Eur Child Adolesc Psychiatry (2011) 20:103–108

DOI 10.1007/s00787-010-0156-y

ORIGINAL CONTRIBUTION

Non-suicidal self-injury
Paul Wilkinson • Ian Goodyer

Received: 1 December 2010 / Accepted: 16 December 2010 / Published online: 11 January 2011
Ó Springer-Verlag 2011

Abstract Self-injury is a relatively common phenomenon Keywords Non-suicidal self-injury
Adolescence

in adolescence. Often there is no suicidal intent; rather, the Suicide
Depression
Borderline personality disorder
action is used for one or more reasons that relate to
reducing distressing affect, inflicting self-punishment and/ Abbreviations
or signalling personal distress to important others. Non- NSSI Non-suicidal self-injury
suicidal self-injury (NSSI) is both deliberate and contains DSM-5 5th Edition of the Diagnostic and Statistical
no desire to die and therefore aetiology is likely to be at Manual of Mental Disorders
least partly different to suicidal behaviour per se. Inter-
estingly, NSSI is associated with subsequent suicide
attempts suggesting that these behaviours and their related
psychology may lie on the same risk trajectory. NSSI
Introduction
neither appears in DSM-IV or ICD 10 as a disorder nor
does it constitute a component of any current anxious or
Seven to 14% of adolescents deliberately injure themselves
depressive syndrome. This lack of nosological recognition
at least once [1]. The most commonly reported behaviour is
coupled with clear psychopathological importance is to be
self-cutting, which is somewhat more frequent in females
recognised in the 5th edition of the Diagnostic and Statis-
than males. In some cases, self-harm is with the explicit
tical Manual of Mental Disorders (DSM-5), with NSSI
intention of trying to end their life. For the majority,
being classified as a syndrome in its own right. We agree
however, there is no suicidal intent. The most common
that this is appropriate and is likely to have several positive
reason for non-suicidal self-injury (NSSI) is to relieve
consequences including: (1) improving communication
intense distressing affect (e.g. sadness, guilt, flashbacks,
between professionals and patients; (2) informing treat-
and depersonalisation) by the use of sharp physical pain,
ment and management decisions; (3) increasing research
which can distract the sufferer from their unbearable feel-
into the nature, course and outcome of NSSI. We agree
ings [2]. Other reasons include: self-punishment, which the
with the proposed DSM-5 diagnostic criteria, although
adolescent sees as ‘deserved’; to gain attention so that other
believe the impairment criterion would be better phrased if
people can see their distress; to make other people feel
it stated that self-injury is associated with, rather than
guilty and change their behaviour; to fit in socially with
causal for, intense distress.
peers who self-injure. While NSSI often results in short-
term relief from distress [2], it frequently leads to longer-
term negative consequences. Emotionally, it can evoke
more complex feelings of guilt and shame towards the self
P. Wilkinson (&)
I. Goodyer [2]. Socially, it can lead to teasing from peers and shock
Developmental Psychiatry Section, University of Cambridge, from parents who may then become over-protective.
Douglas House, 18b Trumpington Road, Physically, it can lead to infection and scarring. Despite
Cambridge CB2 8AH, UK awareness of the negative consequences when in a calm
e-mail: pow12@cam.ac.uk

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104
mood, it can be difficult to resist the strong urge to self-
harm when angry and/or depressive feelings are intense,
especially when self-injury has been rewarded in the past
by reduction of distress. It is a problem, and adolescents
often want help in stopping it.
But, is NSSI enough of a problem to warrant a diag-
nostic label of its own? NSSI has been proposed as a new
diagnostic category within DSM-5 [3], see ‘‘Appendix’’.
This review will first discuss whether we think it appro-
priate to include NSSI as a separate DSM-5 psychiatric
diagnosis. It will then discuss the proposed DSM-5 diag-
nostic criteria.
Should NSSI be included within DSM-5?
In some cases of adolescent self-injury, it is difficult to
distinguish between suicidal and non-suicidal intent. But in
many cases, patients are clear that there was no desire to die
associated with the act. Therefore, it is feasible to phe-
nomenologically separate suicidal from non-suicidal self-
injury. That this adverse behaviour is clinically significant
over the life course with origins in childhood and adoles-
cence is suggested by its inclusion as an entry criterion for
borderline personality disorder (BPD) in adult life. To date,
there is no psychopathological significance given to this
behaviour in younger people, despite research findings that
in adolescent groups the condition is prevalent, impairing
and under-recognised [1]. Furthermore when present, there
is nowhere in the current classification of axis I emotional
disorders in young people to record this behaviour as a
symptom. While NSSI is a symptom of BPD [4], this is
generally seen as an inappropriate diagnosis for children and
younger adolescents, whose personalities are still develop-
ing. This implies by default that mental health professionals
do not need to consider this behaviour as abnormal or even
non–normative. We believe that the combination of the
feeling of intense negative distress (often characterised by
anger and/or sadness) and self-harm, together with their
adverse consequences, is both necessarily within the clinical
domain and of sufficient importance to warrant a separate
diagnostic category in young people.
We believe that the new proposed category of NSSI will
be helpful for several reasons: to improve communication;
to reduce problems from the lack of diagnostic specificity
for NSSI; to improve provision of treatment for adolescents
who engage in NSSI; improve research on aetiology,
treatment and outcome. These will be detailed below.
Improved communication
Concurrent as well as sequential co-morbidity of psychi-
atric diagnoses is common in mentally unwell and
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Eur Child Adolesc Psychiatry (2011) 20:103–108
behaviourally disturbed children and adolescents. It greatly
aids communication when all psychiatric diagnoses are
listed as a part of inter-professional communication,
especially if a multi-axial format is used. It also helps
clinicians to think of all the problems that need addressing.
Elevating NSSI to a full diagnostic category will increase
the visibility of this abnormal behaviour, ensuring that it is
recorded within a clinical formulation, thereby giving
greater clarity to the range of problems suffered by an
adolescent. Of course, this will only be useful if the pres-
ence of NSSI has implication in terms of treatment and
prognosis. We shall argue below that this is indeed the
case.
Reduced problems from lack of diagnostic specificity
for NSSI
The only DSM-IV psychiatric diagnosis which includes
NSSI as a criterion is BPD (301.83) [4]. This can lead some
clinicians to make an automatic assumption that a patient
who engages in NSSI may have this condition (BPD). This
is not appropriate for multiple reasons. First, many clini-
cians believe that a diagnosis of personality disorder should
not be given to a child or younger adolescent, whose per-
sonality is still developing [5]. Second, NSSI is often
present in patients with psychiatric disorders, including
depression, post-traumatic stress disorder, other anxiety
disorders, conduct disorder and substance misuse disorders
[6, 7]. Third, NSSI may be present and may be a problem
in a patient who does not meet diagnostic criteria for a
mental illness or personality disorder. It is clearly crucial to
make the correct diagnosis, so that appropriate treatment is
given. Assigning a specific diagnostic category to NSSI
makes it more likely that clinicians will consider treatment
and management in more flexible ways than may occur if
the assumption is made that NSSI is simply indexing a
BPD. Third, an assumption of BPD may lead to a bias in
clinician perception of an adolescent with mental health
difficulties. We know little about BPD components from a
developmental context and there is a risk of translating
down to the adolescent years information about treatment
and management generated from an older and putatively
different clinical population.
Improved provision of treatment
NSSI may be present with a psychiatric disorder, but for
many who engage in this behaviour, there is no associated
set of signs and symptoms to warrant a psychiatric diag-
nosis. In the absence of a mood or behavioural disorder (or
personality disorder in older adolescents), there is currently
no place for recording this behaviour. Nevertheless, ado-
lescents who engage in NSSI are deserving of treatment:
Eur Child Adolesc Psychiatry (2011) 20:103–108
both to reduce the distress and impairment from their
negative emotional state that leads them to self-injure, and
to reduce the harms from the NSSI. In health care systems
where funding may be dependent on diagnostic labels for
payment, a distressed self-harming adolescent will not
receive treatment unless they are labelled with an ‘incor-
rect’ diagnosis for their presenting complaint. It is not
known if this is currently occurring. The addition of NSSI
to DSM-5 will improve the chances of assessment, treat-
ment and management being given in the absence of other
emotional conditions.
NSSI has prognostic implications
NSSI in itself has negative emotional, physical and social
consequences. However, it is also associated with the more
worrying behaviour of suicide attempts. Cross-sectional
studies have demonstrated that adolescents who engage in
NSSI are more likely to make suicide attempts than those
who do not engage in NSSI [8]. Longitudinal research has
demonstrated that a history of NSSI before the index sui-
cide attempt is more likely in adolescent in-patients who
have attempted suicide than those who have suicidal ide-
ation but not suicide attempts [9]. Data from one of our
own studies (a secondary analysis of the ADAPT data)
demonstrate that the strongest predictor of a suicide
attempt over a 6 months follow-up in depressed adoles-
cents receiving treatment under randomized controlled trial
conditions is NSSI, but not suicide attempts, at baseline
[10]. This significant association holds when controlling
for other potential confounders at entry, including suici-
dality, gender, severity of depression and current family
dysfunction. A large follow-up study of people who pre-
sented to hospital with self-harm demonstrated that com-
pleted suicide is predicted by both NSSI and suicide
attempt as the index presentation, with no difference in the
likelihood of future suicide between baseline suicidal and
non-suicidal self-harm [11]. This longitudinal research
suggests that NSSI is a risk factor for future suicide
attempts. As only a minority of people who have suicidal
ideation attempt suicide; it may be that the presence of
NSSI is a marker for crossing the boundary between ideas
and suicidal acts. From the neuropsychological perspec-
tive, it may be that it represents a behavioural outcome of
impaired behavioural inhibition at a time of an acute rise in
negative emotional tone (fear, anger, irritability or sad-
ness), increasing impulsivity for and decreasing regulatory
factors against adverse self-harming behaviour [6]. Once
NSSI is established, it is possible that recurrence habituates
people to the pain from self-harm suggesting that they are
insensitive to punishing outcomes and/or more directed to
the acute rewards [6]. Most studies to date have not been
large enough to determine predictors for completed suicide
105
but suicide attempts are the strongest risk factor for future
suicide in adolescents [12]. Therefore, NSSI is likely to be
a predictor of completed suicide adding to the evidence
that the behaviour is clinically important.
The association of NSSI with future suicide risk means
that adolescents who engage in NSSI without any apparent
emotional or behavioural disorder are properly assessed for
suicide risk. Furthermore adolescents with other known
psychiatric risks factors for suicide, such as existing clin-
ical depression, substance misuse and conduct disorder,
should be assessed for a current and lifetime history of
NSSI [12]. Finally, NSSI may well have prognostic sig-
nificance for the development of BPD in young adult life
and earlier recognition and treatment may reduce the risk
of developing this pervasive and disabling condition.
Specific treatment for NSSI
The presence of short- and long-term adverse consequences
of NSSI means that treatment needs to be considered in its
own right and not just if the adolescent meets criteria for a
mental illness or behavioural disorder. Successful treat-
ment of existing psychiatric disorders may mean that NSSI
stops, but this does not always happen. Assigning NSSI as
a separate disorder is likely to increase the chance that
specific treatment will be offered. Once this occurs, there is
a greater chance than hitherto that effective treatments will
be developed. Sadly, research that has investigated strate-
gies to reduce self-injury (whether separated into suicidal
and non-suicidal self-injury or whether these two catego-
ries were combined) has failed to demonstrate efficacy or
effectiveness more than control treatments. Dialectical-
behaviour therapy has been demonstrated to be more
effective than treatment as usual at reducing suicidal and
NSSI in adults. There have been no randomized controlled
trials of DBT in adolescents and the non-randomized pilot
studies that have taken place have not demonstrated any
difference between DBT and treatment as usual [13].
Despite encouraging findings from an earlier study, a
specific group intervention (using CBT and DBT tech-
niques) led to higher self-harm rates than treatment as usual
in a study of self-injuring adolescents [14]. Two random-
ized controlled trials have demonstrated that adding cog-
nitive-behavioural therapy (CBT) to selective serotonin
reuptake inhibitor (SSRI) antidepressants leads to a sig-
nificant additional reduction in depressive symptoms. In
contrast neither study demonstrated that adding CBT to
SSRI led to a significant additional reduction in self-injury,
whether suicidal and NSSI were classified together [15] or
separately [16].
The lack of evidence for effective treatments for NSSI
in young people demonstrates the need to develop treat-
ments that are more specific than assuming indirect
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response via treating the primary psychiatric condition; and
subsequently test these in large, adequately powered
studies.
Improved research
Although there is an abundance of descriptive research on
adolescent self-injury, most fails to distinguish suicidal
from non-suicidal behaviours. From the above, we have
asserted that the two are not the same thing and they may
have different as well as shared aetiological components.
For example there are common aetiological factors, which
increase the risk of both behaviours: depression can contain
intensely distressing affect, which may be relieved by
NSSI, or a wish to be dead; the combination of impulsivity
and a lack of alternative coping strategies may lead to a
mentally ill young person to cross the threshold between
thinking of self-injury and carrying out the act; a childhood
history of abuse can lead to both suicidality and NSSI [2].
Some evidence is also emerging for distinct aetiologies:
adolescents who only attempt suicide are more likely to
have a concurrent clinical disorder of depression or PTSD
than those who only engage in NSSI; those who only
engage in NSSI are more likely to have features of BPD
[7]. In our ADAPT study, suicide attempts but not NSSI
were predicted by family problems; whereas, NSSI but not
suicide attempts were predicted by concurrent anxiety
disorders and female gender [10].
It is important that future research distinguishes the two
forms of self-injury. This will provide more information on
the prevalences of these behaviours, thus revealing the
public health implications and treatment needs. A more
detailed study of mechanisms of self-injury and comparing
these with suicide will ensue, including the neural systems
that may underpin each or both. Such mechanistic studies
would provide more information than is currently present
on the aetiologies of the two behaviours and is likely to
inform the design of specific treatments. Most importantly,
it should lead to treatment studies testing specific inter-
ventions for NSSI in the presence and the absence of other
psychopathologies.
We believe that the inclusion of NSSI in DSM-5 will
encourage research specifically on NSSI, rather than
including it within the broader category of self-injury.
Commentary on proposed DSM-5 criteria for NSSI
The proposed name of the condition:
non-suicidal self-injury
We think this to be an appropriate name that is consistent
with the term used in a lot of the literature [6]. It
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Eur Child Adolesc Psychiatry (2011) 20:103–108
appropriately and explicitly labels the behaviour as non-
suicidal. The term self-mutilation implies an extreme
degree of damage, whereas the usual behaviour is milder
(e.g. skin scratching with a blunt implement). Self-harm is
sometimes used, but some people include behaviours such
as gambling and substance use within this. As detailed
below, we do not think such a broad definition should be
used, and the use of the term self-injury makes it clear that
this behaviour is just referring to physically injuring
oneself.
Criterion A: definition of self-injury
We believe that criterion A is appropriate: the self-injury
needs to be significant, is explicitly non-suicidal and a
threshold of at least 5 days over 1 year limits this to people
who have truly repetitive NSSI, rather than just experi-
menting on a small number of occasions. The proposers of
this threshold for DSM-5 state that there is not good
research that correlates frequency of self-injury with an
external validator [3]; however, 5 days is around the
middle of the accepted range for the definition of NSSI in
most studies. We agree that it is reasonable to go with the
consensus view from extant literature in the absence of
evidence for criterion validity.
