Self-Injury

What Causes Self-Injury?

Doctors and researchers have not yet determined the exact cause(s) of self-injury, but they have identified several risk factors that increase an individual’s likelihood of developing the behavior.

• Social context. Having friends, family members, or close acquaintances who engage in self-injurious behavior increases the likelihood that a person will engage in the conduct themselves.
• Life circumstances. Self-injury is more common in people who experience difficult situations such as abuse, neglect, trauma, family instability, issues with sexual identity, or social isolation.
• Age. The behavior often develops in the preteen or early teen years. However, it may emerge at any stage of life.
• Mental health issues. Self-injury is often associated with other mental health-related issues, including depression, anxiety, or post-traumatic stress disorder (PTSD).
• Alcohol or drug use. Self-injury is more common in people who have substance abuse problems.

The situations that trigger self-injury are varied and complex, but they typically involve negative emotional states such as:

• Loneliness
• Anger
• Guilt
• Low self-esteem
• Social rejection
• Confusion around sexuality or gender

Is Self-Injury Hereditary?

In most cases, self-injury behavior does not seem to be inherited. However, studies have indicated a genetic component exists in both suicidal behavior and nonsuicidal self-injury. Research has identified some genes that may be associated with the behaviors, but no single gene has been conclusively identified as a cause. Genetic factors may increase the risk of self-injury behavior, but the behavior likely arises from a combination of genetic and external environmental factors.

How Is Self-Injury Detected?

Identifying self-injury behavior in children and teens can be difficult because the person usually takes steps to hide both the behavior and the evidence of injuries after the fact.

Potential warning signs of self-injury include:

• Avoidance of social situations
• Problems in relationships with family or friends
• Changes in behavior or emotional state
• Moodiness
• Emotional numbness
• Depression
• Expressions of negative self-image
• Spending a lot of time alone
• Wearing long sleeves or long pants, even in inappropriate weather
• Claiming to have frequent accidents that cause injuries
• Appearance of fresh cuts, scratches, or scars

How Is Self-Injury Diagnosed?

To diagnose nonsuicidal self-injury (NSSI), a doctor will first rule out other potential medical causes of the symptoms. If the symptoms seem to meet the diagnostic criteria for NSSI, the patient will likely be referred to a mental health professional for further assessment.

The results of the psychological assessments will be compared to the diagnostic criteria for NSSI in the Diagnostic and Statistical Manual of Mental Disorders. Comparing these criteria will help a mental health professional decide whether the symptoms indicate NSSI or another psychiatric problem (such as borderline personality disorder, anxiety disorders, or depression).

The diagnostic criteria for NSSI include:

• The person has engaged in socially unacceptable self-injurious behavior for at least five days.
• The behavior has the intent to cause harm but not death.
• The behavior is associated with negative feelings and is expected to provide relief from those feelings.
• The behavior may cause distress or impairment of the person’s daily functioning.
• The behavior is not associated with another medical or mental health issue and is not caused by substance use.

How Is Self-Injury Treated?

NSSI currently has no cure, but psychotherapy may effectively reduce the severity of symptoms in many patients. When NSSI is associated with an underlying mental health-related issue, medications may be used to treat the underlying disorder.

Psychotherapy

Psychotherapy is the most common course of treatment for nonsuicidal self-injury. Commonly used therapeutic approaches include:

• Cognitive-behavioral therapy (CBT)
• Dialectical behavioral therapy (DBT)
• Emotion-regulation group therapy (ERGT)

Medication

No medications have proven effective at treating self-injury behavior by itself, but medications may be used to treat other mental health disorders that coincide with NSSI. Treatment of underlying disorders sometimes improves the symptoms of NSSI as well.

Hospitalization

In severe cases in which self-injury is frequent and/or potentially dangerous, mental health professionals may determine that short-term hospitalization and intensive treatment are necessary to keep a person safe.

How Does Self-Injury Progress?

Left untreated, self-injury may eventually lead to long-term mental and physical complications, including:

• Lack of close relationships
• Emotional distress
• Depression
• Anxiety
• School or work problems
• Damage to the skin, bleeding, scarring, or infections
• Unintentional severe injuries

Although self-injury behavior is usually not intended to cause serious harm, people who engage in the behavior are at increased risk of suicide or suicide attempts. Therefore, it is important to take the behavior seriously and seek professional help when signs of self-harm emerge.

How Is Self-Injury Prevented?

NSSI cannot be prevented, but early diagnosis and a consistent treatment plan can help manage symptoms and prevent them from leading to potentially serious consequences. Therefore, adherence to a treatment plan is essential for those diagnosed with NSSI.

Self-Injury Caregiver Tips

Caregivers for someone with NSSI should consider these tips to help the sufferer and themselves cope with the disorder:

• Learn as much as possible about the disorder, including its warning signs and potential complications.
• Seek out appropriate professional treatment.
• Help your loved one forge healthy relationships and social connections.
• Find a support group for caregivers.

Many people with NSSI also suffer from other brain and mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with NSSI:

• Many people with NSSI suffer from depression or an anxiety disorder.
• Many people with NSSI  also have borderline personality disorder.
• NSSI is often associated with alcohol or substance use disorders.
• Antisocial personality disorder is often associated with NSSI.
• NSSI and eating disorders are often co-morbid.

Self-Injury Brain Science

The patterns of brain activity that underlie nonsuicidal self-injury are not well understood, but researchers have noted some types of activities and connections between parts of the brain that are more common in people who engage in the behavior. These findings have led scientists to develop theories about how atypical brain function can lead to NSSI.

• Emotional processing. People with NSSI may show increased activity in several different brain areas, including the amygdala, a part of the brain responsible for detecting threats and triggering responses to them. An overactive amygdala may put a person into a persistent state of distress. Hyperactivity in the anterior cingulate cortex and orbital frontal cortex could interfere with emotional processing. In addition, overactivity of the hippocampus, which plays a role in memory retrieval, could cause excessive access of negative emotional memories.
• Reward-consequence disconnection. Poor connections between the orbital frontal cortex and the parahippocampus may make people with NSSI less able to associate the pleasurable feeling they get from self-harming behaviors with the negative consequences of those behaviors.
• Self-image disruption. Overactivity in the cortical midline structures, a part of the brain involved in developing a sense of self, may lead to a negative or poorly developed self-image.

Self-Injury Research

Title: Digital Mental Health Intervention for Nonsuicidal Self-Injury in Young Adults

Stage: Not Yet Recruiting

Principal investigator: David C. Mohr, PhD

Northwestern University

Evanston, IL  

The primary purpose of this trial is to test the feasibility of conducting a randomized controlled trial (RCT) of an 8-week digital mental health intervention (DMHI) for non-treatment engaged young adults with repeated nonsuicidal self-injury. The DMHI will be a highly interactive conversational agent that conveys psychoeducational content and guides participants through skill-based activities. Researchers will conduct a 3-arm feasibility trial, randomizing participants to receive the self-guided DMHI, the DMHI with low-intensity coaching, or an active control involving the delivery of non-interactive psychoeducational content via the same app interface. Initial randomization will be generated in permuted blocks of 6 using a computer program, with participants assigned on a 1:1:1 ratio. To prevent allocation bias, randomization will be conducted by the biostatistician, who will not inform the study team of the treatment arms until the baseline assessment has been completed and the patient has been enrolled. The control group will serve as the reference group to verify the effectiveness of the DMHI, while the comparison of self-guided to coached deployments will evaluate the added benefit of coaching.

The primary clinical outcome measures will be the frequency of NSSI behavior (ABASI) and frequency of NSSI urges (ABUSI). Secondary outcomes will include suicidal ideation (DSI-SS), depressive symptom severity (PHQ-9), and anxiety symptom severity (GAD-7).

This study will enroll individuals who have met the following eligibility criteria: 1) current NSSI, defined as 2+ self-injury episodes (e.g., cutting, burning) in the past month; 2) Age 18 to 24; 3) English language skills sufficient to engage in the consent and intervention procedures. Participants will be excluded if they 1) Have a severe mental illness diagnosis (e.g., psychotic disorder); 2) Are imminently suicidal, with a plan and intent; or 3) Are currently receiving psychotherapy.

Coaching will provide users with support and accountability via positive reinforcement, goal and expectation setting, and monitoring. Coaching outreach will focus on adherence to the treatment but will not provide treatment advice. Coaches will provide a brief (20-30 minute phone call or equivalent depending on the medium) engagement phone call. Thereafter, coaches will check in with participants via messaging, phone call, or email twice weekly and respond to patient messages.

Title: Signatures of N-Ac for nonsuicidal Self-Injury in Adolescents

Stage: Recruiting

Contact: Kathryn Cullen, MD

University of Minnesota

Minneapolis, MN

This study is a double-blind, placebo-controlled, 4-week course of two-tiered N-acetylcysteine (NAC) dosing focused on identifying the optimal dose to achieve meaningful change in measurable biomarkers (glutathione and glutamate).

This design will allow researchers to confirm acute biological changes, select the optimal dose for achieving biological effects, and examine dose/concentration-response relationships with respect to biological markers and pharmacokinetics.

Brief schedule of activities: Subjects will be recruited through community and clinical settings and screened over the phone. There will be a total of 4 in-person visits and two sets of online study activities.

Eligible participants will be assigned to one of 3 groups (double-blinded): a low-dose NAC group (3600 mg/day), a high-dose NAC group (5400mg/day), and a placebo (PBO). The study intervention period is 4 weeks. Total participation is up to 8 weeks, depending on the length of time between Day 0 and Day 1.

The investigators will recruit 36 adolescents and young adults aged 16-24. There will be 12 participants in each group (PBO, 3600mg/day, 5400mg/day). The investigators will use a minimization procedure to ensure that the participants in these 3 groups will have similar age, clinical severity, and medication status.

Title: Technology Enhanced Adolescent Mental Health (TEAM) (TEAM)

Stage: Not Yet Recruiting

Principal investigator: Theodore P Beauchaine, PhD

University of Notre Dame

South Bend, IN

Adolescent nonsuicidal self-injury (NSSI) and alcohol misuse, alone and especially in combination, portend significant functional impairment in adulthood (e.g., relationship dysfunction, depression, suicidality). Although psychosocial interventions for NSSI and substance use are effective for some, they are also expensive and require highly trained clinicians. Treatment is therefore often unavailable to disadvantaged adolescents and those who live rurally. Thus, lower-cost alternative treatments are needed. Researchers will evaluate the efficacy of noninvasive transcutaneous vagus nerve stimulation (tVNS), an effective treatment for depression, in reducing the risk for NSSI and substance misuse among vulnerable adolescents.

The overarching goals of the proposed project are threefold. AIM 1: Evaluate the clinical efficacy of tVNS in reducing NSSI and alcohol misuse among vulnerable adolescents. Researchers hypothesize that self-administered tVNS, delivered in 25-minute sessions, will reduce self-reported NSSI and alcohol use, improve adolescents’ self-reported emotion regulation, and yield improvements in sympathetic and parasympathetic nervous system markers of emotion regulation and vulnerability to NSSI and alcohol misuse. AIM 2: Evaluate treatment adherence compared with traditional psychosocial interventions of similar duration. Researchers hypothesize that adolescents will demonstrate greater treatment adherence than observed in traditional psychosocial interventions of similar duration, and rate tVNS as acceptable, unobtrusive, and favorable to face-to-face treatment. AIM 3: Evaluate maltreatment effects on tVNS. Researchers hypothesize that tVNS will be effective for those with histories of maltreatment.

Although rarely used to date among adolescents, tVNS alters neural and emotional responses to sad stimuli, and among adults, reduces suicide risk up to five years later. At present, it is being evaluated as a treatment for alcohol misuse in an NIH-funded clinical trial. This suggests the potential for treating NSSI, alcohol misuse, post-traumatic stress symptoms (PTSS), and other disorders of emotion dysregulation. As outlined above, Researchers will test the efficacy of tVNS in altering behavioral, emotional, and autonomic nervous system risk for NSSI and alcohol misuse, evaluate adherence and acceptability of tVNS among adolescents, and determine if maltreatment histories moderate treatment response.