Rana Elmaghraby, MD

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

The goal of this activity is to provide an understanding of the treatment modalities for the management of nonsuicidal self-injury (NSSI) in adolescents.

At the end of this CE activity, participants should be able to:

• Describe the evidence-based behavioral interventions that are used in the management of NSSI;

• Appreciate the current status of knowledge on somatic treatments for NSSI behavior; and

• Discuss the recommendations for future research on treatment development.

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

 This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and 

. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 

. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: 

AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Rana Elmaghraby, MD, has no disclosures to report.

Ozra Nobari, MD, has no disclosures to report.

Kathryn R. Cullen, MD, reports that she has received research support in the form of Grant R61AT009995 Identifying Biological Signatures of N-acetylcysteine for Nonsuicidal Self-Injury in Adolescents from the National Center for Complementary and Integratvie Health.

Kaz Nelson, MD (peer/content reviewer), reports that she has received research support in the form of a grant from the American Board of Psychiatry and Neurology; she has received honoraria for writing a chapter on medications for personality disorders, and she receives royalties from Oxford University Press.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

For content-related questions, please email us at 

; for questions concerning CME credit call us at 

Non-suicidal self-injury (NSSI), or the deliberate act of self-inflicted damage to one’s body without suicidal intent, is a maladaptive and potentially habitual behavior that often serves to relieve strong negative feelings. NSSI typically emerges in adolescence. The average prevalence of NSSI behavior in adolescents is 18%, while 7% of adolescents potentially qualify for the diagnosis of NSSI disorder as proposed in the DSM-5.

 NSSI is associated with multiple psychiatric disorders including depression, anxiety, substance use, eating disorders, personality disorders, and developmental disorders; it can also occur in the absence of any psychiatric disorder.

“Mary” is a 15-year-old high school student with no previous psychiatric history who was brought to the emergency department (ED) by her parents because of self-inflicted lacerations on her arms. During the assessment, Mary revealed to the physician that she had been cutting herself one to two times a week for several months.

In the past year, Mary had experienced episodes of intense sadness and anxiety. She had learned about self-cutting through social media outlets; she also said her peers were using this strategy to manage stress. Mary reported that cutting served to numb her feelings and described it as “the only thing that helps.” Mary reported that about 8 months ago, she had thoughts of wanting to die and took 5 pills from the medicine cabinet; the next morning she woke up feeling fine and told no one about this incident until now. She denied any current suicide attempts, but reported occasionally wishing that she had not been born.

While suicidal behavior and NSSI are separate phenomena, they commonly co-occur. In fact, NSSI is a strong predictor for suicide attempts. Therefore, effective treatment of NSSI represents an avenue for preventing suicide, the second leading cause of death among adolescents. Previous empirical treatment reviews that have summarized ­behavioral and pharmacological interventions for NSSI have largely focused on adults. Since adolescence is a notable period both for onset of NSSI and for brain development, it represents a critical time for adequate treatment of NSSI. Here, we review the available evidence for treatments of NSSI, focusing on studies that include children, adolescents, and young adults (

Although CBT has not been directly tested as a treatment for adolescent NSSI, two large randomized controlled trials (RCTs) that evaluated CBT as an adjunct treatment to SSRIs for treating depression in adolescents examined change in NSSI as a secondary outcome.

 Neither found that the addition of CBT reduced NSSI frequency in these adolescents.

Dialectical behavioral therapy (DBT) is a CBT-based intervention that was originally designed for adults with chronic suicidal behavior.

 DBT includes individual and group components and teaches skills including distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness. A robust literature supports the use of DBT in adults with self-harm behaviors (both suicide attempts and NSSI). Study results show that DBT is helpful in reducing NSSI in adolescents and college students.

 Furthermore, randomized controlled trials comprising adolescents and college students have confirmed efficacy of DBT in reducing NSSI and suicide attempts in youth.

Mentalization-based treatment (MBT) promotes the understanding of mental states underlying behavior for self and others. A recent RCT reported that MBT was more effective in reducing NSSI in adolescents with NSSI compared with treatment as usual.

Findings from preliminary research suggest that therapy involving the expressive arts, such as voice movement therapy, may have some promise for reducing NSSI in youth, but these approaches remain understudied.

In summary, the efficacy of several behavioral intervention for addressing NSSI in youth have been explored and tested to date. At present, DBT has the strongest evidence base as a well-established, empirically supported treatment for reducing both NSSI and suicide attempts in adolescents.

Somatic treatments: pharmacological and neuromodulation approaches

There are currently no somatic treatments that have approval from the Food and Drug Administration for the specific treatment of NSSI. Therefore, in the following paragraphs, all discussion of potential effects on NSSI behavior by somatic treatments refers to off-label use of these agents.

