|Year : 2021 | Volume
| Issue : 4 | Page : 166-171
Nonsuicidal self-injury in children and adolescents
Chien- Lin Jong1, Wen- Jiun Chou2, Cheng- Fang Yen3
1 Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
2 Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital, Kaohsiung Medical Center and College of Medicine, Chang Gung University, Kaohsiung, Taiwan
3 Department of Psychiatry, Kaohsiung Medical University Hospital; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
|Date of Submission||03-Feb-2021|
|Date of Decision||17-Mar-2021|
|Date of Acceptance||19-Mar-2021|
|Date of Web Publication||21-Dec-2021|
M.D., Ph.D Cheng- Fang Yen
No. 100, Tzyou First road, Kaohsiung 807
M.D Wen- Jiun Chou
No. 123, Dapi Road, Kaohsiung 833
Source of Support: None, Conflict of Interest: None
Background: Nonsuicidal self-injury (NSSI), self-harm behavior without suicidal intent, is a serious problem that is prevalent among adolescents. The fact that NSSI is listed as “condition for further study” in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, indicates that its severity is recognized in clinical medicine. Methods: In this paper, we review the recent literature on the risk factors for NSSI, as well as its epidemiology, etiology, risk factors, and treatment. Results: The prevalence of NSSI in adolescents is about 17%–18%. Notably, it is more common in girls. In psychiatric units, the reported rate of NSSI among adolescents is 60%. Considered a strategy by which adolescents blanket their emotional discomfort with physical pain, NSSI may increase the risk of developing psychiatric disorders and involve physical sequelae. NSSI has many etiologies and risk factors, including interpersonal problems, social contagion, adverse childhood experiences, and neurobiological factors. No definite evidence supports the psychopharmacological treatment of NSSI in adolescence. Recent studies showed that dialectical behavioral therapy, cognitive behavioral therapy, and mentalization-based treatment have therapeutic effects in adolescent patients with NSSI. Conclusion: NSSI is highly prevalent and highly comorbid with other psychiatric disorders. To prevent and manage this problem more effectively, further research on and understanding of the etiological characteristics is warranted.
Keywords: adverse childhood experiences, media influence, risk factor, suicide
|How to cite this article:|
Jong CL, Chou WJ, Yen CF. Nonsuicidal self-injury in children and adolescents. Taiwan J Psychiatry 2021;35:166-71
| Introduction|| |
Nonsuicidal self-injury (NSSI) is a behavior that a person deliberately inflicts harm on their own body without suicidal intent and for nonsocially sanctioned reasons . Thus, it does not concern accidental injuries, indirect self-harm (e.g., pathological eating behaviors and substance abuse), suicidal behaviors, tattoos, piercings, socially acceptable behaviors, or physical harm inflicted in religious or cultural rituals.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) , NSSI is listed as “condition for further study,” indicating that its severity and prevalence is recognized in clinical medicine. The DSM-5 proposes diagnostic criteria for NSSI, including: engagement to intentional self-inflicted damage to the surface of bodies to induce bleeding, bruising, or pain (Criterion A); the individual engages in the self-injurious behavior with one or more of the following expectations: (a) to obtain relief from a negative feeling or cognitive state, (b) to resolve an interpersonal difficulty, or (c) to induce a positive emotional state (Criterion B); the intentional self-injury is associated with at least one of the following: (a) interpersonal problems or negative thoughts or emotions immediately before NSSI, (b) preoccupation with NSSI that is difficult to manage, or (c) frequent thoughts about NSSI (Criterion C); the NSSI is not socially sanctioned or restricted to minor self-injurious behaviors (Criterion D); the NSSI caused clinically significant distress or interference in different domains of functioning (Criterion E); and the NSSI does not occur only during psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies (Criterion F) .
The most common manifestations of NSSI include cutting, scratching, hitting, and scraping . NSSI is especially common in middle adolescence ; thus, it constitutes a crucial issue deserving of particular attention from child and adolescent psychiatrists, psychotherapists, social welfare personnel, teachers, parents, and health care personnel who work with children and adolescents.
