Nonsuicidal Self-Injury DSM-5

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DSM-5 Category: Conditions for Further Study

Introduction

Nonsuicidal self-injury (NSSI) refers to any premeditated, self-directed actions that leads to direct damage of body tissues (Kerr, Muehlenkamp, & Turner, 2010)This action is often marked in an array of ways, like hitting or punching an object to inflict injury to self, cutting, extreme scratching, skin carving, and interference with wound healing and burning. NSSI may even entail even more destructive actions like breaking bone, injury to limbs, eye injury or auto-amputation. It is frequently linked to multiple of probable health issues, both physical and psychiatric and can occasionally result in more severe medical complications.

NSSI is normally used by individuals to handle worrying negative affective emotional states, in particular anger and depression, as well as mixed forms (Kerr, Muehlenkamp, & Turner, 2010). Empirical research indicates a growing inclination toward an increasing prevalence of self-injury, particularly with teenagers and young adults (In-Albon, Ruf, & Schmid, 2013).

In the past, NSSI was seen as part of borderline personality disorder (BPD), but recent research has linked NSSI to numerous psychological issues including anxiety, depression, suicidality, as well as a plethora of personality disorders (In-Albon, Ruf, & Schmid, 2013). As a result, NSSI can be seen as a big public health issue on its own. It is for this reason that the American Psychiatric Association’s DSM-5 Child and Adolescent Disorders Workgroup pushed for the classification of NSSI with its own diagnostic criteria (In-Albon, Ruf, & Schmid, 2013).

Symptoms of Nonsuicidal Self-Injury

According to DSM-5, NSSI diagnostic criteria are as follows (American Psychiatric Association, 2013):

Over the past year, the person has for at least 5 days engaged in self-injury, with the anticipation that the injury will result in some bodily harm. No suicidal intent.

  • The act is not socially acceptable.
  • The act or its consequence can cause significant distress to the individual’s daily life.
  • The act is not taking place during psychotic episodes, delirium, substance intoxication, or substance withdrawal. It also cannot be explained by another medical condition.
  • The individual engages in self-injury expecting to
  • Get relief from a negative emotion
  • To deal with a personal issue
  • To create a positive feeling
The self-injury is associated with one of the following:
  • The individual experienced negative feelings right before committing the act.
  • Right before self-injury, the individual was preoccupied with the planned act
  • The individual thinks a lot about self-injury even if act does not take place.

Epidemiology

NSSI has a prevalence rate of about 1 to 4 percent in the adult population in the United States (Kerr, Muehlenkamp, & Turner, 2010) Furthermore the extremely severe form of self-injury is seen in about 1 percent of the population (Kerr, Muehlenkamp, & Turner, 2010). Though some research has indicated a lifetime prevalence of NSSI being as high as 5.9 percent and an increased 2.7 percent that have self injured greater than five times (Klonsky, 2011). NSSI is more common among teenagers, with a reported 15 percent admitting to some type of self-injury (Kerr, Muehlenkamp, & Turner, 2010). Furthermore, there is a greater risk for NSSI among college students when compared to the general population, where rates range from 17 to 35 percent. Males and females have comparable NSSI rates, even though men more often report using burning and hitting methods, while women report using cutting and burning methods. Cutting is the most common form of NSSI, where as much as 70 percent of NSSI patients, state that they have used the cutting form in the past.

Psychiatric Disorders

There is an increased rate of self-injury among the psychiatric populations, where about 2 to 20 percent reportedly engaged in NSSI (Kerr, Muehlenkamp, & Turner, 2010). This is especially seen among teen psychiatric patients, with high prevalence rates of about 40 to 80 percent. Certain psychiatric disorders are noted for having greater rates of self-injury. These include Borderline personality disorder (BPD), dissociative disorders, eating disorders and major depressive disorders.

BPD highlights a very high prevalence rate of individuals who commit self-injury, ranging from about 70 to 75 percent (Kerr, Muehlenkamp, & Turner, 2010). Self-injury is noted to be one of the criteria for establishing a diagnosis of BPD. Much evidence from research indicates that it is used by BPD patients to experience great relief from horrible emotions. NSSI is also seen highly in dissociative disorders where as much as 69 percent are indicated to have exhibited some self-injury.

Individuals with eating disorders tend to engage in NSSI. Research reports prevalence rates of about 26 to 55 percent for individuals that are diagnoses with bulimia nervosa, while much higher for those with anoxeria nervosa binge-purge type, about 27 to 61 percent (Kerr, Muehlenkamp, & Turner, 2010).

