Nonsuicidal Self-Injury

      Abstract

      Nonsuicidal self-injury (NSSI) is a serious and prevalent problem within the adolescent population. NSSI is associated with a variety of psychiatric diagnoses and behavioral concerns. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, has recognized NSSI as its own separate diagnosis. Although there are unique differences between NSSI and suicidal behaviors, a link exists between these behaviors. It is crucial that pediatric nurse practitioners who provide care for adolescents possess a thorough understanding of NSSI. In this continuing education article, NSSI will be discussed in terms of epidemiology, diagnosis and co-morbidity, risk factors, relationship with suicidal behaviors, and implications for practice.

      Key Words

      • 1.
        Identify diagnostic criteria for nonsuicidal self-injury (NSSI) from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
      • 2.
        Discuss risk factors related to NSSI.
      • 3.
        Understand the relationship between NSSI and suicidal behaviors.
      • 4.
        Understand possible motivations for NSSI behavior.
      • 5.
        Describe assessment and screening questions for NSSI.
      • 6.
        Identify NSSI prevention strategies the pediatric nurse practitioner can incorporate into practice.
      Nonsuicidal self-injury (NSSI) is defined as the deliberate infliction of damage, pain, or both to one's own body tissue without the intention of suicide (
      • Nock M.
      • Favazza A.
      Non-suicidal self-injury: Definition and classification.
      ). NSSI is a serious and prevalent problem within the adolescent population. It is crucial that pediatric nurse practitioners (PNPs) who provide care for adolescents possess a thorough understanding of NSSI. This continuing education article will explore NSSI in terms of epidemiology, diagnosis and co-morbid symptomatology, risk factors, relationship with suicidal behaviors, and implications for practice.

      Epidemiology

      It is estimated that 7% to 14% of adolescents deliberately injure themselves at least once (
      • Wilkinson P.
      Non-suicidal self-injury.
      ). Recent studies suggest NSSI is on the rise, perhaps up to a 24% 1-year prevalence (
      • Miller A.
      • Smith H.
      Adolescent non-suicidal self-injurious behavior: The latest epidemic to assess and treat.
      ). Onset of NSSI typically occurs in early adolescence between the ages of 11 to 15 years and can continue into adulthood (
      • Rodav O.
      • Levy S.
      • Hamdan S.
      Clinical characteristics and functions of non-suicide self-injury in youth.
      ). It is estimated that 4% of the adult population engages in NSSI (
      • Selby E.
      • Bender T.
      • Gordon K.
      • Nock M.
      • Joiner T.
      Non-suicidal self-injury disorder: A preliminary study.
      ). The prevalence of NSSI is slightly higher in females than in males. Common forms of NSSI include cutting, skin carving, biting, scratching, hitting, head banging, and interfering with wound healing (
      • Rodav O.
      • Levy S.
      • Hamdan S.
      Clinical characteristics and functions of non-suicide self-injury in youth.
      ). Gender differences exist for the methods of NSSI employed: burning and self-hitting are endorsed more frequently by males, with cutting and scratching more common in females (
      • Rodav O.
      • Levy S.
      • Hamdan S.
      Clinical characteristics and functions of non-suicide self-injury in youth.
      ). Persons who engage in NSSI tend to use more than one method and repeat the behavior. Behaviors such as body piercing or tattoos, which are more socially accepted, are not considered examples of NSSI. Scab picking or nail biting are also not considered forms of NSSI.

      Diagnosis and Comorbid Symptomatology

      NSSI is associated with a wide range of severe clinical psychiatric diagnoses and other dysfunctional behavioral problems (
      • Vaughn M.
      • Salas-Wright C.
      • Underwood S.
      • Gochez-Kerr T.
      Subtypes on non-suicidal self-injury based on childhood adversity.
      ). NSSI is in fact a diagnostic criterion for borderline personality disorder (
      • Selby E.
      • Bender T.
      • Gordon K.
      • Nock M.
      • Joiner T.
      Non-suicidal self-injury disorder: A preliminary study.
      ). However, NSSI can also be present in persons without borderline personality disorder. NSSI can occur as a symptom of other psychiatric diagnoses including anxiety and depressive disorders, substance abuse, eating disorders, post-traumatic stress disorder, and personality disorders other than borderline personality disorder (
      • Vaughn M.
      • Salas-Wright C.
      • Underwood S.
      • Gochez-Kerr T.
      Subtypes on non-suicidal self-injury based on childhood adversity.
      ).
      NSSI can exist in persons with no other diagnosable psychopathology. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V;
      American Psychiatric Association
      Diagnostic & statistical manual of mental disorders.
      ), lists NSSI as a separate diagnosis, whereas prior editions of the DSM included NSSI only as a symptom of borderline personality disorder and not as a distinct diagnosis (
      American Psychiatric Association
      Diagnostic & statistical manual of mental disorders.
      ). According to the DSM-V, in order to meet the criteria for the NSSI diagnosis, a person must engage in 5 or more days of intentional self-injury to the body surface without suicidal intent within the past year. The self-injurious behavior must be associated with one of the following criteria: interpersonal difficulties or negative thoughts/feelings (such as depression or anxiety) occurring right before the act, premeditation (i.e., planning the self-injury), and repetitive thoughts or rumination on the NSSI. Premeditation means that right before the act of self-injury, the individual was preoccupied with thoughts about the planned act. Even when the individual does not engage in the self-injurious behaviors, he or she is frequently thinking about them. Crucial to the behavior meeting the criteria for the NSSI diagnosis is that the self-injurious behavior is not socially acceptable and often can result in significant distress to the individual's life. In addition, the self-injurious behavior does not take place during psychosis, delirium, substance intoxication, or substance withdrawal.

      Risk Factors

      Adolescence is a vulnerable period of development when changes occur that can result in stress for the individual. Stress occurs when mental, emotional, and/or physical demands exceed the regulatory capacity of the organism (
      • Cohen M.
      • Tottenham N.
      • Casey B.
      Translational developmental studies of stress on brain and behavior: Implications for adolescent mental health and illness?.
      ). Adolescents are transitioning from dependence on parents to relative independence, which places new demands on them (
      • Cohen M.
      • Tottenham N.
      • Casey B.
      Translational developmental studies of stress on brain and behavior: Implications for adolescent mental health and illness?.
      ). It is a time marked by incredible change with increased responsibility and choices that can result in rewards as well as stresses. Most adolescents have adequate coping mechanisms to process their changing lives and can transition through adolescence without experiencing NSSI. However, a variety of external factors (e.g., adverse childhood experiences, poor parenting practices, and negative peer influences) and internal factors (e.g., emotional dysregulation and psychological distress) can place adolescents at risk for NSSI.
      Adolescents who experience adverse childhood experiences are at increased risk to develop cognitive distortions that can lead to the endorsement of NSSI behaviors (
      • Vaughn M.
      • Salas-Wright C.
      • Underwood S.
      • Gochez-Kerr T.
      Subtypes on non-suicidal self-injury based on childhood adversity.
      ). Severe childhood adversity is linked to psychopathology, leading to more frequent or severe NSSI behaviors (
      • Vaughn M.
      • Salas-Wright C.
      • Underwood S.
      • Gochez-Kerr T.
      Subtypes on non-suicidal self-injury based on childhood adversity.
      ). See Box 1 for familial psychosocial factors that can place a person at increased risk for NSSI. Parenting behaviors that are not necessarily abusive in nature can also influence NSSI. Problematic caregiver-child attachment can predispose to the development of NSSI (
      • Gonzales A.
      • Bergstrom L.
      Adolescent non-suicidal self-injury interventions.
      ). Studies have shown that high parental support coupled with low parental control are associated with higher levels of child/adolescent adaptive psychosocial functioning (
      • Barber B.
      • Stolz H.
      • Olsen J.
      Parental support, psychological control, and behavioral control: Assessing relevance across time, culture, and method.
      ,
      • Bureau J.
      • Freynet N.
      • Poirier A.
      • Lafontaine J.
      • Cloutier P.
      Perceived dimensions of parenting and non-suicidal self-injury in young adults.
      ). Parental control is defined as behavior wherein a parent wishes to influence the behavior of the child either by harsh physical punishment or psychological control (
      • Baetens I.
      • Claes L.
      • Onghena P.
      • Grietens H.
      • Van Leeuwen K.
      • Pieters C.
      • Griffith J.
      • et al.
      Non-suicidal self-injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting.
      ). Parental support refers to a parent showing warmth, acceptance, and understanding to the child. Parenting styles reflecting high behavioral control and low support have been found to be a risk factor for the development of NSSI behaviors (
      • Baetens I.
      • Claes L.
      • Onghena P.
      • Grietens H.
      • Van Leeuwen K.
      • Pieters C.
      • Griffith J.
      • et al.
      Non-suicidal self-injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting.
      ).
      Persons with a diagnosis of borderline personality disorder, dissociative disorders, eating disorders, and major depressive disorders have more NSSI symptomatology.
      Psychosocial risk factors for nonsuicidal self-injury
      • Child maltreatment
        • Sexual abuse
        • Physical abuse
        • Emotional abuse
        • Neglect
      • Parental drug/alcohol use
      • Exposure to domestic violence
      • Parental mental health concerns
        • Mental retardation/low functioning
        • Anxiety
        • Depression
        • Other diagnosis
      • Poverty
      As previously discussed, the existence of certain mental health disorders can certainly predispose an adolescent to engage in NSSI behaviors. Persons with certain psychiatric disorders have a higher prevalence of NSSI than do persons with other disorders. Persons with a diagnosis of borderline personality disorder, dissociative disorders, eating disorders, and major depressive disorders have more NSSI symptomatology. The prevalence of NSSI among adolescent psychiatric patients is high, ranging from 40% to 80% (
      • Kerr P.
      • Muehlenkamp J.
      • Turner J.
      Non-suicidal self-injury: A review of current research for family medicine and primary care physicians.
      ).
      However, adolescents without a mental health disorder can possess certain intrinsic personality factors that make them vulnerable to NSSI. The most important of these factors to consider when discussing risk for NSSI are emotional regulation and psychological distress (
      • Baetens I.
      • Claes L.
      • Onghena P.
      • Grietens H.
      • Van Leeuwen K.
      • Pieters C.
      • Griffith J.
      • et al.
      Non-suicidal self-injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting.
      ). Emotional regulation is defined as the external and internal processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one's goals (
      • Matthews B.
      • Kerns K.
      • Ciesla J.
      Specificity of emotion regulation difficulties related to anxiety in early adolescence.
      ). Dysfunction in the monitoring processes of emotional regulation can result in emotional hypervigilance or a lack of emotional self-awareness. Faulty emotional evaluation can result in biased evaluation of emotional stimuli. Difficulties in the modification processes of emotional regulation can result in an individual being unable to adjust his or her emotions to fit the context appropriately (
      • Matthews B.
      • Kerns K.
      • Ciesla J.
      Specificity of emotion regulation difficulties related to anxiety in early adolescence.
      ). Adolescents with emotional dysregulation are at risk for NSSI. Adolescents who experience higher levels of subjective psychological distress in response to adverse or stressful situations and who are less capable of tolerating distress are at increased risk to engage in NSSI (
      • Anestis M.
      • Knorr A.
      • Tull M.
      • Lavender J.
      • Gratz K.
      The importance of high distress tolerance in the relationship between non-suicidal self-injury and suicide potential.
      ,
      • Najimi S.
      • Wegner D.
      • Nock M.
      Thought suppression and self-injurious thoughts and behaviors.
      ). These adolescents who are experiencing higher levels of subjective psychological distress may engage in NSSI to cope with their distress (
      • Baetens I.
      • Claes L.
      • Onghena P.
      • Grietens H.
      • Van Leeuwen K.
      • Pieters C.
      • Griffith J.
      • et al.
      Non-suicidal self-injury in adolescence: A longitudinal study of the relationship between NSSI, psychological distress and perceived parenting.
      ).

      Motivation and Consequences

      It is important for the PNP to understand why individuals engage in NSSI. The most common reason is to relieve intense distressing feelings such as sadness, guilt, flashbacks, or depersonalization (
      • Wilkinson P.
      • Goodyer I.
      Non-suicidal self-injury.
      ). The NSSI behaviors help them escape from negative thoughts and/or emotions (
      • Nock M.
      • Prinstein M.
      Contextual features and behavioral functions of self-mutilation among adolescents.
      ). The sharp physical pain caused by NSSI can help to distract from their unbearable feelings. Adolescents may think they need to punish themselves by engaging in NSSI. NSSI may also be a vehicle to gain attention so that others can see their distress. Adolescents may engage in NSSI to make other people feel guilty and change their behavior or to fit in socially with self-injuring peers (
      • Wilkinson P.
      • Goodyer I.
      Non-suicidal self-injury.
      ). Another motivation for NSSI is to elicit feelings, “to feel something because the adolescent was feeling numb or empty” (
      • Klinsky E.
      Non-suicidal self-injury in United States adults: Prevalence, sociodemographic, topography, and functions.
      ). These adolescents want to feel something, even if the feeling is pain. Other self-injurers state that they engage in NSSI to feel positive sensations such as satisfaction. It is hypothesized that NSSI results in the release of endogenous opiates in response to tissue damage, which yields feelings of euphoria (
      • Selby E.
      • Bender T.
      • Gordon K.
      • Nock M.
      • Joiner T.
      Non-suicidal self-injury disorder: A preliminary study.
      ). The ability to elicit these feelings tends to reinforce or promote the NSSI behavior (
      • Selby E.
      • Nock M.
      • Kranzler A.
      How does self-injury feel? Examining automatic positive reinforcement in adolescent self-injurers with experience sampling.
      ). The sight of blood while self-injuring may be a reinforcing aspect of NSSI because it is reported that seeing blood helps the adolescent feel real and to focus (
      • Selby E.
      • Nock M.
      • Kranzler A.
      How does self-injury feel? Examining automatic positive reinforcement in adolescent self-injurers with experience sampling.
      ). Other motivations for NSSI include fun and excitement (
      • Laye-Gindhu A.
      • Schonert-Reichl J.
      Nonsuicidal self-harm among community adolescents: Understanding the “whats” and “whys” of self-harm.
      ).
      • Zetterqvist M.
      • Lundh L.
      • Dahlstrom O.
      • Svedin C.
      Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder.
      discuss NSSI motivation in terms of four functions: automatic negative reinforcement (to stop feeling numb or empty or to feeling an undesired emotional state); automatic positive reinforcement (to feel something, even pain); social negative reinforcement (to avoid doing something they do not want to do or find unpleasant); and social positive reinforcement (to get a reaction even if it is negative). Automatic reinforcement (negative greater than positive) appears to be the primary motivation for NSSI.
      • Selby E.
      • Nock M.
      • Kranzler A.
      How does self-injury feel? Examining automatic positive reinforcement in adolescent self-injurers with experience sampling.
      found that persons who are motivated to engage in NSSI due to automatic positive reinforcement engaged in NSSI more frequently and that these persons may be at increased risk for suicide. This increased risk for suicide stems from habituation to sensations of pain over time, the development of fearlessness in the process, and the erosion of the barrier to suicide of fear of pain (
      • Selby E.
      • Nock M.
      • Kranzler A.
      How does self-injury feel? Examining automatic positive reinforcement in adolescent self-injurers with experience sampling.
      ). This phenomenon is especially true for persons who engage in NSSI to feel pain.

      NSSI and Suicidal Behaviors

      Suicide is a major pediatric health concern. Suicide is the third leading cause of death among 10- to 24-year-olds in the United States (
      • Kim K.
      • Dickstein D.
      Relationship between teen suicide and non-suicidal self-injury.
      ). Studies suggest that up to 70% of persons engaging in NSSI have had at least one previous suicide attempt (
      • Kim K.
      • Dickstein D.
      Relationship between teen suicide and non-suicidal self-injury.
      ). It is crucial for PNPs to understand the relationship between NSSI and suicide. NSSI differs from suicidal behaviors in three essential ways: intention, repetition, and lethality (
      • Hamza C.
      • Stewart S.
      • Willoughby T.
      Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model.
      ). The fundamental distinction between NSSI and suicide can be found in intention. As opposed to adolescents engaging in suicidal behavior, adolescents who engage in NSSI do not intend to end their own lives, nor do they perceive that their injuries will result in death (
      • Andover M.
      • Gibb B.
      Nonsuicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients.
      ). Both behaviors may be engaged in because of a desire for relief from a distressing affective state; however, the end intention differs. Adolescents who engage in NSSI have a more positive attitude about life compared with adolescents who engage in suicidal behavior, and they also have a more negative attitude toward death; their end intent is not death (
      • Muehlenkamp J.
      • Gutierrez P.
      An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents.
      ). NSSI tends to occur more frequently than suicidal behaviors. In a sample of adolescent psychiatric inpatients,
      • Nock M.
      • Prinstein M.
      Contextual features and behavioral functions of self-mutilation among adolescents.
      found that the mean number of NSSI incidents occurring in the past year was 80, whereas the mean number of suicide attempts for adolescents with a prior suicide attempt was 2.8. NSSI behaviors are also low in lethality when compared with suicidal behaviors. Frequent NSSI behaviors include cutting (not on the wrist), burning, scratching, or biting, compared with much more lethal suicidal behaviors such as overdosing, cutting wrists, using firearms, and hanging. NSSI rarely requires medical attention, whereas suicidal behaviors frequently do require medical attention (
      • Whitlock J.
      • Muehlenkamp J.
      • Purington A.
      • Eckenrode J.
      • Barreira P.
      • Abrams G.
      Non-suicidal self-injury in a college population: General trends and sex differences.
      ).
      Frequent NSSI behaviors include cutting (not on the wrist), burning, scratching, or biting, compared with much more lethal suicidal behaviors such as overdosing, cutting wrists, using firearms, and hanging.
      Although NSSI and suicidal behaviors differ in fundamental ways, they often co-occur (
      • Victor S.
      • Klonsky E.
      Correlates of suicide attempts among self-injurers: A meta-analysis.
      ). When compared with their non-NSSI peers, adolescents who self-injure tend to have more suicidal ideation with more suicidal attempts (
      • Rodav O.
      • Levy S.
      • Hamdan S.
      Clinical characteristics and functions of non-suicide self-injury in youth.
      ). Numbers vary according to different studies, which report that from 33% to 70% of adolescents who self-injure have at least one suicide attempt (
      • Asarnow J.
      • Porta G.
      • Spirito A.
      • Emslie G.
      • Clarke G.
      • Wagner K.
      • Brent D.A.
      • et al.
      Suicide attempts and nonsuicidal self-injury in the treatment of resistant depression in adolescents: Findings from the TORDIA study.
      ,
      • Nock M.
      • Joiner T.
      • Gordon K.
      • Richardson E.
      • Prinstein M.
      Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts.
      ). NSSI is in fact considered one predictor of suicidal behavior (
      • Rodav O.
      • Levy S.
      • Hamdan S.
      Clinical characteristics and functions of non-suicide self-injury in youth.
      ).
      • Victor S.
      • Klonsky E.
      Correlates of suicide attempts among self-injurers: A meta-analysis.
      explored which suicide risk factors, when present in adolescents engaging in NSSI, are most predictive of suicidal behavior (see Box 2). Persons who engage in NSSI more frequently are at increased risk to engage in suicidal behavior. The more different methods of NSSI employed, the higher the risk for suicidal behaviors.
      • Nock M.
      • Joiner T.
      • Gordon K.
      • Richardson E.
      • Prinstein M.
      Non-suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts.
      also found having a longer history of engaging in NSSI and an absence of physical pain when engaging in NSSI to be predictive of suicidal behavior. Symptoms of or the diagnosis of borderline personality disorder in a person who engages in NSSI also increases the likelihood of suicide attempts. The existence of higher levels of hopelessness and impulsivity among persons engaging in NSSI also increases the frequency of suicide attempts (
      • Doughterty D.
      • Mathias C.
      • Marsh-Richard D.
      • Prevette K.
      • Dawes M.
      • Hatzis E.
      • Nouvion S.
      Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide.
      ,
      • Victor S.
      • Klonsky E.
      Correlates of suicide attempts among self-injurers: A meta-analysis.
      ).
      Risk factors for suicidal behaviors in adolescents who engage in nonsuicidal self-injury
      • Strong and moderate correlates
        • Increased NSSI longevity
        • Increased NSSI frequency
        • Higher number of methods of NSSI employed
        • Increased severity of NSSI methods employed (e.g., cutting vs. hair pulling)
        • Borderline personality disorder
        • Hopelessness/depression
        • Impulsivity
        • Posttraumatic stress disorder
        • Other mental health diagnosis
        • Sexual and physical abuse
      Note. NSSI, nonsuicidal self-injury.
      Data from
      • Victor S.
      • Klonsky E.
      Correlates of suicide attempts among self-injurers: A meta-analysis.
      .
      Different theoretical explanations exist to explain the link between NSSI and suicidal behaviors. One theory describes NSSI as a gateway to suicidal behaviors (
      • Brausch A.
      • Gutierrez P.
      Differences in non-suicidal self-injury and suicide attempts in adolescents.
      ). NSSI and suicidal behaviors exist on a continuum, with NSSI at one end of the spectrum and suicidal behaviors at the other. Both behaviors involve intentional acts to harm one's own body. NSSI behaviors act as a gateway to more extreme suicidal behaviors, much in the same way as marijuana use acts as a gateway to more extensive drug use.
      Another theory suggests the existence of a third variable to explain the co-occurrence of NSSI and suicidal behaviors. The existence of a diagnosable psychiatric disorder (
      • Jacobson C.
      • Muehlenkamp J.
      • Miller A.
      • Turner J.
      Psychiatric impairment among adolescents engaging in different types of deliberate self-harm.
      ), higher level of psychological stress (
      • Brausch A.
      • Gutierrez P.
      Differences in non-suicidal self-injury and suicide attempts in adolescents.
      ), and biological markers such as serotonin system dysfunction (
      • Sher L.
      • Stanley B.
      Biological models of nonsuicidal self-injury.
      ) have been suggested as possible third variables.
      • Joiner T.
      Why people die by suicide.
      , in exploring the possibility for an acquired capability for suicide, hypothesizes that in order to commit suicide, a person must overcome the fear and pain associated with killing oneself. NSSI may be one way to become desensitized to the fear and pain of suicide. However,
      • Joiner T.
      Why people die by suicide.
      does not believe that NSSI is the only desensitizer to suicidal behaviors and believes that other behaviors can be a precursor to suicidal behavior.
      • Joiner T.
      Why people die by suicide.
      also states that these behaviors, including NSSI, that tend to decrease pain and fear associated with suicide, are not enough to lead to suicide unless they lead to perceived burdensomeness (i.e., feelings that one is a strain on others) and social isolation. According to Joiner's theory of acquired capability, the reason why some persons who engage in NSSI do not attempt suicide is because of a lack of the development of feelings of perceived burdensomeness or social isolation.
      • Hamza C.
      • Stewart S.
      • Willoughby T.
      Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model.
      integrate aspects of the three previously discussed theories exploring the link between NSSI and suicidal behaviors. The Integrated Model states that NSSI may uniquely and directly predict suicidal behavior in persons who are currently engaging in only NSSI behaviors but are also demonstrating greater levels of depression, hopelessness, and negative self-esteem. The level of intrapersonal distress felt by the individual moderates his or her own personal relationship between NSSI and suicidal behavior. Thus persons who are experiencing greater psychological distress are at increased risk to engage in suicidal behaviors. The Integrated Model envisions the expression of both NSSI and suicidal behaviors to be influenced by linkage with a latent third variable or shared risk factors such as borderline personality disorder, hopelessness, dysfunctional family functioning, posttraumatic stress, and a history of child abuse. These shared risk factors can predict both NSSI and suicidal behaviors. The Integrated Model also views an indirect path from NSSI to suicidal behavior, similar to descriptions in Joiner's theory. This indirect link is moderated by acquired capability and suicidal desire. The severity of NSSI behaviors (cutting versus hair pulling) moderates the link between NSSI and acquired capability, with persons engaging in more severe forms of NSSI having a stronger link between the two and being more likely to engage in suicidal behavior. The link between NSSI and suicidal behavior is also moderated by suicidal desire. Suicidal desire will be higher in persons endorsing higher feelings of burdensomeness and social isolation.