When NSSI occurs frequently, the wounds may increase in number and depth. Individuals with NSSI may feel a sense of desire or urgency to do the behavior, the patterns of which are similar to those in addiction. Injuries in NSSI are primarily inflicted using knives, needles, razors, or other sharp objects and in an easily accessible area, such as the front of the thigh and the dorsal side of the forearm . A single injury may consist of many superficial, parallel cuts, which are separated by 1–2 cm, on a visible or accessible location . These cuts often result in bleeding and the eventual formation of a characteristic pattern of scars. Other methods of NSSI include piercing, most commonly in the upper arm using a needle or a sharp thin blade; using lit cigarette butts to cause superficial burns; and repeatedly rubbing the skin with an eraser to cause abrasions. Using multiple methods to perform NSSI is related to more serious psychopathology, which may manifest as attempted suicide.
Many individuals who do NSSI do not seek medical treatment . Whether the stigmatization of the behavior plays a rôle in treatment avoidance remains unclear. Patient's attitude may influence them to seek help. For example, individual may think that “the problem will resolve itself,” “no one can help,” and “it is too embarrassed to discuss with anyone.” The feeling of relief that NSSI provides may also reduce the motivation to seek treatment. Comorbidity, such as social anxiety disorder , may also influence patient's attitude of seeking professional help.
| Epidemiology of Nonsuicidal Self-injury|| |
In recent years, increasing scholarly attention has been focused on NSSI, including its epidemiology, etiology, risk factors, and affective functions. One study reported that the prevalence of NSSI in the form of self-mutilation is 14% . According to the results of studies from community samples reported between 2005 and 2011, the prevalence of NSSI is relatively stable, even when adjustments have been made for differences in methodology, assessment tools, the motivation for study participation, and the definition of NSSI . Two systematic reviews of international studies indicated that 17%–18% of adolescents have performed at least one NSSI behavior ,. This finding contrasts with the prevalence of NSSI among children and adolescents who meet the criteria in DSM-5 of 1.5%–6.7% .
A study conducted on inpatients at a psychiatric university hospital  observed rates of 60% and about 50% with regard to the presence of at least one NSSI behavior and repeated engagement in NSSI among adolescents, respectively. NSSI constitutes a symptom of various mental disorders, including mood disorder, borderline personality disorder, substance use disorders, anxiety disorders, and posttraumatic stress disorder. It may also present independently without psychiatric comorbidities ,,,.
Few follow-up studies have been conducted on the emergence of NSSI. An Australian follow-up study  noted that the prevalence of self-harm behaviors, including suicide, decreases between adolescence and early adulthood – about the ages of 15 to 29 years. A systematic review  has been found that the prevalence of NSSI is peaked in middle adolescence and declined in later adolescence (about the ages of 15 to 18 years) to middle adulthood.
Although these studies indicate that NSSI subsides in later youth, repeated NSSI predicts future emotional dysregulation. According to a two-year study , even if NSSI does not recur later in life, adolescents with repeated NSSI are more likely to misuse substances in future. Notably, NSSI can also predict future suicidal ideation  and suicide attempts . Moreover, a prospective cohort study has been reported that the risk of suicide is higher among individuals who do NSSI on body parts other than the arms and wrists . In addition, the onset of NSSI in early adolescence is associated with a higher likelihood of developing borderline personality disorder in future . Taken together, these findings indicate that NSSI in adolescence is a critical indicator of mental health.
| Possible Causes and Risk Factors of Nonsuicidal Self-injury|| |
According to the result of a meta-analysis , risk factors for NSSI with large effect sizes (indicated by odds ratio [OR] > 3) are the following: past NSSI, type B personality disorder, and hopelessness. Previous suicidal thoughts and behaviors, exposure to peer NSSI, self-reported likelihood of engaging in future NSSI, and abuse are the factors with moderate effect sizes (OR > 20). But the overall weighted mean OR is only 1.56 and is dropped to 1.16 after adjusted for publication bias. Numerous factors, including age, NSSI assessment method, sample source, and analytical method, can affect the results. Therefore, the possible causes of and risk factors for NSSI require further research.
Results on demographic factors, social factors, media influence, adverse childhood experiences, and neurobiological factors from studies on NSSI are summarized as follows.
NSSI most often presents itself in middle adolescence and then subsides in early adulthood. The onset of NSSI in adolescence may be related to brain development, increased impulsivity, and emotional reactivity that characterize this period .