There appears to be some association between individuals who commit NSSI and major depressive disorder. While data in this area is lacking, research has shown that 42 percent of a particular self-injuring sample met the criteria for major depressive disorder (Kerr, Muehlenkamp, & Turner, 2010).

Suicidal Behavior

Evidence indicates a strong association that exists between suicidality and self-injury. Research states that as high as 40 percent of those NSSI patients have dealt with suicidal thoughts while inflicting the injury. Additionally as high as about 50 to 85 percent of NSSI patients have a previous history of at least one suicidal attempt. The association also indicates that as the type of self-injury increases, the severity of suicide also increases.

Many NSSI patients use at least 2 different ways to perform self-injury, as high as 69 percent. One should also pay close attention regarding when NSSI greatly increases the risk for suicide. While much concrete data has not been performed concerning this, it is important to gauge how the patient perceives suicide, and life, since this can indicate when self-injury increases the risk for suicidality (Kerr, Muehlenkamp, & Turner, 2010).

Course and Outcome

Research shows that the normal age of onset for NSSI is 14 and 24 years of age, with an increase among those between 12 to 14 and those who are 18 to 19 years of age. Over a long period of time, BPD patients tend to have decreased prevalence rates of NSSI, from 80 percent to 28 percent, over a 6 year time span. This was also seen with other personality disorders, where incidence rates decreased from 16.7 to 1.6 percent.

Treatment for Nonsuicidal Self-Injury

While psychotherapy is the first line of treatment, medications are needed, especially to treat co-morbid psychiatric issues, such as BPD, depression and anxiety (Washburn, Gebhardt, Styer, Juzwin, & Gottlieb, 2012). Problem solving therapy which aims to provide good coping mechanisms assists individuals with depression who commit self-injury (Washburn, Gebhardt, Styer, Juzwin, & Gottlieb, 2012). Other forms of therapy include cognitive behavioral therapy (CBT), group and residential placement (Washburn, Gebhardt, Styer, Juzwin, & Gottlieb, 2012). Since people looking for treatment for NSSI tends to also have a co-occurring disorder, it is important to also target a joint treatment that addresses both conditions and not just NSSI solely.

CBT assists in recognizing any negative ideologies and substituting them with healthy, constructive ones (Mayo Clinic, 2012).

Dialectical behavior therapy (DBT), a form of CBT, provides behavioral skills and teaches good coping mechanisms on how to handle emotions and help with relationships with others (Mayo Clinic, 2012).

Psychodynamic psychotherapy, looks at any personal issues from the past, and tries to guide the patient through emotional struggles that may be lingering. Mindfulness-based therapies, offers the NSSI patient the tool to exist in the present, to properly distinguish the thoughts and behaviors of others, which helps in decreasing anxiety levels, and improving depressed states (Mayo Clinic, 2012).

In cases were severe NSSI occurs some inpatient hospitalization may be needed in order to stabilize the patient, and provide a secure environment.

References

American Psychiatric Association. (2013). Nonsuicidal Self-injury. In Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition ed.). Washington, DC: American Psychiatric Publishing Inc.

In-Albon, T., Ruf, C., & Schmid, M. (2013). Proposed Diagnostic Criteria for the DSM-5 of Nonsuicidal Self-Injury in Female Adolescents: Diagnostic and Clinical Correlates. Psychiatry Journal, 2013. doi:10.1155/2013/159208

Kerr, P., Muehlenkamp, J., & Turner, J. (2010, March-April). Nonsuicidal Self-Injury: A Review of Current Research for Family Medicine and Primary Care Physicians. 23(2), 240-259. doi:10.3122/jabfm.2010.02.090110

Klonsky, E. (2011). Non-suicidal self-injury in United States adults:prevalence, sociodemographics, topography and functions. Psychological Medicine, 41(9), 1-6. doi:10.1017/S0033291710002497

Mayo Clinic. (2012, December 6). Self-injury/cutting. Retrieved March 14, 2014, from Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/self-injury/basics/treatment/con-20025897

Washburn, J., Gebhardt, M., Styer, D., Juzwin, K., & Gottlieb, L. (2012). Co-Occurring Disorders in the Treatment of Nonsuicidal Self-Injury: An Evidence-Informed Approach. Journal of Cognitive Psychotherapy: An International Quarterly, 26(4), 349-364. Retrieved March 14, 2014


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