Some people have a looser definition of self-harm,
including risky behaviours, such as gambling and sub-
stance misuse. We agree with the proposed definition that
only includes self-injury that has the explicit aim of
injuring the self. While there are multiple reasons for such
self-injury, the person doing this is fully aware that this
injury will happen and wants the injury to happen. On the
other hand, behaviours such as gambling and substance
misuse have more complex motivations. In particular, they
are often motivated by the short-term pursuit of potentially
pleasurable rewards or insensitivity to losses, and any harm
to the self is incidental, not sought or intended. Behaviours
such as body piercing and tattooing are normally carried
out to improve physical appearance—the pain involved is
normally an unwanted rather than a desired side-effect. It is
important that research focuses on one homogenous
behaviour and we believe that NSSI is a reasonable
homogenous behaviour that is different to other types of
‘self-harm’.
Criterion B: associated features
People who engage in pathological NSSI have associated
negative thoughts and feelings that lead to the NSSI. It is
appropriate that this is reflected in the diagnostic criteria,
which here include both the negative feelings/thoughts
(and use of NSSI to relieve these) and the degree of pre-
occupation and urge. A threshold of two of these criteria
Eur Child Adolesc Psychiatry (2011) 20:103–108
makes it likely that all people who engage in truly patho-
logical NSSI will meet such criteria.
Criterion C: impairment criterion
It is essential to have a functional impairment criterion for
most diagnoses to demonstrate that somebody’s life is
adversely affected through distress or functional impair-
ment. Self-injury that is significant is associated with short-
and/or long-term adverse consequences (physical, social
and/or emotional). It is usually associated with significant
distress—before and/or after the self-injury. It may be more
appropriate for the criterion to state ‘The behaviour and its
consequences are associated with clinically significant
distress or impairment’ rather than using the word cause, to
reflect the fact that in some cases, the intense distress may
immediately precede, and trigger, the self-injury, and are
not caused by it.
Criterion D: exclusion criteria
We agree that it is important that for NSSI to be diagnosed
there must be clear intent to self-injure. Therefore, it is not
appropriate to diagnose it when intent may be clouded by
intoxication, delirium or psychosis. We also agree that
conditions with stereotyped behaviour that may include
self-injury should be excluded.
Conclusions
NSSI is common in adolescents. It is associated with
intense negative thoughts and feelings and negative emo-
tional, physical and social consequences. The behaviour
may occur in isolation or in association with one of a
number of specific psychiatric syndromes. We believe that
NSSI warrants a diagnostic category in its own right and
agree with inclusion of this in DSM 5.
Conflict of interest The authors have no conflicts of interests to
declare.
Appendix: Proposed DSM-5 criteria for NSSI [3]
A. In the last year, the individual has, on 5 or more days,
engaged in intentional self-inflicted damage to the
surface of his or her body, of a sort likely to induce
bleeding or bruising or pain (e.g. cutting, burning,
stabbing, hitting, excessive rubbing), for purposes not
socially sanctioned (e.g. body piercing, tattooing,
etc.), but performed with the expectation that the
injury will lead to only minor or moderate physical
107
harm. The absence of suicidal intent is either reported
by the patient or can be inferred by frequent use of
methods that the patient knows, by experience, not to
have lethal potential. (When uncertain, code with
NOS 2.) The behaviour is not of a common and trivial
nature, such as picking at a wound or nail biting.
B. The intentional injury is associated with at least two of
the following:
1. Negative feelings or thoughts, such as depression,
anxiety, tension, anger, generalised distress, or
self-criticism, occurring in the period immediately
prior to the self-injurious act.
2. Prior to engaging in the act, a period of preoc-
cupation with the intended behaviour that is
difficult to resist.
3. The urge to engage in self-injury occurs fre-
quently, although it might not be acted upon.
4. The activity is engaged in with a purpose; this
might be relief from a negative feeling/cognitive
state or interpersonal difficulty or induction of a
positive feeling state. The patient anticipates these
will occur either during or immediately following
the self-injury.
C. The behaviour and its consequences cause clinically
significant distress or impairment in interpersonal,
academic, or other important areas of functioning.
D. The behaviour does not occur exclusively during
states of psychosis, delirium, or intoxication. In
individuals with a developmental disorder, the behav-
iour is not part of a pattern of repetitive stereotopies.
The behaviour cannot be accounted for by another
mental or medical disorder (i.e. psychotic disorder,
pervasive developmental disorder, mental retardation,
Lesch-Nyhan syndrome).
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