In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is nonsuicidal self-injury.
Nonsuicidal self-injury (NSSI) is a fancy way of saying self-harm behaviour that differentiates it from suicidality. Cutting and burning are the most common methods, but there are a variety of other methods people use, including scratching, burning, and hitting.
Demographics
The onset of NSSI on average is between ages 11 and 15, and it tends to be more severe and prolonged if it starts when people are under 12 years old. About 15-20% of adolescents self-injure at some point. It’s difficult to say if this has changed over time because it just hasn’t been studied for all that long, so there isn’t historical data. There’s some indication that there’s an element of contagion in the spread of NSSI through populations, but it’s unclear what might be driving that process.
A common misconception is that self-injury is a female thing, but NSSI is only slightly more common in females than males. Females tend to start younger and self-injure longer. In terms of method, females are more likely to cut, while males are more likely to punch/hit or burn themselves. There’s an elevated risk in transgender and bisexual youth and young adults. Being homosexual doesn’t appear to have a large impact on risk, but the elevated risk among bisexuals has been consistently demonstrated, although the reason is unclear.
Psychological factors and mental illness
People who self-injure tend to be more sensitive to interpersonal stress/conflict and have difficulties with emotion regulation. Self-directing negative emotions and self-criticism can make people more susceptible.
Self-injury often occurs alongside other mental disorders, including borderline personality disorder, eating disorders, substance use disorders, PTSD, depression, and anxiety disorders. Around 15-20% of adolescents who engage in NSSI don’t have any diagnosable mental disorder.
Motivators for self-injury
There can be many reasons behind self-injury. It’s often a means of relieving inner emotional pain, but it can also be a way of creating physical pain to counteract inner numbness. It can be a way of channelling anger at the self or self-punishment.
It’s sometimes used for interpersonal reasons, such as conveying a message to others, but that’s much less common.
Suicide risk
Suicide isn’t typically on people’s minds while self-injuring, but they are at increased risk of suicide overall, and often have comorbid conditions that also increase their risk. Specifically with NSSI, there appears to be an increase in the risk of suicidality up until around 50 lifetime self-injury episodes, at which point the risk levels off and then starts to drop closer to population norms. When people with a history of NSSI are suicidal, there may be less reluctance to try more lethal methods because of previous self-injury.
Self-injury as quasi-addiction?
NSSI doesn’t currently have a diagnosis attached to it, although it’s been included in the DSM-5 as a proposed disorder to be studied for future inclusion. While it’s not classified as an addiction, it does have addictive elements to it. Self-injury stimulates the release of endogenous opioids. Tolerance can develop to this, so a greater degree of injury is needed to produce the same opioid release.
Treatment involves addressing any co-occurring disorders. Naltrexone (which blocks the action of endogenous opioids) or atypical antipsychotics are sometimes helpful. In terms of therapy, dialectical behaviour therapy (DBT) can be useful. Another option is emotional regulation group therapy, a 14-week group that focuses on awareness and management of emotions. CBT, mindfulness-focused therapies, and family therapy may also be helpful.
People like to get judgy, and nonsuicidal self-injury is the target of a lot of misconceptions and judgments. Attention-seeking is a popular label, and one of the misconceptions is that only people with borderline personality disorder self-harm. As with anything else that’s stigmatized, the stigma certainly doesn’t help people get the help they need.
Resources
- Cornell Research Program on Self-Injury factsheets:
- National Self-Harm Reduction Network
- Rethink Mental Illness: Self-Harm Coping Strategies
You may also be interested in the post Harm Reduction for Self-Harm.
References
- Cornell University College of Human Ecology Self-Injury & Recovery Resources: About self-injury
- International Society for the Study of Self-Injury
- Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal self-injury: What we know, and what we need to know. Canadian Journal of Psychiatry, 59(11), 565-568.
- Merck Manual Professional Version: Nonsuicidal Self-Injury
The Psychology Corner has an overview of terms covered in the What Is… series, along with a collection of scientifically validated psychological tests.
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
I’m terrible for this. I can’t have a conversation with anyone unfamiliar face to face without nipping or scratching myself because I can’t control the anxiety and stress crashing around in my body. Also interestingly, I know that when I am harming frequently it usually ends in a suicide attempt, be that intentional or accidental. I have tried time and time again to get help when I feel I’m getting out of control and I am constantly told I’m not serious or I’m attention seeking. I am not!! I am asking for help because I don’t want to end up seriously hurting myself. People never listen until it’s too late. I used to be afraid I’d accidentally kill myself. 😒
I wish people who use that attention-seeking label would get whacked over the head with a rubber chicken every time they did so.
😂😂😂 thats a great idea. Or slapped in the face with a wet fish. Xx
Yes!!!!!! 🐟
A very interesting read! I used to cut myself as a teen – Started doing it when I was about 14 (so pretty much in line with the average age of onset that you’ve mentioned)
And well..it was an absolutely nonsuicidal self-injury, one of the reasons why I was doing it is that I was anxious and I felt that harming myself could calm me down.
Yeah, I think there are a lot of mistaken assumptions about the “why” among people who’ve never been in that place themselves.
Indeed – the vast majority of people who saw my scars would think that I wanted to die but….I really did not.
I only self-harmed briefly when I first got sick, and it was a coping strategy to handle the suicidal thoughts, not to act on them.
We hit our head repeatedly (hundreds of strikes) with a rock on a few occasions. It was self-punishment and a way to get rid of anger. Enough hits and we did go numb, which apparently was a more desirable state.
