1. Non-Suicidal Self-Harm in Youth
Peggy Scallon, M.D.
Clinical Associate Professor
Child and Adolescent Psychiatry
UW School of Medicine and Public Health

3. Non Suicidal Self Injury (NSSI)
Defined as intentional, direct injury to one’s body tissue without suicidal ideation in a non socially sanctioned manner.
Examples are cutting, burning, scratching, or interfering with wound-healing.
Does not include overdosing, substance use, eating disorders, body piercing or tattooing

4. Cutting

5. NSSI 20% of adolescents engage in self-harm behaviors
Estimated 6% of youth are actively engaged in chronic NSSI
Typically begins between ages of 12-15
80% stop within 5 years, but may persist into adulthood

6. NSSI
Females self-harm more often, but less than previously assumed. Best estimates are 60% female; 40% male.
No known ethnicity or race differences
No known socioeconomic differences
Risk is much higher among bisexual or questioning youth

7. Cultural influences NSSI becoming more frequent
Movies and songs increasingly depict self-harm
Facebook and YouTube postings make it appear nearly normal and increase contagion effect.
Tattooing and piercing may normalize it

8. Celebrities who cut (and talk about it)

9. NSSI
Over time, repetitive cutting can lead to scarring, shame, low self-esteem, substance abuse, family and school problems, depression and suicide attempts
Depression, Anxiety, PTSD, Conduct Disorder, or Borderline Personality Disorder (BPD) may co-exist, but not always
Although common, few adolescents receive treatment for NSSI

10. DSM 5

11. NSSI in the DSM 5
NSSI is now recognized as a distinct condition in DSM 5 (released May 2013).
Placed in Section 3- so insurance does not reimburse for its treatment
Criteria-
5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent within the past year.
And at least 1 of the following expectations: to relieve negative feelings or thoughts, or to resolve a relationship problem, or to induce a positive mood.
And the behavior must meet 1 of these criteria: triggered by a relationship problem or negative feelings; includes premeditation, and rumination about the self-injury.

12. Neuroscience
These youth exhibit more stress (in the brain’s limbic system as seen on brain scans) from negative images and even misinterpret neutral images compared to a control group
In the face of a negative situation, distraction with another task decreases the emotional spike.

13. Deficits in social interpretation
These youth have deficits in interpreting and attributing the emotions, thoughts and intentions of others.
They are less trustful of others, and they interpret negative intentions from others.
They also express mixed and hard-to-read emotional signals to others, so they receive more negative responses from others.
In fact, this negative relational style may be the most specific feature of these youth.

14. Deficits in social interpretation
“The world and the people in it are dangerous and malevolent.”
Interpreted projective testing and social stories, interpretation of video clips.

15. NSSI can be addictive
Commonly report little or no pain with cutting or burning- instead it releases endorphins
Activates the same dopamine brain circuits (reward centers) as drugs of addiction
Can become addictive and hard to stop, because it is a powerful emotional regulator (very rewarding)
Usually not done together with alcohol or drugs (both serve the same function-to change mood and relieve stress)
Dopamine blocking meds (naltrexone) have been tried with little success

16. Cutting becomes rewarding

17. Why do they do it? 1) Emotional regulation-”to calm myself down”
2) Self-punishment- “express anger toward myself”
3) Anti-suicide- “put a stop to suicidal thoughts”
4) Anti-dissociation- “stop feeling numb”
5) Interpersonal influence- “let others know the extent of my pain”
6) Excitement seeking- “generate excitement”
Not mutually exclusive

18. Why do they do it? 7) Peer Bonding- “fitting in with others”
8) Self care- “creating an injury easier to fix than my distress”
9) Marking distress- “creating a physical sign that I feel awful”
10) Interpersonal Boundaries- “creating a boundary between myself and others”
11) Toughness- “seeing if I can stand the pain”
12) Revenge- “getting back at someone”
13) Autonomy- “demonstrating I do not need to rely on others for help”

19. NSSI works to change emotions
Before: “Overwhelmed”, “Sad”, “Hurt Emotionally”
During: “Angry at Self”, “Hurt Emotionally, “Isolated”
After: “Relieved”, “Angry at Self”, “Calm”
Thus, negative, high arousal goes down (overwhelmed and sad), and positive, low arousal goes up (relief and calm)
In summary, NSSI moves people from overwhelmed and sad; to relief and calm. It relieves emotional pressure

20. Why do they do it?
Frequent emotional distress and limited coping strategies (never normal)
Because they are emotionally reactive and have difficulty recovering or communicating
Cutting is rarely attention-seeking (normally done in private, and is hidden)
Sometimes a contagion effect among real and virtual peers
They are uncomfortable with emotions

21. Why do they do it?
Greater emotional sensitivity, (low threshold for upset, and longer time to recover)
Likely due to a biological predisposition
And emotionally invalidating environment
Therefore, these youth have intense, negative emotions, but they are confused, overwhelmed and flooded by emotions
Have to rely on impulsive strategies to keep emotions at bay.

22. Why do they do it?
Limited ability to express emotions, or trust others enough to communicate about feelings
They may lack good role models for coping with stress
Not necessarily related to abuse, but often insecure attachment relationships
After they do it, they describe relief, but also shame, disgust, and guilt
Cutting on face and genitals may reflect more psychopathology

23. Why do they do it?

24. Why is it worse in adolescence?
Transition from childhood to adulthood
Many new stressors and peer pressures
More separation from parents- reactivates attachment insecurities
Rapid brain changes
Changes in dopamine regulation
Hormonal changes affect mood and behavior

25. Suicidality and NSSI

26. Suicidality and NSSI
NSSI is distinct from suicidal behavior due to difference in intention, severity, and frequency
With NSSI- there is no intention to die, it is less severe than a suicide attempt, and it may be much more frequent
But 70% of kids with NSSI had also made at least one suicide attempt
Most kids with NSSI also have SI

27. Suicidality and NSSI
Important to clarify SI from NSSI to avoid unnecessary hospitalization, misuse of resources, and misunderstanding.
Ask, “Is your goal to die?”
NSSI is distinct from SI, but it is a strong risk factor for a suicide attempt

28. Suicidality and NSSI
In order to attempt suicide, need desire +capability. Suicide is scary, even if you have SI
Those with NSSI often have the desire for suicide, triggered by hopelessness, and high self-criticism
And they have the capability because of desensitization to pain and self injury.
So those with NSSI are at high risk for suicide
However, suicide is a rare event, and NSSI is common, so suicide is hard to predict

29. What makes it worse?

30. What makes it worse? Family stressors and conflict
Invalidation in the family environment
Excessive affective responses from parents or adults
Break-ups and “drama” with friends

31. How can mental health professionals help?
Insure safety
Assess for co-existing psychiatric disorders
Anxiety, depression, PTSD, eating disorders, or personality disorders can often be present.
No specific medication to treat NSSI, but should treat the co-existing disorders
Initiate psychotherapy

32. What can other concerned adults do to help?
Be direct and express concern
Keep the door open for later disclosure
Stay connected
Educate about emotions and positive coping
Ask for help or advice about how to handle this
Respond calmly- avoid shock and emotionality, but don’t minimize. Assess severity
Refer for more help
Insist that kids cover wounds and scars and educate about contagion

33. Developing emotional regulation
Become self-reflective about emotions (poor insight is typical)
Understand origins of one’s emotional experience
Understand the process of emotional regulation (starts with thumb sucking, social referencing)
Understand the consequences of emotional expression in different circumstances
Help draw connections between “emotional snapshots”, and make their narrative into a continuous video

34. What about therapy?
Therapy may include individual, family and group forms
Individual therapy focuses on support, skill-building, emotional expression, validation
Family therapy helps with communication, validation, conflict resolution
Group and individual therapy should be Dialectical Behavioral Therapy (DBT) focused

35. Therapy options- What is DBT?
Dialectical Behavioral Therapy is an intervention shown to reduce self-harm behavior
4 Modules- Mindfulness, Interpersonal Effectiveness, Distress Tolerance, Emotional Regulation
DBT may be delivered through group or individual therapy
Parents may be involved. It is a skills-based group.

