In working with adolescents, mental health care professionals often draw on their own developmental experiences to help guide their patients; however, nonsuicidal self-injury (NSSI) is not likely to be a personal experience that psychiatrists can often draw on. In fact, today's youth face new challenges, including increasing exposure to the practice of self-injury. We can best help adolescents by being aware of this problem, asking directly about self-injury, understanding basic therapeutic approaches, and having knowledge of more specific evidence-based psychotherapeutic and psychopharmacological interventions that can be used to treat NSSI.
In this article, NSSI, which is used interchangeably with self-injury, is defined as deliberate, self-directed tissue injury inflicted without conscious intent to kill oneself.1 In most studies, skin cutting is the most common form, followed by burning and self-hitting or banging; the forearms, wrists, and thighs are common locations of self-injury.2,3 Other forms of self-injury include scratching and interfering with wound healing. Klonsky4 reports that many individuals who engage in NSSI practice more than one method.4 The prevalence of self-injury in adolescents and young adults, including the nonclinical population, may be increasing.4-7 One out of 3 self-injurers reports an onset of self-injurious behavior in childhood, with a peak incidence in mid- to late-adolescence.8 Relatively late development of brain circuits (pruning and myelination) involved with emotion, judgment, and inhibitory control may explain the heightened propensity of adolescents to act impulsively and ignore the negative consequences of their behavior.9 Studies have found that approximately 15% of high school adolescents and 17% of college students engage in self-injury, with estimates as high as 40% to 60% for adolescent inpatients.5,6,10 In one study, researchers found that 1 out of 5 students attending an Ivy League school endorsed these maladaptive behaviors, and 1 in 10 respondents were repeat self-injurers.5
Other psychiatric conditions often predispose patients to self-injurious behavior. Borderline personality disorder (BPD) and other personality disorders, anxiety, eating disorders, and substance abuse are all risk fac-tors for NSSI.11-14 Additional risk factors include adolescence to college age, maltreatment, and family turmoil.5,12-14 A recent study noted that identification with Goth subculture is also a risk factor.15 Although most studies report females as being more likely to engage in NSSI, a number of studies have found no significant differences between females and males.2-6 There are several potential reasons for this disconnect. First, a majority of the earlier studies were completed with patients who had BPD, a disorder that is more common in females. Second, self-hitting and banging, which may not have been included in analyses of NSSI, may be more common among males; females are more likely to cut themselves. Third, a significant increase in male NSSI may have made a strong contribution to the overall increasing prevalence of NSSI in adolescents and young adults.5,6
Possible reasons for increased prevalence
An increase in some risk factors (eg, child abuse, substance abuse, family turmoil, anxiety) may explain the possible increase in incidence of NSSI in the adolescent population. Likewise, the phenomenon of contagion may be affecting rates of NSSI. "Behavioral contagion" is an increased tendency to engage in a behavior when socially related people also engage in that behavior.16 Contemporary routes for transmission include direct contact with self-injurers (often friends or family), direct or indirect exposure over the Internet, exposure via the media, and role modeling through the cult of celebrity, including adolescent antiheros.17,18In addition to risk factors and modes of transmission, there are variables that motivate and reinforce the behavior of each individual. Nock and Prinstein1 hypothesized that NSSI may be automatically reinforced (eg, emotion regulation) or socially reinforced (eg, avoidance/escape, attention/communication of distress). The primary function of most NSSI appears to be reinforced by the individual, involving an affect-regulation function (reduction of negative affect).4 There is also strong support for a self-punishment function.4 Additional functions with more modest evidence include antidissociation, interpersonal influence, antisuicide, sensation seeking, and interpersonal boundaries functions.4
What should you do when there is a new adolescent patient seated in your office? Ask directly about self-injury, "Have you ever cut or done other damage to your skin on purpose?"5 In my experience, most adolescents will be forthcoming about a number of risky behaviors, including NSSI, when directly questioned without their parents present. If the adolescent seems particularly guarded under direct questioning, you may consider having the patient fill out a written self-report scale on NSSI.19-21 You should also assess the general appearance of the adolescent, noting any obvious scarring on visible skin and unusual dress, such as a Goth look or wearing long-sleeve shirts in hot weather.
After NSSI is disclosed, or if the adolescent was specifically referred for this issue, it is important to proceed with the interview and approach the patient in a nonjudgmental manner. Families (and sometimes clinicians) may overreact when they learn of self-injury. In many cases, NSSI may be a form of brief experimentation causing superficial tissue injury as part of the separation-individuation process; rarely does the self-mutilation involve suicidal intent.4,22 I would be reluctant to recommend psychiatric hospitalization with NSSI as the chief concern in the absence of other signs or symptoms of severe disturbance. However, even though NSSI usually does not constitute an acute emergency involving imminent danger, it does increase overall suicide risk, and clinicians should react accordingly.23,24 Following disclosure of NSSI, the clinician should attempt to ascertain why the patient is engaging in such behaviors and the function(s) of NSSI (Table 1). Because NSSI is nonspecific, like a fever, it is necessary to understand the motivation behind the behavior to develop a treatment plan. Similarly, it is important to inquire about the emotions that precede and follow the NSSI.