That sounds really hard ❤️❤️❤️❤️
We gave it to a T. We don’t see that T anymore. That rock was special and not special at the same time ❤️❤️❤️
Yeah, that makes sense.
I once was going through a rough patch with my depression, this was 5 years ago. I tried cutting and was hoping to experience the same release that I’ve heard others feel. It didn’t work and I felt stupid for doing it. I have a forearm full of scars which is pretty noticeable from a certain angle. But you know what, I don’t care to hide them. So many people are ignorant to mental illness and think that everyone who acts happy isn’t suffering. Maybe they’ll see my scars and are reminded to be kind to people no matter what. This is what I hope, at least.
Yeah, if people can wake up to reality that would be a good thing.
It bugs me so much when people assume that when you self-harm, you want to kill yourself. I’ve been self-harming since I was a teen, or if we include all the passionate nails/cuticles/lips biting/picking then since forever (but I didn’t really consider that self-harm for most of my life nor did anyone else) and when I once cut and my Mum saw it she was convinced that I wanted to kill myself, and there was no way for me to reason with that. I also found it hard because even if I could reason with her I’d have to tell her why I cut myself and I didn’t feel like I was able to open myself uup like that to her, the more that I was pretty sure she wouldn’t understand my motives anyway. When she eventually somehow realised that I did not want to kill myself, she indeed couldn’t understand the self-harm thing anyway, and I think she still can’t really.
I think that at different times I have done it for all of the purposes you mentioned, even attention-seeking at some point, though most of the time I’d do everything for my injuries to be totally invisible. But it’s awful when people assume that everyone who self-harms does it for attention.
I think it really is very much like an addiction in so many ways.
And just like an addiction, it’s complicated and very poorly understood by most people.
Whenever I read about NSSI or see it depicted in a movie or tv show, it just hurts my heart – I want to reach out and just hug that person (and I’m not a hugger) and make them feel safe.
Now if only more people reacted that way…
Thank you for this post! I’ve recently realised that I may have been engaging in forms of NSSI for a while… I’ve always been a nail biter for as long as I can remember, and I’ve definitely been better at resisting the urge to do this recently, but I do still have episodes of biting or picking at my nails/cuticles, amongst other things… I’ve never really considered these things as a potential form of self harm until very recently. Its definitely not attention seeking, on the contrary I’m extremely self conscious about it and don’t like people looking at my hands! I’ve struggled with mild anxiety and depression for several years and have wondered if this is an unconscious coping mechanism, or whether its more of a compulsion, as sometimes I don’t even fully realise I’m doing it, or if I am conscious of it it’s like I know I shouldn’t do it, but I do it anyway. Some food for thought here for sure, and a concept I wasn’t really aware of before, so thank you for bringing it to light! Will definitely be researching more on this. 🙂
A blogger I know, although she’s on a blogging break now, had something similar to what you’ve described. https://www.bfrb.org/learn-about-bfrbs/nail-biting
Thank you for this post. Too many people assume self injury with attention seeking or suicidal ideation when it primarily is not. This is quite informative.
Thanks! And yeah, far too many wrong assumptions around this topic.
Thanks for another great read.What you wrote in the last paragraph is sadly a common practice. People judge too quickly indeed.
Yes, sadly they do.
When I was at university, I did actually self-harm, not for attention, but to try to communicate how terrible I felt, which I couldn’t manage to do in words. It wasn’t terribly successful.
I’ve heard that from other people as a motivator, and yeah, it doesn’t seem to work very well.
I found this post to be very insightful. As someone who has a history of self-harm I have struggled in the past to explain the reasonings behind it. This post is very insightful, easy to understand and full of information. Thank you for such a helpful post.
I’m so glad it was helpful!
Hi Ashleyleia,
Thank you for always putting in effort to share something new here.
I have learned a lot from this post.
Sometimes, I feel a very strong urge to self-harm again especially at night when I have difficulty falling asleep.
Just like yesterday night. My brain was so noisy. I was shutting my eyes forcefully, creating wrinkles on my eyebrows without realizing it at first. It felt like I was losing control of my brain and body. It was so noisy and scary.
I felt so tired today, having no appetite. Luckily I feel better now after a nap. Just realise this morning that I forgot to take my Olanzapine yesterday. Haha… I felt so much pain and was so worried. I thought I should schedule for a therapy session. Now I have learned again that I need to take my pill on time. This is not my first time of being so careless. The same symptoms also occur when my menses comes. Just sharing with you here:)
Thanks for sharing this piece <3 Have a bright day ahead:) Take care and stay safe!
Sometimes I forget my medication too. I need my quetiapine to sleep, and if I forget it I’ll get into bed feeling sleep and then all of a sudden I’m wide awake. 💕
I see we are quite similar in this way. Remember your medication ya <3
Yes!
I’ve suffered with self-injury since I was 13 and am diagnosed with every one of those illnesses listed. I’m such a textbook case of mental illness. 😂
Not exactly the more the merrier in that sense…
I hated the amount of times I heard nurses or care staff saying that “oh, she just does it for attention.” Did they learn nothing at college/unit?
It’s disturbing how common that crap is.
Great article!
I cut for a long time, and in the beginning it was a suicidal seeking behavior. As time passed it became more NSSI. Eventually I was able to stop cutting, but I haven’t kicked the habit of picking. I pick and chew my fingers and cuticles until they bleed, oftentimes. I’ve been picking since I was a kid. This is also NSSI, mostly an anxiety response along with my other mental illness.
Coping mechanisms don’t need to be healthy to work, and it seems like a lot of people have a very hard time moving away from them.
Agreed!