Self-harm

Nonsuicidal self-injury (NSSI) has become more prevalent in youth over recent years and has many inherent risks. In the Diagnostic and Statistical Manual, Fifth Edition (DSM-5), NSSI is a diagnosis suggested for further study, and criteria include engaging in self-injury for 5 or more days without suicidal intent as well as self-injury associated with at least 1 of the following: obtaining relief from negative thoughts or feelings, resolving interpersonal challenges, inducing positive feelings. It is associated with interpersonal difficulties or negative thoughts/feelings. The behavior causes significant impairment in functioning and is not better explained by another condition.¹

Estimates of lifetime prevalence in community-based samples of youth range from 15% to 20%. Individuals often start during early adolescence. It can pose many risks including infection, permanent scarring or disfigurement, decreased self-esteem, interpersonal conflict, severe injury, or death. Reasons for engaging in self-harm can vary and include attempts to regulate negative affect, to manage feelings of emptiness/numbness, regain a sense of control over body, feelings, etc., or to provide a consequence for perceived faults. Youth often may start to engage in self-harm covertly, and it may first become apparent in emergency or primary care settings. However, upon discovery, the response given also may affect future behavior.

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Risk factors include a history of trauma; mental health disorders such as depression, anxiety, or emerging personality disorder traits; substance use; and a peer milieu that sanctions self-harm. In one study of 1,560 Internet-using youth aged 10-17 years in the United States, 1% reported visiting a website or social media that encouraged self-harm or suicide. These individuals were found to be 7 times more likely to have suicidal ideation and 11 times more likely to harm themselves.² Regarding interpersonal difficulties, those who engaged in self-harm were more likely to have decreased contact with family or friends, to perceive having less support from friends, and to be less likely to seek out support. In contrast, these individuals tended to have increased contact with a significant other.³

Efforts also have been underway to distinguish between youth who engage in self-harm with and without suicidal ideation. Girls are more likely than are boys to report NSSI, although male NSSI may present differently. In addition to cutting or more stereotypical self-injury, they may punch walls or engage in fights or other risky behaviors as a proxy for self-harm. Risk factors for boys with regard to suicide attempts include hopelessness and history of sexual abuse. Maladaptive eating patterns and hopelessness were the two most significant factors for girls.⁴

With regard to issues of confidentiality, it will be important to carefully gauge level of safety and to clearly communicate with the patient (and family) limits of confidentiality. This may result in working within shades of gray to help maintain the therapeutic relationship and the patient’s comfort in being able to disclose potentially sensitive information.

In assessing youth for self-harm, maintaining a nonjudgmental stance in eliciting information is important. Screening for precipitants, intent of self-harm, experience of self-harm (Does the patient dissociate? Does the patient feel pain?), extent of self-injury, methods used, access to other potentially unsafe items, and suicidality is important. In addition, assessing the patient’s perspective about self-harm can be helpful, and distinguishing between patients who tried it and felt it was not helpful versus those who feel it is their most effective tool for coping. Establishing a strong therapeutic alliance is critical.

Families can struggle with how to manage this, and it can generate fear as well as other strong emotions.