Evidence-Based Reviews

Nonsuicidal self-injury: How categorization guides treatment

Current Psychiatry. 2012 March;11(3):21-26

References

1. Walsh BW, Rosen PM. Self-mutilation: theory research, and treatment. New York, NY: Guilford Press; 2008:32.

2. Nock MK, Favazza AR. Nonsuicidal self-injury: definition and classification. In: Nock MK ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association; 2009:9-18.

3. Favazza AR, Conterio K. Female habitual self-mutilators. Acta Psychiatr Scand. 1989;79(3):283-289.

4. Favazza A. Bodies under siege: self-mutilation nonsuicidal self-injury, and body modification in culture and psychiatry. 3rd ed. Baltimore, MD: Johns Hopkins University Press; 2011.

5. Gallina R. Tattoos and body piercing. In: Vale V Juno A, eds. Modern primitives. San Francisco, CA: Re/Search Publications; 1989:101-105.

6. Chapman AL, Gratz KL, Brown MZ. Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav Res Ther. 2006;44(3):371-394.

7. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.

8. Miller F, Bashkin EA. Depersonalization and self-mutilation. Psychoanal Q. 1974;43(4):638-649.

9. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27(2):226-239.

10. Nock MK. Actions speak louder than words: an elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Appl Prev Psychol. 2008;12(4):159-168.

11. Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72(5):885-890.

12. Nock MK, Prinstein MJ. Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol. 2005;114(1):140-146.

13. Favazza AR, Rosenthal RJ. Diagnostic issues in self-mutilation. Hosp Community Psychiatry. 1993;44(2):134-140.

14. Rosen PM, Walsh BW. Patterns of contagion in self-mutilation epidemics. Am J Psychiatry. 1989;146(5):656-658.

15. Large M, Babidge N, Andrews D, et al. Major self-mutilation in the first episode of psychosis. Schizophr Bull. 2009;35(5):1012-1021.

16. Kushner AW. Two cases of auto-castration due to religious delusions. Br J Med Psychol. 1967;40(3):293-298.

17. Moskovitz RA, Byrd T. Rescuing the angel within: PCP-related self-enucleation. Psychosomatics. 1983;24(4):402-403,406.

18. Cleveland SE. Three cases of self-castration. J Nerv Ment Dis. 1956;123(4):386-391.

19. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757-766.

20. Kahng S, Iwata BA, Lewin AB. Behavioral treatment of self-injury 1964 to 2000. Am J Ment Retard. 2002;107(3):212-221.

21. Levy KN, Yeomans FE, Diamond D. Psychodynamic treatments of self-injury. J Clin Psychol. 2007;63(11):1105-1120.

22. Lott IT, McGregor M, Engelman L, et al. Longitudinal prescribing patterns for psychoactive medications in community-based individuals with developmental disabilities: utilization of pharmacy records. J Intellect Disabil Res. 2004;48(Pt 6):563-571.

23. Sandman CA. Psychopharmacologic treatment of nonsuicidal self-injury. In: Nock MK ed. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association; 2009:291-322.

24. Sweeny S, Zamecnik K. Predictors of self-mutilation in patients with schizophrenia. Am J Psychiatry. 1981;138(8):1086-1089.

25. Grant JE, Odlaug BL, Kim SW. N-acetylcysteine a glutamate modulator, in the treatment of trichotillomania: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2009;66(7):756-763.

First-line treatment: Psychotherapy

Clinical Point

No medications are FDA-approved for NSSI but clinical experience suggests pharmacotherapy may help some NSSI patients

Many studies have demonstrated the efficacy of psychotherapy as the primary treatment for NSSI.^19-21 Except for patients with Lesch-Nyhan syndrome or other rare neurologic syndromes, the biologic causes of NSSI, including the role of endogenous opioids, are unclear. No medications are FDA-approved for NSSI. Pharmacotherapy may help NSSI patients, but such treatment recommendations are based on clinical experience, and polypharmacy is common.²² Studies have not demonstrated specific benefits or consistent efficacy of pharmacotherapy for NSSI.²³

Major NSSI. Prevention is key to addressing major NSSI. Consider atypical antipsychotics for psychotic patients who are preoccupied with religion, the Bible, or sexuality, as well as those who dramatically and suddenly change their appearance by cutting off their hair, engaging in extreme body modification practices, or wearing bizarre clothes.²⁴ In my clinical experience, agitated patients who have committed major NSSI are at high risk for a second episode and should receive pharmacotherapy based on treatment guidelines and hospitalized until the agitation is controlled.

Stereotypic NSSI. Patients with this form of NSSI often cannot articulate what is bothering them. With input from caretakers, assess the likelihood that a patient is reacting to pain. Analgesics may be effective. Also check for infections such as otitis media. Selecting a medication can be challenging. 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.²³ Behavior therapy is the primary treatment.

Compulsive NSSI. Compulsive NSSI patients typically seek help from dermatologists or family physicians. Literature on psychiatric treatment is limited, but SSRIs, lithium, benzodiazepines, and atypical antipsychotics (for delusional parasitosis) may be effective. N-acetylcysteine, 600 mg twice a day, may relieve trichotillomania.²⁵ Treatment should include psychotherapy.

Clinical Point

Psychotherapy, especially dialectical behavior therapy, is vital for impulsive NSSI patients

Impulsive NSSI. Patients who engage in episodic impulsive NSSI should receive pharmacotherapy for underlying psychiatric illnesses such as generalized anxiety disorder, posttraumatic stress disorder, or depression. Do not automatically diagnose borderline personality disorder. 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 such as lamotrigine. Psychotherapy is vital, especially dialectical behavior therapy. Cognitive-behavioral and interpersonal therapies also are effective, as is psychodynamic therapy.^19-21

NSSI patients and their families may benefit from Web sites that provide information, advice, monitored blogs, and support groups (see Related Resources).

Related Resources

Favazza A. Bodies under siege: self-mutilation, nonsuicidal self-injury, and body modification in culture and psychiatry. 3rd ed. Baltimore, MD: Johns Hopkins University Press; 2011.
Nock MK. Understanding nonsuicidal self-injury: origins, assessment, and treatment. Washington, DC: American Psychological Association; 2009.
Cornell University Family Life Development Center. About self-injury. www.crpsib.com/whatissi.asp.

Drug Brand Names

Clonidine • Catapres, Kapvay
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Naltrexone • ReVia

Disclosure

Dr. Favazza reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.