Research by Tsion Melkamu
Non-suicidal self-injury (NSSI) behavior in adolescents is an ongoing societal health concern and is defined as the deliberate, direct, and socially unacceptable destruction of body tissue, such as skin cutting, skin burning, and hitting oneself, but without an attempt at suicide. The possible motivation and potential purpose of NSSI behavior in adolescents might be to remove difficulties in life, release pressure or control emotion. NSSI behavior often carries a high risk of personal injury and high risk of repetition, which can increase the occurrence of suicidal behavior and seriously endanger the physical and mental health of adolescents . Many lines of evidence(4th citation) indicate that while adolescents are physically mature during puberty, they have yet to reach psychological maturity, have higher levels of impulsivity, and may experience difficulty in regulation of negative emotions and be prone to engage in NSSI behaviors. Moreover, NSSI during adolescence can have long-lasting and far-reaching developmental consequences, manifesting as anxiety, depression, and suicidal behaviors later in life as well as increased burden on society and families. The prevalence of NSSI in adolescents increased significantly at the beginning of the 21st century, and the incidence remains high.
Risk factors
These factors encompass physical symptoms(eg,disabilities and sleep problems),mental disorders, low health literacy, adverse childhood experiences,bullying,and problem behaviors. Regarding personal factors, a mental disorder diagnosis may heighten the risk of NSSI.Specifically, NSSI was observed to be significantly more widespread among patients with personality disorders,trailed by those with eating disorders,bipolar disorder, substance abuse,or dependence. Moreover,depression and anxiety symptoms are common emotional symptoms in adolescents and are influencing factors of NSSI. Individuals with depressive symptoms are more likely to choose self-injurious behaviors to regulate their emotions compared with those without depression.Lastly, Comorbid anxiety disorder, which refers to the coexistence of an anxiety disorder with another mental health condition or disorder, can be a risk factor for non-suicidal self-injury (NSSI) among individuals with depression.
Negative environmental factors exert a notable influence on the incidence of NSSI,including adverse childhood experiences,negative life events,poor family functioning,and inadequate social support. Life events can serve as short-term and long-term risk factors for NSSI. In the short term, life events may lead to abnormal functions of the immune system and stress response system and lead to individuals being vulnerable to stress.In the longer term, the number of life events predicts the occurrence of self- injury in the next year. year.Therefore,life events may have a significant impact on NSSI.
A case example
Tina was a 15-year-old girl whose boyfriend recently broke up with her. On the way home from school, she saw him kissing another girl. When she arrived home, she immediately went upstairs to her bedroom, locked the door, and cut herself on the wrist several times with a razor blade. Although she wore long sleeves to dinner that evening, her mother spotted the wounds and brought her daughter to the emergency room, saying her daughter had tried to kill herself. Tina, however, stated emphatically that she did not want to die. “I cut myself because it made me feel better,” she said.
A consulting psychiatrist interviewed Tina in the emergency room. A nurse had warned the psychiatrist that Tina was “borderline” and “gamey,” stating, “She just cut herself for attention. Don't let her manipulate you.” However, after an extensive interview with Tina, stated that there was insufficient criteria to merit a diagnosis of borderline personality disorder. In fact, despite her obvious problems coping with distress, Tina did not meet the criteria for any major mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV TR). T
ina explained to the psychiatrist that she cut herself because it was “calming.” She said that a year ago she first started pinching herself as a way to hurt herself. One day she saw her father's razor blades and started cutting herself on her arms. “It helps me chill,” she said. “My mind slows down, I stop crying, and I just feel better.” She said the razor slicing into her skin did not hurt badly—just enough for her to “feel alive.” She felt so much better after cutting herself that afternoon that she was able to concentrate on her homework and not think any more of her ex-boyfriend and the girl he was kissing.
