Cutting and Self-Harm
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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, and interfering with wound healing.
- 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