BHIPP Bulletin

Volume 8, Issue 12

June 2023

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

Non-suicidal self-injury (NSSI) involves intentional self-harm but without suicidal intention. The manifestation of NSSI can take various forms, including cutting, burning, scratching, hitting, or biting (Gilbert et. al., 2020). It is estimated that 7-18% of adolescents deliberately injure themselves at least once (Swannell et. al., 2014; Wilkinson, 2013). The onset of NSSI typically occurs in early adolescence between the ages of 11 and 15 and can continue into adulthood (Rodav, Levy & Hamdan, 2014). There are multiple factors that are associated with NSSI; however, the specific motivations for engaging in NSSI can vary across individuals. 

What is the Function of NSSI?

The emerging research involving the factors that underlie NSSI would suggest that a variety of functions may explain why a given individual resorts to self-injury; however, there are several interpersonal or intrapersonal functions that have gained considerable empirical support (Taylor et. al., 2018). 

Interpersonal functions:

• Emotional regulation: NSSI can be a coping mechanism for individuals who struggle with regulating their emotions effectively. The act of self-injury may provide temporary relief from overwhelming emotions, allowing individuals to control or numb painful emotions.
• Self-punishment: While self-punishment may involve some implicit regulation of emotions, it is linked to specific emotional states (e.g., shame) and implies a distinct negative view of the self (e.g., somehow flawed or bad). Self-injury may also serve as a form of self-punishment or a way to obtain self-validation by internalizing physical pain.

Intrapersonal functions:

• Emotional expression: Some individuals find it difficult to express their emotions verbally or to adaptively communicate with others. Therefore, NSSI can serve as a maladaptive means of communicating their pain to others. In some cases, NSSI may be a cry for help, and the use of NSSI is intended to solicit the support and understanding they desire. 
• Peer influence: In some cases, social contagion can play a role in NSSI. Therefore, individuals who have friends or acquaintances who engage in self-injury are more likely to adopt the behavior as a means of fitting in or bonding with others. In addition to aligning with others with similar behaviors, some individuals may use NSSI as a maladaptive way to somehow influence others.
• Punishment of others: There are some suggestions in the literature that attribute NSSI as a form of negative manipulation. As a result, NSSI could be used as a means of punishing parents or peers for grievances that are real or imagined. 

While there are several functions that may underpin NSSI, there is considerable support for the notion that regulation of distressing emotional states represents the most common function associated with NSSI (Taylor et. al., 2018). Interestingly, functions related to influencing or punishing others seem to be a relatively rare explanation for NSSI, and this finding conflicts with the common myth that NSSI is largely about seeking attention or manipulating others (Caicedo & Whitlock, 2009).

Psychiatric Disorders Associated with NSSI

If someone is engaging in NSSI, it may signal an underlying psychiatric disorder, and consultation with a mental health provider can help provide appropriate assessment, diagnosis, and treatment.  The most common psychiatric disorders that co-occur with NSSI behaviors include depressive disorders, anxiety disorders, eating disorders, substance use disorders and borderline personality disorder. In many cases, addressing the co-occurring psychiatric disorder is key to resolving NSSI; therefore, diagnosis and treatment of the related psychiatric disorder is an important consideration when attending to the symptoms of NSSI. 

The Diagnostic Criteria for NSSI

While NSSI is often associated with a variety of psychiatric disorders, this does not necessarily mean that every person who self-injures has a diagnosable mental illness. NSSI can also occur in the absence of a formal psychiatric diagnosis, as it may stem from a combination of emotional, psychological, and environmental factors. In line with this consideration, the DSM has introduced a specific diagnosis involving NSSI that is in need of further study. Although this diagnostic category has not been codified into the formal DSM nomenclature, the provisional criteria are listed below. Of note, this provisional diagnosis is excluded when self-harm is better accounted for by another psychiatric disorder (Criterion F).  

DSM-5 Diagnostic Criteria for NSSI

The Relationship between NSSI and Suicide

Suicide and NSSI are related in that they both involve intentional acts of self-harm, but they differ in terms of the underlying motivations and intentions. It's important to understand that NSSI and suicide are distinct behaviors, although they can sometimes coexist or be part of a pattern of self-destructive behaviors.

A key distinction is related to the notion that individuals who engage in NSSI may use it as a maladaptive coping mechanism to alleviate pain or to express inner turmoil. In contrast, suicide involves intentionally ending one’s life, typically driven by the belief that it is the only means of ending pain or suffering. 

Suicide and NSSI often share some common risk factors. For example, both are associated with an underlying mental illness or difficulties in emotion regulation; however, not everyone who self-harms is at immediate risk of suicide. Both acts reflect significant psychological distress; therefore, NSSI can be a warning sign for potential suicide risk (Andover & Gibb, 2014; Nock et. al., 2006) and may independently increase the risk for a subsequent suicide attempt by sevenfold (Asarnow, et. al., 2011). Research shows that approximately 12% of adolescents who engage in NSSI will make a suicide attempt by age 21. Nevertheless, many individuals who engage in NSSI do not have suicidal intentions and may eventually find more adaptive means of coping with their emotions.

The Role of the Primary Care Provider (PCP)

When a PCP encounters a pediatric patient who displays NSSI, it is crucial to approach the situation with care and sensitivity. It is important to note that every individual and situation is unique, and professional guidance from a mental health specialist should be sought to ensure appropriate assessment and intervention. 