36. Dialectical Behavioral Therapy

38. Mindfulness “Acceptance of what is” Being fully present Non-judgement
Impermanence
Non-attachment
Curiosity

39. Interpersonal Effectiveness

40. Interpersonal Effectiveness
How to regulate interpersonal relationships
How to establish appropriate boundaries
How to get one’s needs met
How to apologize
Problem-solving
Appropriate assertiveness
Mutual respect
Relational Positivity

41. Distress Tolerance

42. Distress Tolerance Tolerance of pain and discomfort
Enduring in the face of difficulty
Coping skills to persist or survive
Recognizing increasing stress levels
Teach emotion perception

43. Emotional Regulation

44. Emotional Regulation
Coping strategies to try to change a situation or one’s emotional state
Opposite action
Half smile
Coping strategies
Important to have a big “tool box”

45. Healthy coping

46. Healthy Coping Exercise Playing or listening to music
Talking with someone trusted
Meditation or prayer
Distraction
Relaxation
Humor

47. Healthy Coping Journaling or expression Getting outdoors
Looking at photos or happy memories
Cooking
Enjoying pets
Being productive
Helping others
More….

48. Unhealthy coping

49. Unhealthy Coping Self-harm Using alcohol or drugs Sexual acting out
Reckless acts
Isolation
Suicidality
Aggression or violence

50. What about “replacement” behavioral techniques?
Snapping a rubber band, rubbing ice on wrists, marking wrists with a marker have all been suggested
Do they help?
May “take the edge off”, but likely are taking a complex problem and offering a simple solution
Okay to collaborate with kids about whether they would like to try such techniques
Better to replace with a soothing ritual rub good smelling lotion on hands and wrists

51. What should parents do? Seek professional help
Also, be present and offer reassurance to your child

52. Level of supervision

53. What about taking doors off hinges, etc?
79% of adolescents with NSSI state that they want help
Try to avoid power struggles, but parents should supervise closely. Always know where kids are, and who they are with- and verify!
Take all reasonable measures to remove access to harmful objects
Guns in the home increase risk of suicide and violence
Parents should quietly increase positive presence and availability at home

54. Parent education- “Don’t freak out”
Validate- Communicate understanding and value the other person’s perspective
This is the most important skill, and the most difficult
Listen, accept, don’t judge, be caring and nurturing
Express love and concern
Recognize the distress
Don’t offer opinion or fix the problem
Give positive attention

55. More on validation- “Emotion Coaching”
Dr. John Gottman described this, and found it to decrease physiological arousal.
1) Notice emotions
2) Listen without judgment- see emotions as an opportunity to connect
3) Help label feelings
4) Communicate empathy and understanding
5) Support problem-solving process
The opposite of tickling while a child is mad or upset

56. Communicate well- Listen!

57. Offer hope and help

58. References
Niedtfeld I, Schulze L, Kirsch P, Herpertz SC, Bohus M, & Schmahl C (2010). Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury. Biological psychiatry, 68 (4), PMID:
SAMSHA- Suicide Prevention Resource Center (SPRC) Sept 12, E. David Klonsky
Klonsky, E.D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review
Klonsky, E. D. & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology: In session.

59. References
Klonsky, E.D. (2009). The functions of self-injury in young adults who cut themselves; Clarifying the evidence for affect-regulation. Psychiatry Research.
Adler P, Adler P.  2007.  The demedicalization of self-injury.  Journal of Contemporary Ethnography, 36,
Cheng H-L, Mallenckrodt B, Soet J, Sevig T.  2010.  Developing a screening instrument and at-risk profile for nonsuicidal self-injurious behavior in college women and men.  Journal of Counseling Psychology, 57,
Hilt LM, Cha CB, Nolen-Hoeksema S.  2008.  Nonsuicidal self-injury in young adolescent girls: moderators of the distress-function relationship.  Journal of Consulting and Clinical Psychology, 76,

60. References
Nixon MK, Cloutier P, Jansson SM.  2008.  Nonsuicidal self- harm in youth: a population-based survey.  CMAJ, 178,
Rodham K, Hawton K, Evans E.  2004.  Reasons for deliberate self-harm: comparison of self-poisoners and self- cutters in a community sample of adolescents.  Journal of the American Academy of Child & Adolescent Psychiatry, 43,
Whitlock J, Muehlenkamp J, Eckenrode J.  2008.  Variation in nonsuicidal self-injury: identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child and Adolescent Psychology, 37,

61. References
Proposed Diagnostic Criteria for the DSM-5 of Nonsuicidal Self-Injury in Female Adolescents: Diagnostic and Clinical Correlates Tina In-Albon, Claudia Ruf and Marc Schmid; Psychiatry JournalVolume 2013 (2013),
Frontiers in Neuroscience, 14 January 2013| Social cognition in borderline personality disorder; Stefan Roepke, Aline Vater, Sandra Preißler, Hauke R. Heekeren and Isabel Dziobek
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