Antidepressants are commonly used in the treatment of adolescents with NSSI because this behavior often occurs in the context of depression and anxiety symptoms. However, no studies have formally tested if antidepressants reduce NSSI frequency in adolescents. Moreover, combination treatment using SSRIs and CBT has not been shown to help with NSSI.

 One case report noted improvement in NSSI behavior with fluoxetine treatment in an adolescent with intellectual disability in whom a trial of naltrexone had previously failed.

 Despite their common use in neurotypical adolescents with NSSI, there is currently limited evidence to support antidepressant medication efficacy for reducing NSSI specifically.

Opioid antagonists have been investigated as an intervention for NSSI, with the idea of blocking endogenous opioids generated by and reinforcing the behavior. To date, research has focused primarily on adult patients with developmental disorders. However, there are some reports of opioid antagonist use in adolescents with neurodevelopmental disorders. One case series reported that treatment with naltrexone was associated with reduced NSSI behaviors in 3 of 6 male adolescents with profound intellectual disability.

 Two single-subject, placebo-controlled, crossover-design studies added to the evidence that opiate blockade may be useful for decreasing NSSI in youth with developmental disabilities.

 However, there have been no studies in the past two decades on opioid antagonists in adolescents or neurotypical adolescents with NSSI.

Lithium is a mainstay for treating bipolar disorder and is known for its anti-suicide effect in patients with mood disorders. A meta-analysis of 48 RCTs (including adults and children) suggested that lithium is more effective than placebo in reducing the number of suicides, overall mortality, and self-harm in patients with unipolar depression.

However, to date no studies have investigated the role of lithium in treating NSSI in adolescents.

In addition to their use for treating psychotic disorders, atypical antipsychotics have been prescribed off-label with increasing frequency to children and adolescents to address non-psychotic problems. Some studies indicate utility of these medications in reducing NSSI in youth. A placebo-controlled RCT that examined adolescents and adults (mean age=22 years) with borderline personality disorder found that aripiprazole treatment was associated with fewer NSSI episodes than placebo.

 A retrospective chart review found that ziprasidone treatment was associated with lower NSSI frequency in 16 female adolescents.

 In two case studies (consisting of 3 non-psychotic adolescents), clozapine treatment was associated with a reduction in NSSI behaviors.

 However, the adverse effects of atypical antipsychotics limit their broad use for treating NSSI in adolescents.

Given the wide-spread problem of NSSI in adolescents, interventions that are safe and broadly accessible are needed. Off-label use of N-acetylcysteine (NAC), an inexpensive and widely-available nutritional supplement, has shown treatment potential in multiple psychiatric disorders.

 NAC is a precursor in the formation of glutathione (GSH), the primary antioxidant in the brain, which suggests its potential to confer neuroprotection. NAC also modulates glutamate and dopamine receptors that play a role in motivation and reward, therefore it has relevance in the treatment of habitual behaviors.

An 8-week open-label study showed that an oral NAC was associated with reduced frequency of NSSI, decreased depressive symptoms, and global psychopathology.

 However, there are no results from placebo-controlled RCTs for NAC in adolescents with NSSI.

Neuromodulation approaches such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) may have a role in the treatment of self-harm behaviors. ECT is known to have an important anti-suicide effect, and case reports have suggested its ability to reduce aggression and self-mutilation in adolescents with autism spectrum disorders and intellectual disability.

 There is no research on non-invasive neuromodulation such as TMS for the treatment of NSSI; this may represent an important avenue for future research.

Auricular acupuncture involves stimulation of acupuncture points on the external surface of the ears. Nine adolescents on an inpatient unit with depression and NSSI were administered auricular acupuncture bilaterally at five ear sites for five days per week for three weeks.

 The treatment was well tolerated, and a reduction in NSSI and internalization of anger was seen.

In the ED, Mary’s injuries were treated with topical ointment. The emergency physician disclosed the past suicide attempt to Mary’s parents and engaged the family in a detailed safety plan (eg, removal of access to sharps in the home, locking up home medications). Mary was discharged to home with referrals to an adolescent DBT program and to a child psychiatrist for further assessment of depression and anxiety.

NSSI is a highly prevalent problem in youth and represents an important risk factor for later suicide attempts. Early and effective treatment is therefore critical for suicide prevention. Because of ongoing neurodevelopment during adolescence, this represents an especially important time for effective intervention, as these developmental processes likely:

• Play a role in disease vulnerability;

• Contribute to how adolescents respond to different interventions; and

• Enhance brain plasticity, potentially allowing maximal impact from interventions.

While some evidence is available to support interventions for adolescents with NSSI, the field stands in need of significant advancement in multiple areas.

The next steps in treatment development for adolescents with NSSI (both behavioral and pharmacological approaches) should incorporate:

• Larger samples and rigorous, unbiased study designs with improvement of NSSI symptoms as the primary outcome;

• An experimental medicine approach to identify not only whether a treatment works but also how it works, providing the basis for optimization based on biological effects; and

• A personalized medicine approach, to discover for whom each treatment is most suitable based on patient factors such as demographic, clinical and biological characteristics, patient preferences. and available community resources.

