Nonsuicidal self-injury in an adolescent patient

Discussion

Nonsuicidal self-injury is defined as the “deliberate, self-inflicted destruction of body tissue without suicidal intent, and for purposes not socially sanctioned.”⁴ Nonsuicidal self-injury was previously considered primarily in the context of borderline personality disorder; however, emerging research demonstrates that NSSI occurs in the context of other psychiatric disorders while also existing as a separate clinical condition. As a result, NSSI became a separate diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, under Section 3 (“Disorders Requiring Further Research”).⁵ Table 1 shows the diagnostic criteria for NSSI disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.^5,6

The causes of NSSI are multifactorial. Previous research suggested a strong association between NSSI and early childhood sexual abuse; however, a meta-analysis found a modest correlation, likely owing to shared psychiatric risk factors.⁷ Nonsuicidal self-injury manifests in various forms, such as cutting or carving skin, burning, punching, scratching, and breaking bones.⁸ Nonsuicidal self-injury is predominantly used to reduce a perceived intolerable negative affect and regulate distressing thoughts.⁷ Most individuals begin self-injuring during adolescence between the ages of 13 and 15 years.⁹ Adolescents are at a particularly high risk of NSSI, with 14% to 21% of community-sample adolescents self-injuring at least once in their lives, and 25% self-injuring repeatedly.^8,10 Research suggests that NSSI is increasing in prevalence, especially among adolescents, which makes it highly likely that family physicians will be the first point of contact for patients presenting with self-injury.¹ Nonsuicidal self-injury is also of concern because it is associated with other mental health issues that have to be considered in the differential diagnosis such as depression, borderline personality disorder, substance use disorder, developmental disabilities, eating disorders, generalized anxiety disorder, and post-traumatic stress disorder.² Although NSSI is distinct from suicidal behaviour, NSSI frequently occurs in adolescents who have considered or attempted suicide; typically, those who both self-injure and attempt suicide have longer histories of self-injury and use more methods.³ Thus, it is important for family physicians to have an appropriately high index of suspicion for those who self-injure who are at higher risk of suicidal behaviour.

The family physician–patient relationship is often built on trust developed over years; thus, those who self-injure might seek help from their family physicians as a first resource.¹¹ This therapeutic relationship enables the use of effective motivational interviewing techniques to encourage the change process while also assessing risk and allowing family physicians to determine appropriate referrals.¹² Probing questions include asking about the function of NSSI and effects that NSSI is having on patients’ lives, encouraging reflection on the disadvantages of continuing NSSI, and asking patients what resources they think they need to stop self-injuring.¹² Assessing NSSI involves first determining the severity of the self-injury, which is based on the frequency and number of methods used. Typically, low severity is 10 or fewer NSSI episodes and 1 NSSI method. Moderate severity is 11 to 50 NSSI episodes and 2 to 3 methods of self-injury, while high severity is more than 50 NSSI episodes and more than 3 methods.^12,13 Second, assessment involves evaluating the risk of suicidal behaviour, which increases with higher severity of NSSI.^3,12 There are also several validated questionnaires, such as the Functional Assessment of Self-Mutilation, that can be used to assess NSSI.¹⁴ Red flags for referral to behavioural health services include intense thoughts about suicide while self-injuring, multiple NSSI methods, early onset of NSSI, extended duration of NSSI (longer than 6 months), injuries requiring suturing or hospitalization, and high frequency of episodes (multiple episodes per week or more than 5 wounds per episode).¹² Research has suggested that NSSI might be a precursor to developing borderline personality disorder, especially in those who engage in both NSSI and suicide attempts, and early referral for mental health support might be beneficial.¹⁵

There are currently no approved medications specifically for NSSI disorder, but pharmacologic treatment should target any underlying psychiatric disorder that might have NSSI as a symptom.¹⁶ Family and interpersonal supports are essential in implementing management plans such as psychotherapeutic treatment to help the patient understand NSSI and use more adaptive coping strategies.¹⁶ Dialectical behaviour therapy, typically as a 12-month outpatient program with weekly individual cognitive-behavioural therapy sessions and skills training, has been shown to be effective in reducing NSSI in patients with severe or chronic symptoms.^16,17 In addition, general psychiatric management entailing case management, psychodynamically informed therapy, and medication management has been shown to be as effective as dialectical behaviour therapy.¹⁸