Any form of self-injury or suicidal act should be approached with empathy, understanding and appropriate interventions. Within this context, some basic considerations are typically important in dealing with any patient exhibiting self-harm and suicidal thoughts or actions (Lieberman, Poland & Niznik, 2018). 

• Create a safe space. By maintaining a non-judgmental and compassionate attitude toward the patient and their circumstances, the PCP can create a safe place for the patient to express their feelings and concerns in an open manner. Encourage the patient to discuss their feelings and triggers for self-injury. Actively listen to their concerns and never discount their circumstances or the reasons for their self-harm.
• Assess severity. To help determine the appropriate level of intervention, it is important to assess the severity and frequency of self-injurious behaviors. 
• Refer to appropriate level of care. If the injuries are severe or life-threatening, ensure the patient's safety by providing the necessary medical treatment or hospitalization.
• Screen for psychiatric conditions. Assess for underlying mental health conditions, such as depression, anxiety, trauma, or other emotional struggles, that may contribute to self-injurious behaviors.
• Refer to a mental health specialist. Involve a mental health specialist to provide a comprehensive assessment and appropriate therapeutic interventions such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT).
• Involve the family. Engage the patient's parents or caregivers to provide support and understanding. Offer information and resources on how to effectively communicate with their child and create a safe and supportive environment at home.
• Identify healthy coping strategies. Help the youth identify healthier coping strategies to manage emotional distress. Having a range of healthy coping strategies that can be accessed any time is useful (e.g., breathing techniques, listening to music, going for a walk).
• Develop a safety plan. Collaborate with the patient, their family and mental health professionals to create a safety plan (e.g., Stanley-Brown Safety Plan) that includes alternative coping strategies, emergency contacts, and strategies to prevent self-injury (Stanley et. al., 2009).
• Monitor progress. Regularly assess the patient's progress, ensuring that they are engaging in appropriate treatment and that any necessary adjustments are made. Schedule follow-up appointments to ensure ongoing treatment. 

Evidence-Based Treatments for NSSI

The existing literature examining treatments for NSSI mainly focuses on treatment for the associated psychiatric disorder; therefore, the empirical support for the specific treatment of NSSI is limited. Moreover, for any given individual, different factors underlie NSSI which may explain why no specific treatment approach has demonstrated to be robustly effective in addressing the symptoms associated with NSSI. Provided below is an overview of treatments with some support for improving the outcomes of young people with NSSI and related conditions.

Cognitive Behavioral Therapy (CBT) for NSSI involves identifying triggers and underlying emotions, developing coping skills, improving problem-solving abilities, and challenging negative thoughts and beliefs associated with self-injury.

Dialectic Behavioral Therapy (DBT) combines elements of CBT with mindfulness techniques. It has shown promising results in treating NSSI in adolescents. DBT focuses on enhancing emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills. 

Effective interventions for self-harm in adults were observed for several treatments (Witt et al. 2022), including CBT and DBT. By comparison, the number of well-designed studies for young people is very limited. A recent Cochrane review (Witt et. al., 2022), would suggest that there is inconclusive evidence regarding the efficacy for any of the psychosocial interventions in specifically treating children and adolescents who engage in self-harm. This may reflect the notion that an array of functions underpin NSSI and the specific intervention should be tailored depending on the individual's circumstances. The use of DBT has the most consistent empirical support for young people exhibiting NSSI; by comparison, other treatments (e.g., CBT) have more inconsistent results. Notably, given the supporting evidence with adults, individual CBT‐based psychotherapy should also be considered as a reasonable treatment approach for older adolescents with NSSI (Witt et. al., 2022). 

Psychopharmacological interventions Randomized controlled trials using medications to specifically target reductions in NSSI have not been proven to be particularly effective in addressing NSSI. However, interventions such as selective serotonin reuptake inhibitors (SSRIs) and other antidepressants can be effectively used in conjunction with psychotherapy to manage underlying psychiatric conditions associated with NSSI, such as depression or anxiety (Witt et. al., 2022). 

Related Resources:

Websites:

1. The National Alliance on Mental Illness (NAMI) offers support groups for family members.

2. Information for Parents on Self-Injury. This handout is empirically based and offers parents information about how to address NSSI with teens, how to manage urges for self-injury, and how to support teens with treatment.

3. Self-Injury Outreach and Support website provides information about self-injury to those who self-injure, those who have recovered, and those who want help, as well as specific resources for parents.

4. The S.A.F.E. Alternatives website offers links to finding a therapist in each state. It provides a nationally recognized treatment approach, professional network, and educational resource base targeted toward ending self-injurious behavior.

Books:

1. Ashfield, J. (2016). Teenagers and Self-harm: What Every Parent and Teacher needs to know. Australia: You Can Help Publishing.

• This short, easy-to-read publication written for parents, teachers, and health professionals provides current information on understanding and responding appropriately to teenagers who engage in self-harm.

2. Hollander, M. (2017). Helping Teens Who Cut: Using DBT Skills to End Self-injury (2nd ed.). New York, NY: Guilford Press.

• The author, a psychologist who specializes in DBT, offers practical DBT methods aimed at parents in an easy-to-read format. The book covers how to address self-injury behavior with teens, methods for teaching coping skills, how to find help, and methods for reducing family stress.

 3. McVey-Noble, M. E., Khelmlani-Patel, S., & Neziroglu, F. (2006). When your child is cutting: A Parent's Guide to Helping Children Overcome Self-injury. Oakland, CA: New Harbinger Publications.

• This book offers information for parents about how self-injury occurs, how to identify the behavior, how to obtain professional help, and how to support the teen's recovery.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.