Cutting and Self-Harm
Synonyms: nonsuicidal self-injury (NSSI); deliberate self-harm; self-injurious behavior; self-mutilation; self-wounding; parasuicide; cutting
- 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”
- 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.
Average age of onset is 12 to 14 years with significantly higher rates of NSSI in adolescents.
Limited data; mean incidence rate within a 12-month time frame was 4.32%.
- 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
- 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
- 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
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Domino, Frank J., et al., editors. "Cutting and Self-Harm." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816934/all/Cutting_and_Self_Harm.
Cutting and Self-Harm. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2020. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816934/all/Cutting_and_Self_Harm. Accessed May 31, 2023.
Cutting and Self-Harm. (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816934/all/Cutting_and_Self_Harm
Cutting and Self-Harm [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2020. [cited 2023 May 31]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816934/all/Cutting_and_Self_Harm.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Cutting and Self-Harm ID - 816934 ED - Domino,Frank J, ED - Baldor,Robert A, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816934/all/Cutting_and_Self_Harm PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -