Who Self-Harms?

Patient Presentation
A pediatrician got a telephone call about a 15-year-old male who he had been following for several years. The youth was last seen 9 months previously and had been healthy. There had been previous discussions about interpersonal problems such as a playground fight, having difficulty accepting authority such as referee decisions at a soccer match, and having more problems calming down when he was agitated. These were considered sporadic and minor incidents. His mother noticed bandaids on his wrist and asked him about it the previous evening. He confessed that he had started cutting himself 2-3 times over the past few weeks. She said that he expressed that he didn’t like himself very much because he would be angry at other people when he knew that it really wasn’t a big deal. He said he felt like he was going to explode at someone, but knew it was wrong, so he hid his anger until later. Later he felt really bad about the incident and did the cutting. She said he felt bad about doing the cutting too because he knew he shouldn’t be doing it. She had asked about him feeling very anxious about other things or feeling depressed. He said he felt a bit of both, but had no intention or plans of suicide.

The diagnosis of a teenager with self-harm behaviors and mental stress and anger issues was made. The teen was at school at the time and pediatrician discussed a safety plan with the mother. He also contacted a local youth mental health agency that provided emergency mental health screening and therapy referrals that afternoon.

The patient’s clinical course over the next few months, found him doing well in his therapy without additional episodes of self-harm. He also decided to use an anti-depressant medication in addition to his therapy. The following spring he was weaned off of the medication, denied any more self-harm episodes and had learned additional ways to manage his anger better. He was continuing his therapy monthly.

IF YOU ARE IN A CRISIS SITUATION AND NEED HELP, call 1(800) 273-TALK(8255) there IS someone there who can help you, En Espanol 1-888-628-9454, or Text “HOME” to 741-741. Other resources are available at http://www.suicidepreventionlifeline.org

Non-suicidal self-injury (NSSI) is defined as the intentional, self-inflicted damage to the surface of the body without suicidal intention, which is not socially sanctioned[,]” such as piercing or tattooing. Examples of NSSI include self-cutting (70-97%), hitting (21-44%), burning (15-35%), scratching, banging, scraping or carving.

The prevalence is increasing with more awareness and definition. In the beginning of the 1980s, the prevalence was 0.4% and increased to 0.75% by the end of the decade. About 4% is cited as a general population statistic, but rates are highly dependent on the age and population. Prevalence rates currently are estimated to be around 14-18% of adolescents with at least 1 incident in their lifetimes of “self-harm” or “self-mutilation.” Rates for adolescents meeting proposed criteria for NSSI by the DSM-V are lower at 1.5-6.7%. Other studies cite 13-45% of adolescents and 5-35% of young adults. It is unusual in childhood. NSSI is more common in 12-16 year olds and decreases after that time.

Self-harm episodes are not usually impulsive episodes but are often planned to take place when the person is alone and experiences negative ideas or emotions. “Paradoxically, most people who self-harm report feeling little or no pain during the self-injury. This phenomenon, which sometimes makes it more difficult to treat NSSI, is related to a process of habituation or to the release of endorphins…”

NSSI is associated with psychiatric diagnoses including borderline personality disorder, anxiety disorder, major depressive disorder, post-traumatic stress disorder, and substance abuse for example. A diagnosis of NSSI does not necessarily imply another psychiatric disorder. There is a high co-occurrence of borderline personality disorder (BPD) and NSSI. “The results suggest that 52% of adolescents who meet the criteria for a diagnosis with NSSI also have BPD, while 78% of individuals with BPD also meet the criteria for NSSI….[W]hile NSSI is a robust predictor of BPD, they are independent entities.” “NSSI is also the most robust risk factor for future suicide attempts (e.g. more than the presence of depressive symptomatology or family problems).”

NSSI is currently in Group III of the DSM-V which is for emerging measures and models. Additional research is encouraged for these potential disorders. There are models for the reasons or functionality for self-harm which use different measures in research. The Inventory of Statements about Self-Injury looks at intrapersonal (i.e. affect regulation, anti-dissociation, anti-suicide, marking distress and self-punishment) factors as well as interpersonal factors (i.e. interpersonal boundaries or influence, sensation seeking, peer bonding, revenge, self-care and toughness).

Repetitive self-harm is more likely with minor self-cutting but can be found with any type of self-injury. People with repetitive self-harm are more likely to have emotional dysregulation even after stopping the behavior.

Cognitive behavioral therapy, dialectical behavior therapy and acceptance and commitment therapy have been used to treat NSSI and a brief review of these different treatment options can be found by Thabrew et.al. in To Learn More below.

Learning Point
“In summary adolescent age, female gender, social or media contact with NSSI, bullying, and adverse child experiences like emotional abuse or neglect seem to be major risk factors for the development of NSSI. Findings from neurobiological studies point towards abnormalities in the [hypothalamic-pituitary adrenocortical] axis, the endogenous opioid system, as well as the neural processing of emotionality, socially, or physically adverse stimuli.” (author’s emphasis). A former history of NSSI, more cluster B personality traits, hopelessness and non-heterosexual sexual orientation are also strong risk factors.

Questions for Further Discussion
1. What are some of the major personality disorders?
2. How are mood disorders treated?
3. What should be included in a mental health safety plan? A review can be found here

Related Cases

    Disease: Self Harm | Non-Suicidal Self-Injury

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Self Harm

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Thabrew H, Gandeza E, Bahr G, et al. The management of young people who self-harm by New Zealand Infant, Child and Adolescent Mental Health Services: cutting-edge or cutting corners? Australas Psychiatry Bull R Aust N Z Coll Psychiatr. 2018;26(2):152-159. doi:10.1177/1039856217748248

Brown RC, Plener PL. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep. 2017;19(3):20. doi:10.1007/s11920-017-0767-9

Vega D, Sintes A, Fernandez M, et al. Review and update on non-suicidal self-injury: who, how and why? Actas Esp Psiquiatr. 2018;46(4):146-155.

Cully G, Corcoran P, Leahy D, et al. Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry. J Affect Disord. 2019;246:843-850. doi:10.1016/j.jad.2018.10.372

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa