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  1. Murphy, Kathryn DNSc, NP


Nurses caring for adolescents across healthcare settings play a crucial role in the assessment of nonsuicidal self-injury.


Article Content

Nonsuicidal self-injury (NSSI) is described as the direct and deliberate destruction of one's own body tissue in the absence of lethal intent. It's increasingly seen in the adolescent population, affecting 7% to 45% of teens, with continuation into adulthood at rates between 4% and 28%. This prevalence is alarming because NSSI can result in severe scarring, nerve damage, infection risk, and accidental death. NSSI can also lead to academic struggles, interpersonal problems, and increased suicide risk.

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Symptoms usually start in early adolescence between ages 11 and 15, with female teens engaging in NSSI slightly more than their male counterparts. Some examples of NSSI include head banging, cutting, scratching, swallowing things, and burning. Typically, individuals engaging in NSSI use more than one method to self-injure. They may also have other mental health disorders, such as anxiety, depression, posttraumatic stress disorder, borderline personality disorder, dissociative disorders, and eating disorders. However, NSSI can occur without a coexisting mental health disorder.


The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, includes NSSI as a condition for further study. To meet the criteria for NSSI disorder, an individual must engage in 5 or more days of self-injury without suicidal intent in the past year. The self-injury must be related to interpersonal difficulties, negative feelings occurring immediately before the self-injury, planning to engage in self-injury, and repetitive thoughts about the self-injury. The criteria also include the individual's knowledge that this behavior results in significant distress and interferes with daily activities or roles. Lastly, the self-injury can't take place when an individual is experiencing delirium, withdrawing from any substance, or intoxicated.


With suicide being the third leading cause of death among those age 10 to 24 in the United States, how can you distinguish NSSI from suicidal behavior? The most important difference between NSSI and suicide is intention. Adolescents engaging in NSSI don't plan to end their life and they don't perceive that the injury may result in death. However, NSSI and suicidal behavior can co-occur, with NSSI being a possible predictor of suicidal ideation. In fact, suicide risk increases the longer the teen engages in NSSI, if he or she intensifies the frequency or lethality of the behavior, and/or when other mental health disorders are present.


Intense feelings

What motivates an individual to engage in NSSI? One of the most common reasons is to temporarily escape from intense feelings, such as sadness or guilt related to trauma. Adolescents may also use self-injury to punish themselves or make others feel the intensity of their distress. Some may engage in self-injury to fit in with peers. And the teen who's feeling depressed, numb, and empty may engage in self-injury to elicit feelings through physical pain.


Physiologically, self-injury results in the release of endogenous opiates from damaged tissue, leading to feelings of euphoria. At first, small amounts of self-injury provide calm and well-being but as tolerance builds, increasing amounts or lethality are needed to achieve the same result.


Adolescence is a turbulent time of development in a young person's life. Not only is the body undergoing physical changes, but the teen is also transitioning from dependence on his or her parents to substantial independence, which can cause psychological stress. Most adolescents develop good coping skills and may have family support; however, teens who've experienced poor parenting practices; physical, mental, or sexual abuse; and/or emotional dysregulation are at increased risk for NSSI. Trauma can lead to the belief that self-injury is an effective way to cope with stress. Parenting behaviors that can influence the development of NSSI include problematic attachment or exerting tremendous influence on the teen's behavior either by harsh physical punishment or psychological control.


Adolescents without any other mental health diagnosis may possess particular personality factors that make them more vulnerable to NSSI, such as psychological distress and emotional dysregulation. Adolescents who engage in NSSI may actually experience more psychological distress in response to adverse events than peers, which can lead to ineffective coping skills. These teens are then more likely to engage in self-injury to cope.


Emotional regulation is the process of monitoring, evaluating, and modifying emotional reactions based on the outside world. For example, a teen who experiences the loss of his or her first love interest feels that loss deeply, but learns to regulate the expression of those feelings to continue daily functioning. Dysregulation occurs when an individual either can't regulate the emotional response or has difficulty monitoring it. This can result in a lack of emotional awareness, causing the individual to be unable to appropriately adjust the emotions to fit the context. So, a teen who experiences the loss of his or her first love is unable to regulate that emotion and may use NSSI as a way to cope with the strong feelings.


Help with coping

Both cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are useful in decreasing NSSI. The goal of CBT is to change automatic thoughts that arise spontaneously and contribute to dysfunctional thinking. According to CBT, psychological pain comes not from the traumatic events themselves, but from thoughts that accompany these events. A patient engaging in NSSI may have faulty cognitive processes that cause him or her to interpret a minor inconvenience, such as a flat tire, as a disaster. The therapist uses cognitive restructuring to help the patient identify overreactions and modify his or her thinking and emotional response to something more appropriate, such as learning how to put on a spare or joining an automobile club.