Treatment strategies
Self injury in adolescence has only recently been recognized as a commonly occurring phenomenon. Consequently, there are few randomized, controlled trials for the specific treatment of NSSI in adolescents. In adults, the therapeutic intervention with the most research demonstrating efficacy in reducing self-harming behavior is dialectical behavioral therapy (DBT). DBT uses a combination of individual and group therapy to teach skills in emotional regulation, interpersonal effectiveness, distress tolerance, core mindfulness, and self management. The intensive treatment requires the individual clinician to be on call for these patients at all times. DBT has been adapted for adolescents with features of borderline personality, with the additional expectation that the group therapist is on call at all times for the parents. The clinical and financial demands of DBT have led to applications of less intensive treatments to reduce self harm, but these treatments are still under study.
Treatment is based on a thorough psychiatric evaluation, with a focus on acute safety issues, suicidal risk, and clarification of comorbid psychiatric conditions(mental health conditions that tend to show comorbidity include eating disorders,anxiety disorders,and substance abuse). Treating NSSI involves determining the needs that the behavior fulfills and helping the adolescent devise other, healthier ways to meet those needs. For example, if NSSI helps a teen to calm down, what other techniques might provide the same result? In the case of Tina, the psychiatrist might recommend that she develop mindful awareness skills, practice deep breathing exercises, use ice on her wrist to produce a physical distraction, talk to a friend about her emotions, or exercise strenuously. Improving effective language and other communication skills can be key in reducing NSSI. Since adolescents engaging in NSSI often have poor problem-solving abilities, it is important to improve these skills as well. Involving family in the support and treatment of adolescents with NSSI is also very important. Poor communication with family has been associated with suicidal behavior in some adolescents. Improving the family's understanding of NSSI can be useful in decreasing conflicts. It can be helpful for the family to learn deescalation strategies and expand listening and communication skills. Family members can also help with safety plans and practicing problem solving skills.
Involving family in the support and treatment of adolescents with NSSI is also very important. Poor communication with family has been associated with suicidal behavior in some adolescents. Improving the family's understanding of NSSI can be useful in decreasing conflicts. It can be helpful for the family to learn deescalation strategies and expand listening and communication skills. Family members can also help with safety plans and practicing problem solving skills.
Pharmacological treatment of NSSI should primarily focus on any underlying psychiatric disorders. Currently, there are no specific medications approved for the treatment of NSSI. Since depression and anxiety often accompany NSSI, identifying and treating these disorders should be a top priority. Concerns about an increase in suicidal thoughts with adolescents using antidepressant medication should be reviewed with teens and their parents. While the protective effects of antidepressants appear to outweigh the risk of increased suicidal thoughts, medication use should be monitored regularly.
Additional precautions are helpful when prescribing medications for self-harming adolescents. Prescribing larger quantities of potentially lethal medication should be avoided and benzodiazepines should be used cautiously due to the potential for behavioral disinhibition.
References
1 . Peterson J, Freedenthal S, Sheldon C, Andersen R. Nonsuicidal Self injury in Adolescents. Psychiatry (Edgmont). 2008 Nov;5(11):20-6. PMID: 19724714; PMCID: PMC2695720. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695720
2 .Yan H, Yue W. Risk factors, theoretical models, and biological mechanisms of nonsuicidal self-injury: a brief review. Interdiscip Nurs Res. 2023 Aug 29;2(2):112-120. doi: 10.1097/NR9.0000000000000023. PMID: 37645376; PMCID: PMC10461723 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10461723/
3 .Brown, R.C., Plener, P.L. Non-suicidal Self-Injury in Adolescence. Curr Psychiatry Rep 19, 20 (2017). https://rdcu.be/dSl15
4 .Xiao Q, Song X, Huang L, Hou D and Huang X (2022) Global prevalence and characteristics of non-suicidal self-injury between 2010 and 2021 among a non-clinical sample of adolescents: A meta-analysis. Front. Psychiatry 13:912441. doi: 10.3389/fpsyt.2022.912441 https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2022.912441/full
5 .The Comorbidity of Anxiety and Depression https://www.nami.org/education/the-comorbidity-of-anxiety-and-depression/ 6 .By Arlin Cuncic, MA ,Updated on April 08, 2024,Medically reviewed by Steven Gans, MD https://www.verywellmind.com/what-is-comorbidity-3024480
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