Nonsuicidal Self-Injury in Adolescents
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Background: 25–35% of adolescents in random samples drawn from German schools have been found to have manifested at least one episode of nonsuicidal self-injury (NSSI). The prevalence in samples from child and adolescent psychiatric clinics is approximately 50%. NSSI can arise as a symptom in the setting of various types of mental illness.
Methods: This review is based on a selective literature search carried out in the PubMed, PsycINFO, and Cochrane Library databases, with special consideration of regional study samples.
Results: NSSI is usually resorted to as a dysfunctional coping strategy for emotional regulation. The main risk factors for NSSI include bullying, accompanying mental illnesses, and a history of abuse and neglect in childhood. Neurobiological studies have shown abnormal stress processing in persons with NSSI and an elevated pain threshold in persons with repetitive NSSI. Psychotherapeutic interventions of various kinds lessen the frequency of NSSI; to date, no particular type of psychotherapy has been found to be clearly superior to the others. Randomized controlled trials have revealed small to moderate effects from dialectic-behavioral therapy and mentalization-based therapy in adolescent patients. No psychoactive drug has yet been found to possess specific efficacy against NSSI in adolescents.
Conclusion: The first ever German-language clinical guidelines for the treatment of NSSI have now been issued. Psychotherapy is the treatment of first choice. More research is needed so that subgroups with different disease courses can be more clearly defined.
With a lifetime prevalence of 25–35% of at least one incident of nonsuicidal self-injury in adolescents, Germany is one of the countries with the highest rates in Europe (1, 2). For this reason, this topic is of great relevance to physicians in various specialties. In recent years, three guidelines and a Cochrane review have focused on the clinical management of self-harming behaviors in the wider sense (3–6). In the following review article, the authors present the results of a review of the current literature and discuss guideline-conform treatment.
Nonsuicidal self-injury (NSSI) is defined as a direct, repetitive, socially unacceptable injury to body tissues, without suicidal intent (7). This includes cutting, scratching, or burning the body’s surface as well as hitting against objects, resulting in direct injury to skin or bones. In the International Statistical Classification of Diseases and Related Health Problems (ICD-10), NSSI exists only at the level of a symptom and is not defined as an independent disease entity. NSSI occurs in the context of various mental disorders, but also without accompanying psychopathology (8). Box 1 includes details of the history and definition of NSSI.
NSSI is relevant not only in the area of curative medicine. Self-injury also has a role in the setting of faked crimes—for example, in faked sex crimes, abductions, and assaults. Typically, findings will be in marked contrast to the dramatic narrative describing the purported circumstances. As a rule, what is found is a multitude of individual injuries to body regions that are easily accessible to the “victim’s” own dominant hand, with particularly sensitive skin areas spared. The covering garment is often untouched. The scratches, cuts, or abrasions are usually characterized by uniformly low intensity, similar appearance, an elongated pattern, grouping, or parallel order (9). The presenting features of self-injuries without a faked crime are very similar (Figure 1).
We conducted a selective literature review by searching the databases PubMed, PsycINFO, and the Cochrane Library, using the search terms “adolesc*”, “nssi”, “self-injur*”, and “self-harm*”. We included studies reported in German or English and published since 2007. We selected this time period because data from samples of German adolescents are available only from 2007 onwards.
According to a meta-analysis, the mean lifetime prevalence of at least one occurrence of NSSI in school samples worldwide is 17.2% (range 8.0–26.3%) (10). The rates are much lower in young adults (13.4%) and older adults (5.5%) (10). Similar age dependency has been reported for lifetime prevalence rates in Germany: while 25–35% of adolescents in school samples reported at least one incident of NSSI (1, 2), only 3.1% of the adult general population reported such behavior (11). The situation is similar for repetitive NSSI. In a school sample, 12.25% of adolescents reported repetitive NSSI (≥ 5 events within their lifespan) (1). By contrast, in a sample taken from the general population in Germany, only 0.3% reported repetitive NSSI (≥ 5 events within the preceding year) (11). Moran et al. reported a longitudinal study (12), which found that NSSI may peak in adolescence; a systematic review of longitudinal studies of NSSI arrived at the same conclusion. The researchers described how the prevalence of NSSI was highest around the 15th and 16th year of life and fell after the 17th year (13). A recent study reported a decrease in repetitive NSSI and suicidal behaviors in adolescents aged 15–17 in Germany at two-year follow-up, whereas high-risk substance misuse increased in this sample, especially in adolescents with frequent NSSI (14). This could be a first indication that in late adolescence, other dysfunctional behaviors will sometimes take over from NSSI.
A meta-analysis showed that NSSI in adolescence and early adulthood more commonly affects young women (odds ratio 1.5) (15), whereas the difference between the sexes is seen more clearly in clinical samples. A difference between the sexes seems to also exist with regard to the methods of NSSI. Young women tend to inflict cuts in more cases (1, 16), whereas young men seem to hit themselves more than young women (55.0% versus 42.4%) (16).
Risk factors and functions
NSSI seems to be associated with many risk factors. Several systematic reviews and meta-analyses identified sometimes overlapping similar factors (13, 17, 18) (Box 2). Researchers have described the following risk factors in longitudinal studies (13):
- Female sex
- Earlier NSSI
- Earlier suicidal ideation and attempts
- Symptoms of depression
- General psychological stress.
Regarding associations between NSSI and physical maltreatment, abuse, and neglect in childhood (17), a recent study compared different types of maltreatment, abuse, and neglect (19). The study showed that in a pathway model, only emotionally abusive actions were indirectly associated with NSSI via emotional expressiveness (standardized indirect effect = 0.11; p <0.05), although the study also showed significant associations between emotional abuse and sexual abuse or physical maltreatment (19). This seems to complement the findings among German samples regarding associations between NSSI and parental criticism or antipathy towards one’s children (20). Parental factors such as the following also played a part and were associated with NSSI in their children (21):
- Alcohol misuse
- Attention deficit/hyperactivity disorder (ADHD)
- Self criticism
- A low degree of compatibility and diligence.
At the level of peer influence, the phenomenon of social contagion was investigated in different settings (22). The authors point out that any so-called social contagion is likely to have a role in the initial contact with NSSI. Maintaining NSSI is often mediated via intrapersonal functions. Furthermore, associations were shown between the occurrence and frequency of NSSI and belonging to alternative youth cultures, for example, the Goth subculture (23). NSSI is also a hot topic on the internet (24). Bullying is a crucial social factor of influence in NSSI. Large cross-sectional and longitudinal studies have shown an association between self-reported experiences of bullying in childhood and early adolescence and NSSI in adolescence. In two longitudinal studies, the odds ratio for suicidal behavior and NSSI was 1.6–3.0 (25).
The four-factor model by Nock is often used to explain the motives for NSSI (7). The model identifies intrapersonal and interpersonal functions, and positive or negative amplification mechanisms can have an effect in either of these. Several studies have agreed that NSSI is primarily used to affect aversive emotional states (26).
NSSI is not an independent entity in the ICD-10. Other mental disorders are common comorbidities in the context of NSSI (27):
- Affective disorders
- Emotionally unstable personality disorders/borderline personality disorder (BPS)
- Substance misuse and dependence disorders
- Externalizing disorders
- Anxiety disorders
- Post-traumatic stress disorder (PTSD)
- Avoidant personality disorder.
In German-speaking female patients of child and adolescent psychiatrists, the most common comorbid diagnoses described were depression (79.5%), social phobia (38.5%), PTSD (28.2%), or BPS (20.5%) (28).
Even though neurobiological research into the consequences of NSSI mostly takes recourse to the literature on adults with BPS, in recent years an increasing number of studies have been conducted in adolescents with NSSI. One of the most common foci of research is the (altered) sensation of pain in those who harm themselves. Many adult patients with BPS experience hypoalgesia or analgesia during NSSI and a downregulation of limbic areas subsequent to the pain stimuli (29). However, results reported for adolescents have so far been contradictory (30–32).
Since NSSI is often used to cope with aversive emotional states, neurobiological markers of stress regulation have also been investigated in connection with NSSI. In adolescents with NSSI, cortisol concentrations were raised in the morning (e1) and lowered in the dexamethasone suppression test (e2). The finding of a deviating cortisol response in adolescents with NSSI in a situation of social stress (e3) has been replicated in an independent sample (e4). Interestingly, adolescents with NSSI show a stronger cortisol response to pain stimuli (32).
Adolescents with NSSI seem to primarily process social stressors less well. Genetic analyses—in the sense of a gene–environment interaction—also showed that in carriers of at least one short allele in the serotonin transporter-linked polymorphic region (5-HTTLPR) of the SLC6A4 gene, NSSI is more common when such adolescents encounter severe interpersonal stress (F[4, 570] = 2.65; p <0.05; partial eta squared = 0.02) (33). Because of the singularity of the finding, further studies of gene–environment interactions are highly desirable. Similarly, it was shown that social exclusion in depressed adolescents with NSSI, compared with adolescents without NSSI and health controls, resulted in differences in activation in different cerebral regions (medial prefrontal cortex: k: 26, Z: 3.69, p <0.001; parahippocampus: k: 18, Z: 3.72, p <0.001; supplementary motor area: k: 13, Z: 3.45, p <0.001) (34). Consequently, it is possible that adolescents with NSSI are also subject to particular sensitivity regarding social exclusion from groups. The findings shown here ultimately also highlight the extent of interactions between neurobiological deviations and the risk factors described above, such as bullying, in NSSI. However, it is still not possible to reach a final conclusion on causal associations—or otherwise—because of a lack of longitudinal studies.
Diagnostic evaluation and clinical management
The diagnosis of NSSI is based primarily on clinical presentation. In addition, several German-language data collection instruments are available (overview in eTable) that have also been validated in samples of adolescents. However, these are mostly used in research. The first step in care provision is a physical investigation. The depth of the wound is examined, as are possible contamination and tetanus vaccination status, and, if necessary, the relevant surgical procedure is initiated (3). Over the subsequent course, a psychopathological evaluation is necessary, including an exploration of acute suicidality. During history taking, the frequency and methods of NSSI and familial and extrafamilial factors influencing NSSI should be elicited, as should be the effects of NSSI on the patient’s social or familial environment (Figure 2) (3). A thorough exploration of suicidality is particularly important in adolescents with NSSI (35). Clinically, it should be borne in mind that self-injury and attempted suicide are clearly separate entities with different intentions and functions, although they may often go hand in hand (36) (Box 3).
After acute wounds have been dressed, a psychopathological assessment completed, and acute suicidality ascertained or otherwise, a decision has to be made on how to proceed from there onwards.
In patients subject to acute suicidality, inpatient child and adolescent psychiatric therapy should be initiated. In patients with their first event of NSSI without comorbid psychopathology, the physician should recommend that the patient and their parents or persons in loco parentis should seek out a clinic/counseling center (3). In patients with repetitive NSSI (Box 1) or comorbid psychopathological findings, subsequent treatment should be administered by someone with specialist professional skills in treating psychological disorders in children and adolescents—for example, physicians specializing in child and adolescent psychiatry and psychotherapy or psychotherapists for children and adolescents. In this setting, making contact quickly is strongly recommended (immediately in acute suicidality; in other cases, clinical experience would advocate a quick referral, within a week, preferably). The degree of suffering that prompted a patient to present to the doctor sometimes increases his/her motivation to make use of the help available.
Even though to date the situation vis-à-vis studies of the effectiveness of psychotherapeutic treatment is still unsatisfactory, a recent meta-analysis generally confirmed the effectiveness of psychotherapeutic methods in treating NSSI in adolescents (37). The therapies that were identified as effective were cognitive behavioral therapy, dialectic behavioral therapy for adolescents (DBT-A), and mentalization-based therapy for adolescents (MBT-A). MBT-A (38) and DBT-A (39) reduced NSSI in randomized controlled studies. In the MBT-A study with 12 months of follow-up, self-harming behavior decreased in the last three months compared with “treatment as usual.” 56% in the MBT-A group displayed self harming behavior compared with 83% in the control group (χ2 = 5.0; p <0.01; number needed to treat [NNT]: 3.66; Cohen’s d = 0.73) (38). In the DBT-A study, self-harming behavior decreased after 15 weeks—by 29.8% in the control group and by 70.7% in the DBT-A group (delta slope = −0.92; p <0.05; dkorr = 0.32) (39). The effects of the intervention were small to moderate. At 12 month follow-up, the DBT-A group was also superior to the group receiving enhanced usual care (reduction 55.9% versus 44.9%; p <0.05) (e5). A recent Cochrane review of therapy for self-harming behavior reached similar conclusions (6) and explains that the available results for MBT-A and DBT-A justify further evaluation, as does the therapeutic assessment, which is intended to motivate adolescents to undergo further psychotherapy. For the guidelines of the Association of Scientific Medical Societies in Germany (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften) (3), elements were developed that should be heeded when treating adolescents with NSSI (Box 4).
The recently published recommendations from Australia favor a similar approach (4). They name the commonalities of effective programs for reducing NSSI, which include the following interventions:
- Developing the motivation to change
- Support of abstinence
- Support for the environment (family and non-family)
- Strengthening positive affect
- A focus on healthy sleep.
Generally, in psychotherapy NSSI should always be treated in the context of other mental disorders if present.
As regards the effectiveness of treatment with psychopharmaceuticals, two systematic reviews concluded that no evidence exists for any specific psychopharmacological measure in NSSI in children and adolescents (6, 40). There are very few randomized controlled studies. When adolescents and young adults with borderline personality disorder were included, the substance aripiprazole, among others, reduced the NSSI (e6). Current guidelines mention this finding and see a role for psychopharmacological intervention only for the purpose of short-term sedation in states of high tension—for example, a great inner pressure to self-injure. Furthermore, the guidelines emphasize that guideline-conform treatment of comorbid mental disorders is indicated (3).
In the past 10 years, numerous studies have provided new information on risk factors, neurobiological associations, and especially therapeutic approaches, with the result that initial recommendations for treatment strategies have been incorporated into clinical guidelines. It was shown that psychotherapeutic measures may reduce NSSI as the method of choice.
However, there is much research still to be done. The question of whether—or if so, which—measures are effective in preventing NSSI remains unanswered. Furthermore, in spite of recent study results regarding social risk factors such as bullying and difficulties in dealing with social stressors, it remains unclear whether—and if so, which—causal association exists between these findings. For this reason, it seems to be highly desirable in this setting to combine in future studies epidemiological and longitudinal research approaches with neurobiological markers. As far as therapeutic research is concerned, it will be necessary to identify early predictors for the course. Accordingly, stepped care services, including online interventions as well as short term programs and longer term psychotherapeutic approaches, could constitute a treatment chain that meets the actual healthcare need.
Conflict of interest statement
Prof. Plener is in receipt of royalties relating to the subject matter from Springer and Hogrefe publishers. He has received study funding (third party funding) from Lundbeck and Servier. He has received speaker honoraria from Shire.
Prof. Kaess has received author and coauthor fees from Beltz and Hogrefe publishers.
Prof. Schmahl acts as a consultant for Böhringer Ingelheim.
Prof. Fegert has received travel expenses, speaker honoraria, and sponsorship for events and educational events from Shire. He has conducted clinical trials and acted as a consultant on behalf of Servier and Lundbeck.
Prof. Pollack and Dr Brown declare that no conflict of interest exists.
Manuscript received on 2 June 2017, revised version accepted on
17 October 2017.
Translated from the original German by Birte Twisselmann, PhD.
Prof. Dr. med. Paul L. Plener, MHBA
Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie
Steinhövelstraße 5, 89075 Ulm
For eReferences please refer to:
health consequences of peer bullying and maltreatment in childhood: two cohorts in two countries. Lancet Psychiatry 2015; 2: 524–31 CrossRef
Prof. Dr. med. Plener, MHBA, Prof. Dr. med. Fegert, Dr. phil. Brown
University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Switzerland: Prof. Dr. med. Kaess
Department of Child and Adolescent Psychiatry and Psychotherapy, Heidelberg University Hospital:
Prof. Dr. med. Kaess
Department of Psychosomatics and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim: Prof. Dr. med. Schmahl
Institute of Forensic Medicine at University Medical Center Freiburg: Prof. Dr. med. Pollak
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