DBT uses a combination of therapies to teach skills related to emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness. It was developed for patients who exhibit harmful behaviors such as NSSI. DBT helps the patient unlearn these self-destructive behaviors and discover new ways of coping with intense emotions. Patients who undergo DBT are given individual therapy, group skills training, and phone coaching to make them more aware of their reactions and help them moderate their intensity. DBT can also reduce self-harm events, suicidal ideation, and depression.


During the psychotherapy process for NSSI, there are a set of recovery steps to follow. First, it's important to set limits on the behavior to ensure safety. Second, the patient must work on developing self-esteem by understanding why he or she began engaging in NSSI and what role it serves. Next, the patient starts to realize that the behavior can be controlled and healthier coping skills can be chosen. The last step in recovery involves a sustained period in which the patient can maintain an injury-free state. These stages guide the recovery process with the understanding that a patient may not move smoothly from one stage to the next and, with significant stress, may move backward.


Antidepressants can be effective when used to treat symptoms of depression, such as low self-esteem, suicidal ideation, and compulsive behaviors. Sertraline, paroxetine, fluoxetine, escitalopram, and mirtazapine are some of the drugs that may be used. Anticonvulsants, such as valproic acid, are especially helpful in balancing the intensity of feelings that can occur with NSSI or coexisting mood disorders. This class of drugs has some efficacy in controlling impulsive and aggressive behaviors. It's important to note that medications work best in conjunction with psychotherapy.


Be there now

Because self-injury is significant in the adolescent population, and due to the possibility of physical harm, all teens should be assessed for NSSI. Initiate screening questions pertaining to self-injury and suicide risk (see NSSI screening questions). The Non-Suicidal Self-Injury Assessment Tool and the Ottawa Self-Injury Inventory are tools that you can utilize in the assessment process. The Functional Assessment for Self-Mutilation is a self-reporting scale that helps assess frequency, methods, and functions of NSSI, and may be a good start to both assess the extent of the problem and build a relationship with the patient for future therapy or referral.


All of these assessment tools include the lethality of the methods used, the extent of injury, the frequency of NSSI, and the presence of family or environmental stressors. If self-injury is found, perform a suicide assessment, initiate a complete head-to-toe physical exam, and ask questions about how any injuries occurred. It's essential to assess the patient's risk of serious harm or accidental death, regardless of intent. It's also important to understand the variations in NSSI behavior, such as its presentation and function, to provide appropriate patient-centered care (see Signs that a teen may be self-injuring).


Educate both the patient and his or her family on safety measures, such as removing objects used to self-injure. Encourage the patient to notify a trusted person of any self-injuries to ensure necessary medical intervention. These interventions can be part of a safety plan agreement. Because of the enduring pattern of this disorder, it's vital to link patients and families with resources to help them in the long term.


Have empathy

Throughout the course of your practice, you'll encounter and be called on to provide care for individuals engaging in NSSI. Depending on your role, you may be involved in aspects of psychotherapy, medication monitoring, or managing a self-inflicted physical injury. Whether you're performing an assessment, making referrals, or treating NSSI, you can be an advocate for patients and their families. Replacing judgment of the behavior with empathy for the feelings associated with it can lead to successful intervention. By being aware of the effects of NSSI, you can help your patients develop healthy coping strategies.


Reasons for NSSI

cheat sheet


* To relieve intense negative thoughts or feelings, especially resulting from trauma


* To fulfill a need for self-punishment


* To visualize distress to others


* To model peer behavior


* To elicit feelings through physical pain, especially during depression


NSSI screening questions


* Have you ever thought about hurting yourself?


- When did you think about doing it? What did you think about it? Why?


* Have you ever hurt yourself?


- When was your first and last incident? What method did you use? Why?


- How often do you hurt yourself?


- Did you intend to end your life?


- Was medical care ever required?


- Do your parents or a trusted adult know?


* Do you feel isolated from family and friends?


* Do you ever feel hopelessness?


* What plans do you have for the future?


* Do you ever think that your parents, family, or friends would be better off if you weren't around?


Signs that a teen may be self-injuring


* Cut or burn marks on the arms, legs, and/or abdomen


* Hidden razor blades, box cutters, or sharp objects in the teen's bedroom


* The teen locks him or herself in the bedroom or bathroom following peer or family conflicts


* Nurses, teachers, or other adults report cuts or burn marks


* The teen's peers cut or burn themselves


* Wearing clothing, such as long sleeves in the summer, to hide the self-injury


* Siblings or friends report blood-encrusted sharp objects or witnessing the self-injury


on the web

For you

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Mayo Clinic:




National Center for PTSD:


For your patients


National Alliance on Mental Illness:


Project Semicolon:




Self-Injury Outreach and Support:




To Write Love on Her Arms:


did you know?

If you encounter a teen (or adult) with a semicolon tattoo or drawing on his or her wrist, it represents that their "story isn't over." Project Semicolon is a "global nonprofit movement dedicated to presenting hope and love for those who are struggling with mental illness, suicide, addiction, and self-injury."

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