Article summary with Non-suicidal Self-Injury in Adolescence by Brown & Plener - 2017

What is NSSI?

Non-suicidal self-injury (NSSI) refers to intentional self-injury to the body without a suicidal intend. It is not socially sanctioned, and does not include accidental and indirect self-injurious behaviors such as disturbed eating or drug abuse, or tattooing, piercing, or religious rituals. The most common forms of NSSI are cutting, scratching, hitting, banging, carving, and scraping. It is most prevalent in mid-adolescence, and thus it is an important point of concern for people who work with adolescents.

Epidemiology

In 2002, the prevalence of self-mutilation was around 14%. Other studies have found a prevalence of 17-18% for at least one form of NSSI. The rates of adolescents who meet the criteria for DSM-5 are around 1.5 to 6.7%.

NSSI can occur within psychiatric disorders, but also in individuals without a psychiatric disorder. Around 15-16 years NSSI peaks, and declines in late adolescence. Even though in late adolescence there is a decline, adolescents who engage in this behavior are at higher risk to develop dysfunctional emotion regulation strategies, even after they quit the behavior.

One study has shown that adolescents with NSSI behavior more often engage in substance abuse. It is also a risk factor for suicide attempts and suicides.

Etiology and Risk Factors

There are certain risk factors for the development of NSSI.

Demographic Factors

Adolescence is a vulnerable phase for developing NSSI. This is a result of increased impulsivity and emotional reactivity, which result from brain developmental processes. Females are also at higher risk for developing NSSI. They are also more likely to cut themselves compared to males, and males are more likely to hit against a wall. Higher IQ is also associated with a higher risk of engaging in NSSI.

Social Factors

Dysfunctional relationships and bullying are risk factors for developing NSSI. Being bullied poses a greater risk compared to being maltreated. The initial engagement in NSSI may be the result of social contagion (friends do it, so you do it, or the media shows it, and you try it). However, maintaining NSSI is not predicted by thus. Having a non-heterosexual orientation also increases the risk on NSSI.

Media Influence

There are a lot of internet searches on NSSI. There are also YouTube videos with a lot of views about it. However, it is not clear whether this is beneficial or harmful.

Adverse Childhood Events

Experiencing adverse childhood events like neglect, abuse or deprivation also increase the risk for engaging in NSSI. However, there are differentiated findings. For example, in one study only emotional abuse was a significant predictor. In another study, only indirect childhood maltreatment (witnessing domestic violence) was related to NSSI. Parental critique or parental apathy has repeatedly been shown to be a risk factor.

Neurobiological Factors

Studies have shown that there is an altered pattern of HPA axis regulation in NSSI. Individuals with NSSI also show higher cortisol awakening responses. There were also differences found in the activity of the medial prefrontal cortex (mPFC) and the ventrolateral prefrontal cortex (vlPFC) during social exclusion.

Thus, adolescent’s age, gender, social or medial contact with NSSI, bullying, and averse childhood experiences are risk factors for the development of NSSI.

What are the functions of NSSI?

The four-factor model describes what functions NSSI can have. There are intrapersonal and interpersonal processes. One function can be to diminish negative feelings or thoughts (anger, tension). This is called automatic negative reinforcement. Automatic positive reinforcement refers to experiencing positive feelings or thoughts after engaging in NSSI. Social positive reinforcement refers to getting attention from others, and negative social reinforcement refers to escaping unpleasant social interactions.

Automatic negative reinforcement has been found to be the most common function of NSSI. Experiencing physical pain leads to a decrease In negative effect.

What are therapies for NSSI in adolescence?

Surgical Treatments

Sometimes when wounds are deep, surgical treatment is necessary. Then, a good cooperation between all parties involved is necessary. Also, professionals should not show any negative emotions toward NSSI or the patient.

Psychotherapy

Dialectical behavioral therapy for adolescents (DBT-A) and mentalization-based treatment for adolescents (MBT-A) have shown to be effective therapies for NSSI in adolescence.

Treatment with Psychatric Medication

There is not a lot of research conducted on using psychiatric medication for the treatment of NSSI in adolescents.

NSSI as Independent Diagnosis

Currently, NSSI is only a symptom of borderline personality disorder (BPD). However, it has been suggested to be an independent disorder. There needs to be more research conducted before this can be established. If this would happen, this could lead to better communication, research, prevention, and intervention.

What is the conclusion?

NSSI is an important problem in adolescence. Even when adolescents quit, they have greater risks on long-term mental health problems. Bullying and negative social interactions are important risk factors, and childhood sexual abuse and physical abuse are less predictive. There are neurobiological alterations in the HPA-axis and the endogenous opioid system, and in the processing of emotional stimuli. There need to be more studies to validate the effectiveness of treatments such as DBT-A and MBT-A. There is also much research needed on the etiology and treatment of NSSI in adolescence. There is also an ongoing debate about whether it should be an independent disorder in the DSM-5.