The result of meta-analysis indicated that NSSI is more common in female adolescents and adults than in their male counterparts . A study has shown reported more notable gender differences among medical unit patients than among community samples. Women are also more likely to engage in wrist-cutting than men . Regarding the behavioral method of NSSI, Barrocas et al.  noted that adolescent girls most often show cutting or carving their skin whereas adolescent boys most often report hitting themselves.
A study using data from the Avon Longitudinal Study of Parents and Children, which included 4810 adolescents between the ages of 16 to 17 years, indicated that higher intelligence quotients correspond to higher risk of NSSI .
In a 2.5-year follow-up study , Hankin and Abela found that poor social interaction and experience of bullying are found to predict the occurrence of NSSI. In two follow-up studies in the UK and the United States, being bullied by peers in childhood and adolescence is more predictive of adulthood NSSI than maltreatment by parents . Similarly, a study of 12,068 teenagers in 11 European countries has been reported to have a strong association between being bullied and self-harm behavior .
Whether NSSI develops through social contagion remains a subject of debate. The result of systematic review of 16 studies indicated that NSSI has a social contagion effect. NSSI is more likely to occur under exposure to peer NSSI or to NSSI in the media, especially on the Internet . Studies have demonstrated that identification with certain youth subcultures is linked to an increased risk of NSSI ,. Sex-related social norms and values also constitute critical social factors. One study has been reported that nonheterosexual individuals are more likely to engage in NSSI .
The Internet, particularly social media, critically contributes to NSSI. For example, NSSI-related words have an extremely high search rate on Google , and YouTube videos with NSSI content on YouTube have high click-through rates . Moreover, queries concerning NSSI are extremely likely to be made on Yahoo! Answers, a community-run question-and-answer website . Another study has been found that one-third of individuals with NSSI aged between 14 and 25 years have sought help for NSSI online . These results indicated that the Internet may encourage the engagement of NSSI among young people. But Internet activities can also reduce social loneliness, provide support, and reduce the urge to self-harm .
Adverse childhood experiences
Studies have demonstrated that adverse childhood experiences, such as parental neglect, abuse, and deprivation, increase the risk of NSSI later in life ,. But a 2016 study noted that childhood emotional abuse is the only type of adverse childhood experience found to increase the risk of NSSI . Notably, the result of a systemic review and a meta-analysis indicated that sexual abuse has a moderate effect on NSSI ,. Another study showed that only indirect forms of childhood mistreatment, such as witnessing domestic violence, are associated with NSSI, but that direct forms, such as physical or sexual abuse, are not . Studies have been observed that overly critical or indifferent parental attitudes are related to NSSI in children ,.
Because follow-up studies on the occurrence of neurobiological factors for NSSI are limited in number, these factors cannot be confirmed as risk factors. Studies ,,, have investigated the correlations between NSSI, which is often related to stressful events or situations, and the function of the hypothalamic–pituitary–adrenal (HPA) axis, which is involved in coping responses to stress . Variations in HPA axis control, such as higher cortisol awakening response , lower cortisol level after the dexamethasone suppression test , and lower cortisol level after the Trier social stress test , is present in individuals with NSSI. A study in which functional magnetic resonance imaging (fMRI) was used to examine the changes in neural processing in individuals experiencing social rejection traced the differences between participants with and without NSSI to the medial prefrontal cortex and the ventrolateral prefrontal cortex . These studies have indicated the connection between adolescent NSSI and the stressors involved in interpersonal interaction.
A study exploring gene–environment interactions showed that carriers of at least one short allele in the serotonin transporter-linked polymorphic region of the SLC6A4 gene are more likely to engage in NSSI after experiencing severe interpersonal stress compared to those with both long allele genotype groups . Another fMRI study has been observed that limbic responses to emotional stimuli differ among adolescents with NSSI and adolescents without NSSI .
