Cutting and Self-Harm

Description

• NSSI broadly defined as deliberate self-inflicted damage to body tissues and/or infliction of pain without the intent to die
• NSSI and suicidal behavior are separate but often co-occurring behaviors: 55–85% of people with history of NSSI also report history of suicidal behavior.
• Most common behavior is self-cutting (>70%) but can also include scratching, burning, head-banging, self-hitting, interfering with wound healing, and toxic ingestions.
• Self-harm does not include body modifications, piercings, or tattoos; also does not include skin-picking, nail-biting, repetitive stereotypies, psychosis, or delirium.
• Classified in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), under “Conditions for Further Study”

Epidemiology

• Dramatic increase over the past 10 to 20 years in number of cases seen by hospitals involving nonlethal self-injury (both suicidal and nonsuicidal)
• Predominant sex: Some studies have found higher rates in adolescent females than males; however, no difference in adults.
• Predominant race: limited evidence; some studies have found higher rates among Caucasians.

Pediatric Considerations
Average age of onset is 12 to 14 years with significantly higher rates of NSSI in adolescents.

Incidence
Limited data; mean incidence rate within a 12-month time frame was 4.32%.

Prevalence

• Estimates vary widely due to lack of large-scale epidemiologic studies.
• 7.5–46.5% of adolescents, 38.9% of university students, and 4–23% of adults report having self-harmed at least once (1).
• 6–8% of adolescents report recurrent/chronic self-injury.
• Higher prevalence among clinical samples: 40–60% of adolescents, 19–25% of adults; up to 100% of psychiatric inpatients in some studies (1)

Etiology and Pathophysiology

• Several theories for why individuals self-injure, although all emphasize that motivation is not suicidality
• Internally directed affective reasons—effectively reduces emotional distress from intense feelings such as anxiety, anger, depression, guilt, or shame
• Internally directed cognitive reasons—self-punishment, relief from dissociation or depersonalization
• Less commonly, externally directed motivations—self-injury as a means of communicating distress, manipulating relationships, conflict resolution, or attention-seeking

Risk Factors

• History of self-harm and/or suicidality (1)
• Diagnosis of major depressive disorder (MDD), specific phobias, obsessive-compulsive disorder (OCD), externalizing disorders, substance use, and borderline personality disorder (BPD)
• Alexithymia (inability to identify and describe emotions) and dissociation
• Increased impulsivity, emotional reactivity, and hostility
• Stressful life events, history of trauma, and history of sexual abuse
• Dysfunctional family/home environment

General Prevention

• Screen for risk factors in adolescents.
• Destigmatize help-seeking behaviors and address concerns about confidentiality.
• Encourage access to safe and nonjudgmental adults for mentors and role models.
• Provide information to all patients regarding 24/7 access to emergency care and mental health/crisis resources.
• Educate and provide resources to parents/caregivers about NSSI and how to respond.

Commonly Associated Conditions

• MDD (strong association)
• BPD (strong association)
• Eating disorders
• Substance use disorder
• Anxiety disorders
• Specific phobias
• OCD