Treating Nonsuicidal Self-Injury

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While nonsuicidal self-injury (NSSI) is a huge problem for some people, it is eminently treatable.

While psychotherapy is considered frontline treatment, medications are sometimes also prescribed to help with the problems underlying the desire to self-injure. No medication has been approved in the treatment of NSSI alone.

Nonsuicidal self-injury is categorized into four types:

• Major NSSI: characterized by infrequent acts that severely damage the body such as eye inculcation or amputation. Seventy-five percent of these acts occur during a psychotic state and 50 percent of these are during a first psychosis.
• Stereotypic NSSI: repetitive, possibly monotonously so or rhythmic, self-harming behavior like head banging or lip biting. This type is generally associated with severe mental retardation.
• Compulsive NSSI: encompasses repetitive behaviors like severe skin scratching or hair pulling (trichotillomania).
• Impulsive NSSI: perhaps the most common and well-known type which includes episodic self-harming actions like cutting, burning or pin sticking. One person often uses multiple types of self-harm. One or two experiences of self-injury do not qualify as “impulsive,” (unless they require emergency medical attention) that only occurs after five-to-ten episodes.

Major Nonsuicidal Self-Injury

Because major NSSI is closely related with psychosis, the reasons for self-injury often defy logic. Reasons are often centered around religion or sexuality. In addition to schizophrenia, alcohol/drug intoxication and body integrity identity disorders are associated with major NSSI.

Prevention is, of course, key for major NSSI. This typically consists of treating the underlying psychosis. According to Armando R. Favazza, MD, “…agitated patients who have committed major NSSI are at high risk for a second episode and should receive pharmacotherapy… and hospitalized until the agitation is controlled.”

Stereotypic Nonsuicidal Self-Injury

Stereotypic NSSI is associated with autism, Tourette’s syndrome, Lesch-Nyhan syndrome, hereditary neuropathies, and mental retardation. Because people suffering from these disorders show cognitive difficulties, they often cannot articulate what drives their behaviors. It’s possible that the person may be suffering from an infection or pain but not be able to express it.

Behavioral therapy is the primary treatment but medication may also be used. Regarding medication, Favazza states, “Start with a moderate dose of a selective serotonin reuptake inhibitor (SSRI), then slowly add an atypical antipsychotic, followed by a mood stabilizer, then clonidine, and then a beta blocker; a trial of naltrexone also is an option.”

Compulsive Nonsuicidal Self-Injury

Compulsive NSSI is associated with trichotillomania and delusional parasitosis.

As with other forms of NSSI, psychotherapy is important and regarding medication treatment, Favazza states, “…SSRIs, lithium, benzodiazepines, and atypical antipsychotics (for delusional parasitosis) may be effective. N-acetylcysteine, 600 mg twice a day, may relieve trichotillomania.”

Impulsive Nonsuicidal Self-Injury

This type of self-harm is more common among females and often starts between the ages of 12 and 14. Some people consider impulsive NSSI to be an addiction over time, although this is debatable. People may identify as “cutters” and become preoccupied with self-injury.

This type of NSSI, too, is treatable but many people find stopping this behavior very challenging and it can be a day-to-day battle to not self-harm. People can become demoralized if they find they cannot stop their behavior and this can put them at risk for suicide.

While people with borderline personality disorder often self-harm, the presence of self-harming behavior does not necessarily indicate borderline personality disorder. Many other psychiatric disorders are associated with impulsive self-harm including:

• anxiety disorders (generalized, acute stress, posttraumatic stress, obsessive-compulsive, substance-induced)
• histrionic and antisocial personality disorders
• somatoform and factitious disorders
• dissociative identity and depersonalization disorders
• anorexia and bulimia nervosa
• depressive and bipolar disorders
• schizophrenia
• alcohol use disorder
• kleptomania

Treating impulsive NSSI involves treating the underlying mental illness, generally with medication. In addition, people should receive psychotherapy. Dialectical behavior therapy has been shown to be very useful in the treatment of NSSI and cognitive behavioral therapy is another common choice. Of medication, Favazza states, “Patients whose NSSI behavior is uncontrollable initially should receive high doses of SSRIs that can be lowered when impulsivity decreases, atypical antipsychotics and a mood stabilizer…”

Treating Nonsuicidal Self-Injury

There are many psychotherapeutic views on NSSI, but the important thing to remember is that NSSI can be treated. People absolutely can stop NSSI behaviors and one backslide into self-harm doesn’t indicate that a person has been unsuccessful; they just haven’t become as successful as they want to be—yet.
 

Reference: Current Psychiatry: Nonsuicidal self-injury: How categorization guides treatment