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N on-Suicidal Self-Injury (NSSI), commonly referred to as self-injury or self-harm, may be confusing and difficult to understand. Many people have a hard time talking about self- injury because it seems unnatural to them. It is important to understand what motivates someone to harm themselves because not all people do it for the same reason. The best way to help someone to stop self- injuring is to help them address the underlying issues.

When someone self-injures, they do not intend to die. People who self-injure may do so as a method to cope with stress– hurting themselves is often seen as a way to control their upsetting feelings. Others do so to dissociate from their problems (e.g. to distract themselves from emotional pain). Research suggests that self-injury can activate different chemicals in the brain which relieve emotional turmoil for a short period of time.

Other motivations for why someone may self-injure include:

  • To reduce anxiety/tension
  • To reduce sadness and loneliness
  • To alleviate angry feelings
  • To punish oneself due to self-hatred
  • To get help from or show distress to others
  • To escape feelings of numbness (e.g. to feel something)
What are the symptoms of self-injury?

There are many ways in which a person can engage in self-injury behaviours, but the most common is cutting the skin with razor blades or pieces of glass. Injuries can range from moderate to severe.

Other forms of self-injury include:

  • Burning and hitting oneself
  • Scratching or picking scabs (to prevent wounds from healing)
  • Overdosing on medications
  • Pulling out one’s hair, eyelashes, or eyebrows with the intention of hurting oneself
  • Inserting objects into one’s body
Who is at risk for self-injury behaviours?

Self-injury has become more common than most people suspect. People who self-injure often begin in early adolescence, although they can be any age, ethnicity, or socioeconomic status.

People who have symptoms of Depression, Anxiety, or low self-esteem are more likely to self-injure. There isn’t one absolute predictor of self- injury, but the following predictors increase someone’s risk for self- injury:

  • Abuse/neglect (past/present)
  • Bullying
  • Past episodes of self-harm
  • Losses (e.g. deaths, break-ups)
  • Inability or difficulty coping
  • High self-criticism
  • Addictive behaviours/ substance-use
  • Peers/ family members who self-harm
  • Mental illness

Information about the prevalence of people who self-injure varies. This is because not everyone who self-injures seeks help or treatment, and because some jurisdictions combine data on self-injury with data on suicide making it difficult to obtain an accurate picture of either concern. A Canadian study conducted in 2002 found that 13.9% of high school students reported having self-injured. Females are more likely to self-injure than males.

How do you know if someone you love self-injures?

It’s often difficult to know if someone you love self-injures because many people are very secretive about the behaviour. The person may go to great lengths to hide any evidence and cover up any physical injuries. Keep an eye out for:

  • Cuts/scars on arms, legs, and/or stomach
  • Wearing long sleeves/covering legs in situations where it doesn’t make sense (e.g., on a hot summer day)
  • Finding razors and other sharp objects
  • Unexplained or poor excuses for injuries

Emotional warning signs are important to consider as well. Some indicators may include difficulty handling emotions, or problems with relationships. It is critical to recognize the signs and get help early so that the person’s behaviour does not escalate or lead to other serious injuries.

How can you tell the difference between suicide and non-suicidal self-injury?

It is common for those unfamiliar with self- injury to assume that self- injury is a suicide attempt that didn’t work – but that is incorrect. Self- injury is not an attempt to die. People often say that they self-injure so that they don’t attempt suicide. This can be confusing to onlookers because self- injury and suicide often involve the same behaviours, but the key difference is the motivation behind the behaviour. Individuals who self-injure engage in these behaviours so that they can feel better, not so that they can end their life.

Although self- injury is different than suicide, many people who self-injure may be depressed and may indicate that life is not worth living. They may have thoughts of death but no actual intention to die.

People who self-injure have a hard time dealing with their feelings. Self- injury is used to reduce, manage or escape from intense emotions. If someone you know self-injures, listen to what they are saying, talk about their emotions, and encourage the person to get help. If the person is at immediate risk of hurting themselves in a life-threatening way, they should be taken to the hospital.

What are the criteria for diagnosis of non-suicidal self-injury?

It is important to note that NSSI, or self-harm, is not a diagnosable mental disorder. More research is required to help mental health professionals better understand self- injury in people.

