Understanding Non-Suicidal Self Injury (NSSI):
Breaking Through the Myths
By: Rebecca Wenrich Wheeler, MA, MEd – Health Educator
Non-Suicidal Self Injury (NSSI) was classified as a psychiatric disorder for the first time in the most recent 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Hopefully this new classification will increase research and recognition of NSSI. Unfortunately research is lacking on NSSI-specific intervention and treatment, particularly because the disorder was once thought to be conjoined with other psychiatric disorders rather than standing alone (Washburn, et al. 2012). Previous to the DSM-V, self-injury was assumed to be symptomatic of other psychiatric disorders, such as borderline personality disorder, post-traumatic stress disorder and major depression (Walsh 2007). On the contrary, recent research has shown that self-injurious behaviors occur more often in high performing populations, such as Air Force cadets and Ivy League college students, who are not diagnosed with any other psychiatric disorders (Walsh 2007). As new research is conducted on the causes for and treatments of NSSI, one challenge for professionals is to dispel long-held myths about self-injury.
Myth 1: Self-injury equals cutting.
Some of the most common self-harming behaviors are scratching or pinching skin with fingernails, carving words onto the skin, banging or punching objects repeatedly to the point of bruising/bleeding, biting the skin, and pulling out hair, eyelashes, and eyebrows with the intent of harm, preventing wounds from healing. Most who self-injure repeatedly use multiple forms. (Whitlock 2009) Although rare occurrences, injury to the face, breasts, and genitals is an indicator of a psychotic issue or past trauma (Walsh 2007). Tattoos and body piercings are not considered self-harming behaviors, unless done repeatedly with the intent of destroying body tissue (Whitlock 2009)
Myth 2: Self-injurious behavior is a middle school phenomenon.
Among adolescents and young adults surveyed, 13-25% of had some history of self-injury, though many of these youth only engaged in the behavior once or twice and then stopped. In two college studies approximately 25% of students self-reported they started self-injuring in college, with 6% self-injuring chronically. These behaviors may persist well into adulthood. Middle school youth may have slightly higher rates than other age groups since that is when the behavior is typically initiated and tapers off as the student ages. Initiation of self-harming behaviors may begin in childhood or adulthood as well. (Whitlock 2009)
Myth 3: Only upper class white females self-injure.
One cannot designate a single “self-injurer” profile. Very few studies show an indication that rates among upper class white females are higher compared to other groups. In fact, some recent studies have shown similar rates in males and females. (Whitlock 2009)
Studies related to race are mixed. Some studies show higher rates in whites, others show no significant differences between races. As related to socio-economic status, studies have shown little significant difference between SES groups. In comparison with other demographic constructs, LGBTQ teens have higher rates of self-harming behaviors than other teen groups. (Whitlock 2009)
Myth 4: Those who self-injure are suicidal.
A defining characteristic of NSSI is that the self-harming behavior is not motivated by suicidal resolve, as “Individuals who self-injure are generally aiming to feel better, not end life” (Whitlock 2009).
The most common self-harming behaviors rarely cause death, and in fact the forms of self-injurious behavior listed under Myth 1 do not appear on the CDC’s list of lethal suicide methods (Walsh 2007). If those who self-injure are not suicidal then what is the purpose of the behavior? At the core, self-injury is a negative coping response to stress. “There is considerable evidence that most people self-injure to regulate emotional distress and interpersonal relationships” (Walsh 2007). Cognitive-behavioral therapy has shown to be helpful in treating NSSI as the person is taught to decrease emotional triggers and learn alternative ways to handle negative feelings (Walsh 2007).
It should be noted that even though self-injury is not often a result of suicide ideation, self-injury is a risk factor for suicide, especially if the self-injurious behavior has gone untreated for a prolonged period of time, and the person does not experience physical pain while engaging in the self-harming behavior (Walsh 2007).
Myth 5: Self-injury only has psychological motivations.
Recent research has focused on the biochemical connection to NSSI. Some of these biological aspects include: “limbic system dysfunction, depleted serotonin levels, problems with endogenous opioid system, and diminished pain sensitivity” (Walsh 2007). Those with NSSI often report a sense of physical relief after engaging in the behavior which researchers have related to the increase in endorphins and serotonin in the brain. Other biological elements that might impact the severity of self-injury are fatigue, insomnia and substance use (Walsh 2007).
Myth 6: The sole purpose of self-injury is to seek attention.
Those who self-injure often go to great lengths to hide their behavior from family and friends. A person might wear long sleeves or long pants year-round to hide wounds, or avoid participating in swimming or other activities that require less clothing. (Whitlock 2009) Those with NSSI often will injure inconspicuous places on the body that can be easy covered, for instance the abdomen and inner thigh, and typically engage in the behaviors while alone (Walsh 2007).
Some persons who self-injure report reluctance to seek help due to negative encounters with professionals in the past (Walsh 2007). Professionals who have minimal training in NSSI might react with shock and assume the person is suicidal, which is not addressing the concerns of the person with NSSI (Walsh 2007). In order to seek out anonymous support, people who engage in NSSI might visit social networking sites. Some studies have shown that after interacting with these e-communities people exhibit reduced self-harming behaviors, seemingly because they have a forum to express emotion (Lewis, et al. 2012). On the other hand, not all people experience this behavior reduction rather the behavior is reinforced by social media.
For tips on reducing Self-Injurious behaviors:
Serani, D. (2012, February 28). Depression and Non-Suicidal Self Injury. Retrieved June 26, 2015, from https://www.psychologytoday.com/blog/two-takes-depression/201202/depression-and-non-suicidal-self-injury
NSSI as depicted in Media:
Purington, A., & Whitlock, J. (2010, February 1). Non-Suicidal Self Injury in the Media. Retrieved June 28, 2015, from http://www.selfinjury.bctr.cornell.edu/perch/resources/non-suicidal-self-injury-in-the-media.pdf
NSSI and college students:
McCoy, K., Fremouw, W., & McNeil, D. (2010, November 1). Thresholds and tolerance of physical pain among young adults who self-injure. Retrieved June 29, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008662/
- Lewis, S., Heath, N., Michal, N., & Duggan, J. (2012, March 20). Non-suicidal self-injury, youth, and the Internet: What mental health professionals need to know. Retrieved June 28, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464157/
- Walsh, B. (2007). Clinical Assessment of Self-Injury: A Practical Guide. Retrieved June 26, 2015, from http://cemh.lbpsb.qc.ca/professionals/BarentWalsh-ClinicalAssessmentofSelf-Injury.pdf
- Washburn, J., Richardt, S., Styer, D., Gebhardt, M., Juzwin, K., Yourek, A., & Aldridge, D. (2012, March 30). Psychotherapeutic approaches to non-suicidal self-injury in adolescents. Retrieved June 26, 2015, from http://www.capmh.com/content/6/1/14
- Whitlock, J. (2009, December). The Cutting Edge: Non-Suicidal Self-Injury in Adolescence. Retrieved June 26, 2015, from http://www.actforyouth.net/resources/rf/rf_nssi_1209.pdf