Cutting and Self-Harm

Cutting and Self-Harm is a topic covered in the 5-Minute Clinical Consult.

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Basics

Synonyms: nonsuicidal self-injury (NSSI); deliberate self-harm; self-injurious behavior; self-mutilation; self-wounding; parasuicide; cutting

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

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