Evidence on the relationship between self-harm behavior and physical pain management is inconclusive. A study suggested that adolescents with borderline personality disorder have a higher pain threshold . But another study taking NSSI into consideration has shown no clear correlation . With regard to self-reported pain offset relief and neuroimaging examination, NSSI is related to abnormal pain perception . Because pain offset relief contributes to emotional regulation , it may play a pivotal rôle in the automatic-negative reinforcement in NSSI. From a neurobiological standpoint, having physiological pain is related to reduced concentrations of β-endorphin and Met-enkephalin in the brain, which may in turn be related to the difficulty people with NSSI experience in coping with external stressors .
| Functions of Nonsuicidal Self-injury|| |
On the basis of the result of the analysis of functional behavior, two psychopathological theories concerning NSSI have been proposed . The first is based on learning theory, which posits that this behavior is regulated through positive or negative feedback. Positive feedback may result from the engagement of NSSI as a form of self-punishment that the individual feels is deserved. This behavior leads to a state of pleasure and relaxation. It may also be used to express anger or attract attention and assistance from significant others. Negative feedback involves efforts to relieve unpleasant emotions or to avoid painful thoughts (e.g., of suicide). In the second theory, NSSI is considered a form of self-punishing behavior that serves as compensation for causing pain or harm to others.
The four-function model of self-mutilative behavior proposed by Nock and Prinstein in 2004 is most often used to explain why individuals engage in NSSI . These four functions include positive and negative feedback in the process of automatically reinforcing or socially reinforcing: (a) Automatic-negative reinforcement refers to engagement in NSSI to reduce negative feelings or thoughts (e.g., anger and tension). (b) Automatic-positive reinforcement refers to engagement in NSSI to attain a positive physiological state (e.g., feeling alive). (c) Social-negative reinforcement refers to engagement in NSSI to avoid unpleasant social interactions (e.g., disputes and going to school). (d) Social-positive reinforcement refers to engagement in NSSI to strengthen social interactions (e.g., attracting attention from or sending messages to others).
Several studies have indicated that internally automatic-negative reinforcement is the most common function of NSSI [20, 58, 59]. A study using ecological momentary assessment showed that individuals often feel lonely, sad, and overwhelmed before engaging in NSSI . According to the result of a systematic review, the infliction of physical pain can reduce negative emotions .
| Differentiation of Nonsuicidal Self-injury and Suicide|| |
It is sometimes difficult to differentiate NSSI with suicide attempt in clinical practice. According to definition, the differentiation between NSSI and suicidal behavior is based either on the stated goal of the behavior being to experience relief as NSSI or a wish to die . Previous studies showed that NSSI  and frequency of NSSI  are positively correlated with suicide intention. As clinical practice, individuals may provide reports of convenience or false declaration while asked intention of self-harm. To evaluate the suicide intention, comprehensive assessment of past self-harm and suicide history and obtaining information from a third party concerning any recent mood change or stresses are necessary.
| Treatment for Nonsuicidal Self-injury|| |
Repairing wounds caused by self-injury should be the first step in treating individuals with NSSI.
A recent systematic review  indicated that dialectical behavioral therapy for adolescents , cognitive behavioral therapy ,, and mentalization-based treatment for adolescents  are effective in treating adolescent NSSI. Specifically, dialectical behavior therapy  can reduce self-harm behavior in adolescents, and the effects can persist till the time at 12-month follow-up. But no research has compared the effectiveness of these treatments.
A German clinical guideline for diagnostics and therapy  suggested that psychotherapy for adolescents with NSSI must involve in helping the patients motivate for treatment, understand the nature of NSSI, and recognize the triggering or maintaining factors for NSSI. Moreover, behavioral skills to replace NSSI must be identified, conflict resolution strategies must be provided, and comorbid psychiatric conditions must be treated according to relevant guidelines.
No definite evidence supports the use of psychotropic drugs in the treatment of NSSI.
| Conclusion|| |
NSSI is an emerging phenomenon and a serious problem among adolescents. Although NSSI may subside in early adulthood, chronic repeated NSSI may be correlated with mental disorders and increased suicidality. NSSI may constitute a method by which adolescents relieve their negative emotions. Helping adolescents recognize the underlying reasons for this behavior and develop appropriate behaviors to replace it, is essential.
| Financial Support and Sponsorship|| |
This study was supported by grants from Chang Gung Memorial Hospital Medical Research Project, 108-CMRPG8J0651 and 109-CMRPG8K0971.
| Conflicts of Interest|| |
Cheng-Fang Yen, an executive editorial board member at Taiwanese Journal of Psychiatry, had no rôle in the peer review process of or decision to publish this article. Other authors declare no conflicts of interest in writing this paper.
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