Meanwhile, as the field awaits new research to provide improved, evidence-based intervention options, how to we treat adolescents in our offices who present with NSSI?

Information should be drawn from the patient, the family, and the available literature to select the best treatment path. While currently DBT has the strongest evidence as an intervention for NSSI in adolescents, research on other psychotherapies (both individual and family) and somatic (eg, medication, nutritional supplements, neuromodulation) interventions are emerging. Comorbid psychiatric conditions must be assessed and treated, and psychosocial issues, including family dynamics, must be addressed. Healthy connections within supportive networks (eg, family, friends, teachers, coaches, etc.) can play a key role in restoring and maintaining the health and safety of children and adolescents. The final ingredients that a clinician can offer when caring for youth with NSSI include instilling hope, modeling resilience to setbacks, and maintaining the goal of full remission and restoration of healthy brain and behavioral development.

Post-tests, credit request forms, and activity evaluations must be completed online at 

 (requires free account activation), and participants can print their certificate or statement of credit immediately (80% pass rate required). This Web site supports all browsers except Internet Explorer for Mac. For complete technical requirements and privacy policy, visit 

For content-related questions email us at 

; for questions concerning CME credit Call us at 

PLEASE NOTE THAT THE POST-TEST IS AVAILABLE ONLINE ONLY ON THE 20TH OF THE MONTH OF ACTIVITY ISSUE AND FOR 18 MONTHS AFTER.

Dr Elmaghraby, is a Child and Adolescent Psychiatry Fellow, Mayo Clinic, Rochester, MN. Dr Nobari is a Child and Adolescent Psychiatry Fellow, University of California, Davis, CA. Dr Cullen is Associate Professor and Division Director of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Minnesota Medical School, Minneapolis, MD.

 Muehlenkamp JJ, Claes L, Havertape L, Plener PL. International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. 

 Zetterqvist M, Lundh L-G, DahlstrÃ¶m O, Svedin CG. Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. 

 Brent DA, Emslie GJ, Clarke GN, et al. Predictors of spontaneous and systematically assessed suicidal adverse events in the treatment of SSRI-resistant depression in adolescents (TORDIA) study. 

 Goodyer I, Dubicka B, Wilkinson P, et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. 

 Linehan MM, Armstrong HE, Suare, A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 48;1991:1060-1064.

 Goldstein TR, Axelson DA, Birmaher B, Brent D A. Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry. 2007;46:820-830.

 Mehlum L,Tormoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. J Am Acad Child Adolesc Psychiatry. 2014;53:1082-1091.

 Mehlum L, et al. Dialectical behavior therapy compared with enhanced usual care for adolescents with repeated suicidal and self-harming behavior: outcomes over a one-year follow-up. J Am Acad Child Adolesc Psychiatry. 2016;55:295-300.

 McCauley E, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. 

 Pistorello J, Fruzzetti AE, Maclane C, et al. Dialectical behavior therapy (DBT) applied to college students: a randomized clinical trial. 

 Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51:1304-1313.

 Martin S, et al. Voice movement therapy: evaluation of a group-based expressive arts therapy for nonsuicidal self-injury in young adults. 

 Bass JN, Beltis J. Therapeutic effect of fluoxetine on naltrexone-resistant self-injurious behavior in an adolescent with mental retardation. J Child Adoles. Psychopharmacol. 2991;1:331-340.

 Kars H, Broekema W, Glaudemans-van Gelderen I, et al. Naltrexone attenuates self-injurious behavior in mentally retarded subjects. Biol Psychiatry. 1990;27:741-746.

 Walters AS, Barrett RP, Feinstein C, et al. A case report of naltrexone treatment of self-injury and social withdrawal in autism. 

 Bernstein G A, Hughes JR, Mitchell JE, Thompson T. Effects of narcotic antagonists on self-injurious behavior: a single case study. J Am Acad Child Adolesc Psychiatry. 1987;26:886-889.

 Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. 

 Nickel MK, Nuehlbacjer M, Nickel C, et al. Aripiprazole in the treatment of patients with borderline personality disorder: a double-blind, placebo-controlled study. Am J Psychiatry. 2006;163:833-838.

 Libal G, Plener PL, Ludolph AG, Fegert JM. Ziprasidone as a weight-neutral alternative in the treatment of self-injurious behavior in adolescent females. 

 Kumar T, Kathpal A, Demer J. Clozapine for treatment of aggression in non-psychotic adolescents. Asian J Psychiatry. 2016;22:102-104.

Articles

This CME article provides an understanding of the treatment modalities for the management of nonsuicidal self-injury (NSSI) in adolescents.

Rana Elmaghraby, MD

Articles

Treatment of Non-Suicidal Self-Injurious Behavior in Adolescents