal ideation, it is essential to avoid unnecessary and potentially iatrogenic hospitalizations.
• Attend to heightened risk for suicidal behaviors. At the same time, in some studies 50% or more of self-injurers have attempted suicide at least once, and there is increasing evidence that NSSI may be second only to suicidal ideation in conferring risk for a suicide attempt (Klonsky et al., 2011). One interpretation of this relationship is that NSSI confers “double trouble” for suicide risk. Some risk factors, such as depression or hopelessness, only indicate risk for suicidal desire, where as other risk factors, such as fearlessness about death, only increase risk for suicide capability. Because NSSI is associated both with increased negative emotions and habituation to self-inflicted violence, NSSI is relatively unique in that it confers risk both for suicidal thoughts and for acting on those thoughts. In sum, NSSI and attempted suicide are distinguishable phenomena, but NSSI confers heightened risk for suicidal thoughts and behaviors. Therefore, when NSSI is a presenting problem, psychologists should conduct a careful assessment of suicide risk and plan treatment accordingly.
• Avoid misconceptions. It is sometimes assumed that NSSI is a sure sign of BPD, a manifestation of childhood sexual abuse (CSA), or an attempt to manipulate others or get attention. Numerous studies have shown that clinically significant NSSI often occurs outside a diagnosis of BPD. That said, a positive relationship between presence of NSSI and BPD symptoms has been documented in numerous studies. This relationship is probably best understood as being due to the presence of elevated negative emotionality and emotion dysregulation in both conditions. Careful diagnostic assessment is required on a case-by-case basis, as an improper diagnosis of BPD could harm case conceptualization and treatment planning.
Regarding CSA, a meta-analysis of more than 40 studies found that the association between NSSI and CSA is positive but relatively small (Klonsky & Moyer, 2008). Many people who engage in NSSI do not have histories of CSA, and many individuals with histories of CSA do not develop NSSI. Therefore, the evidence views CSA as one potential contributor of NSSI but not as its primary cause. At the same time, for some individuals CSA can contribute to the development of negative emotions and self-criticism that, in turn, can lead to NSSI.
Finally, there are indeed occasions in which NSSI is used for manipulative or attention-seeking purposes, but this is more the exception than the rule. Because NSSI can elicit strong reactions from others, it is easy to assume that the NSSI was performed for the purpose of eliciting such reactions. However, dozens of studies make clear that NSSI is most often a private act performed to cope with overwhelmingly negative and often self-critical emotions. Moreover, many who self-injure experience guilt or shame and concern that others will misunderstand or judge them. (p. 331) Thus, a careful and open-minded approach to assessment and treatment is essential for establishing and maintaining rapport as well as accurate case conceptualization and effective treatment.
References and Readings
Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27, 226–239.Find this resource:
Klonsky, E. D., & Glenn, C. R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the Inventory of Statements About Self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31, 215–219.Find this resource:
Klonsky, E. D., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta-analysis. British Journal of Psychiatry, 192, 166–170.Find this resource:
Klonsky, E. D., & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In Session, 63, 1045–1056.Find this resource:
Klonsky, E. D., Muehlenkamp, J. J., Lewis, S., & Walsh, B. (2011). Non-suicidal self-injury. Cambridge, MA: Hogrefe.Find this resource:
Nock, M. K. (2009). Non-suicidal self-injury: Origins, assessment, and treatment. Washington, DC: American Psychological Association.Find this resource:
Nock, M. K., Holmberg, E. B., Photos, V. I., & Michel, B. D. (2007). Self-injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19, 309–317.Find this resource:
Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72, 885–890.Find this resource: