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Non-suicidal self-injury

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Abstract

Self-injury is a relatively common phenomenon in adolescence. Often there is no suicidal intent; rather, the action is used for one or more reasons that relate to reducing distressing affect, inflicting self-punishment and/or signalling personal distress to important others. Non-suicidal self-injury (NSSI) is both deliberate and contains no desire to die and therefore aetiology is likely to be at least partly different to suicidal behaviour per se. Interestingly, NSSI is associated with subsequent suicide attempts suggesting that these behaviours and their related psychology may lie on the same risk trajectory. NSSI neither appears in DSM-IV or ICD 10 as a disorder nor does it constitute a component of any current anxious or depressive syndrome. This lack of nosological recognition coupled with clear psychopathological importance is to be recognised in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), with NSSI being classified as a syndrome in its own right. We agree that this is appropriate and is likely to have several positive consequences including: (1) improving communication between professionals and patients; (2) informing treatment and management decisions; (3) increasing research into the nature, course and outcome of NSSI. We agree with the proposed DSM-5 diagnostic criteria, although believe the impairment criterion would be better phrased if it stated that self-injury is associated with, rather than causal for, intense distress.

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Abbreviations

NSSI:

Non-suicidal self-injury

DSM-5:

5th Edition of the Diagnostic and Statistical Manual of Mental Disorders

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Correspondence to Paul Wilkinson.

Appendix: Proposed DSM-5 criteria for NSSI [3]

Appendix: Proposed DSM-5 criteria for NSSI [3]

  1. 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 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.

  2. B.

    The intentional injury is associated with at least two of the following:

    1. 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. 2.

      Prior to engaging in the act, a period of preoccupation with the intended behaviour that is difficult to resist.

    3. 3.

      The urge to engage in self-injury occurs frequently, although it might not be acted upon.

    4. 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.

  3. C.

    The behaviour and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.

  4. D.

    The behaviour does not occur exclusively during states of psychosis, delirium, or intoxication. In individuals with a developmental disorder, the behaviour 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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Wilkinson, P., Goodyer, I. Non-suicidal self-injury. Eur Child Adolesc Psychiatry 20, 103–108 (2011). https://doi.org/10.1007/s00787-010-0156-y

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