The following criteria are suggested as an area for further research in the 5th edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V):

  • In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of their body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent).

(Note): The absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behaviour that the individual knows, or has learned, is not likely to result in death.

  • The individual engages in the self-injurious behaviour with one or more of the following expectations:
  • To obtain relief from a negative feeling or cognitive state.
  • To resolve an interpersonal difficulty.
  • To induce a positive feeling state.

(Note): The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behaviour suggesting a dependence on repeatedly engaging in it.

  • The intentional self-injury is associated with at least one of the following:
  • Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.
  • Prior to engaging in the act, a period of preoccupation with the intended behaviour that is difficult to control.
  • Thinking about self-injury that occurs frequently, even when it is not acted upon.
  • The behaviour is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.
  • The behaviour or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.
  • The behaviour does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behaviour is not part of a pattern of repetitive stereotypies. The behaviour is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury, trichotillomania [hair-pulling disorder], excoriation [skin-picking] disorder).
What can you do if someone in your life self-injures?

It is important to encourage someone who self-injures to seek help. Although they may want to avoid discussing the issue, understanding the feelings and emotions that make them want to self-injure is an essential component of treatment. In addition to better understanding what causes someone to self-injure, treatment also focuses on learning more adaptive ways of coping, so that the individual can find healthier and safer ways to solve their problems.

Although it’s important to encourage the person to seek help, they must be ready and committed to change. Trying to force someone to change their behaviour before they are ready will only make the person increasingly resistant to treatment and cause frustration for you. Express your concern to the person, but don’t be overly dramatic or cause a scene. The person needs you to be part of their support system now and when they are in treatment. Self- injury can become addictive and a habit, so it is important to be patient during recovery. Don’t expect the person to change their behaviour right away. Remember that the person needs to have healthier coping strategies in place before completely relinquishing their self-injurious behaviour.

Being a positive influence while the person is seeking professional help is important. Encourage them to avoid things that can be used to hurt themselves. Remind the person to do things that make them happy. Help them connect with other people. Even just spending time with the person and listening to what they have to say can make a difference. Remember not to blame yourself and know that you should not handle someone’s problems with self- injury alone.

What treatment options exist for people who self-injure?

A variety of treatment options exist for people who self-injure. Determining which course of action is appropriate for each individual should be done with the guidance of a trained health professional.

Treatment options for people who self-injure may include one (or a combination) of the following:

  • Psychological Treatments: Psychotherapy or “talk therapy” works by helping your brain better control your thoughts and emotions. There are two different types of psychotherapy that have been found to be effective for treating self-injury:
  • Dialectical Behaviour Therapy (DBT), a type of therapy based on a philosophy of balancing, acceptance and change.
  • Cognitive Behaviour Therapy (CBT), a type of therapy which helps people understand, problem solve, and change the relationship between their thoughts, emotions, and behaviours
  • Medication: Medication may be used for people who have symptoms of Depression and/or Anxiety along with their self-injury behaviours. Rather than treating the self-injury directly, medication helps with the underlying issues that are contributing to why someone chooses to self-injure. For more information on how to properly use medications, check out MedEd.
  • School Supports: Sometimes certain adaptations can be made by the school to assist a student in coping with and managing their self-injury.
  • Regular Routine: Maintaining a healthy, regular daily routine is very important for someone who is struggling with mental health issues. For help maintaining the kind of healthy lifestyle that should accompany professional treatment, check out Taking Charge of Your Health.
Contagion and Self-Injury

For someone who uses healthy coping strategies to deal with emotion, knowing that someone else self-injures is unlikely to make them start. If, however, someone has difficulty coping with intense emotions, they may be more likely to self-injure after finding out that someone they know self-injures. It’s important to be aware that for some people, but not all, media portrayal and peer awareness of self-injury may act as a trigger for their own self- injury. Be attentive to what the person watches and hears, and talk to them about how they are feeling.

Related Disorders:

It’s important to note that many people who self-injure do not have a mental illness; although it is more common for someone who self-injures to have a mental illness than someone who does not self-injure. Most often, people who self-injure are looking for a way to deal with their emotions, and they will continue to self-injure until they learn more effective coping strategies.

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