      Nursing Implications

      NSSI is a significant problem in the adolescent population. NSSI may be a symptom of an underlying psychiatric illness, or it may be the psychiatric illness. NSSI can result in physical harm to the adolescent and has been linked to suicide attempts. Adolescents must be assessed for NSSI. A thorough head to toe skin assessment should be completed, with an exploration of causation for any injuries noted. Adolescents should be asked screening questions related to NSSI (see Box 3). The potential for lethality must also be considered. If screening questions reveal suicidal ideation, it is crucial to explore this issue thoroughly. Is the suicidal ideation coupled with social isolation, hopelessness, or burdensomeness? Does the adolescent believe that his or her family and friends would be better off if he or she were not around? Does the adolescent have an actual plan for killing himself/herself? Has he or she had past suicide attempts? Can the teen promise the PNP that he or she will not hurt or kill himself/herself? Any adolescent endorsing current suicidal ideation must be linked immediately with emergency mental health care and may require an inpatient admission. Knowledge of local mental health resources is vital.
      Nonsuicidal self-injury screening questions
      • Have you ever thought about hurting yourself?
      • Why/when/what did you think about doing?
      • Have you ever hurt yourself?
      • Last incident
        • When?
        • What method did you use?
        • Why?
        • Suicidal intent?
      • First incident
        • When?
        • What method did you use?
        • Why?
        • Suicidal intent?
      • Explore frequency and severity of methods for NSSI
        • When/how often?
          • Last week/last month/last year
        • Methods used?
        • Medical care ever required?
        • Suicidal intent?
        • Parental awareness?
      • Explore social isolation
        • Friends
        • Family
      • Explore hopelessness
        • Plans for future
        • Things you like to do/activities
      • Explore burdensomeness
        • Do you ever think your parents/family/friends would be better off if you were not around?
      Note. NSSI, nonsuicidal self-injury.
      It is important to gather a thorough psychosocial assessment for all adolescent patients, and this step is crucial in adolescents who report engaging in NSSI (see Box 4). It is vital to link adolescents and their families to appropriate resources to address any concerns revealed in the psychosocial assessment. If a concern of suspected child maltreatment is revealed, a report to child protective services is indicated.
      • Bergen H.
      • Hawton K.
      • Waters K.
      • Cooper J.
      • Kapur N.
      Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses.
      suggest that performing the psychosocial assessment may actually decrease the future incidence of NSSI for that adolescent. It is vital that parents/caregivers be made aware of the NSSI if they were previously unaware of it to ensure the safety of the patient. Appropriate steps must be made to eliminate safety risk based on the patient's method/methods of NSSI behaviors. Access to knives, razors, pins, or other sharps should be limited for adolescents engaging in cutting behaviors. The PNP must inform the adolescent that he or she needs to inform his or her parent of the NSSI for his or her safety. The PNP should also ask the teen if he or she believes he or she can promise not to engage in the NSSI in the future.
      Although no treatment for NSSI can be considered evidence-based, some treatment modalities show promise.
      Psychosocial assessment
      • Draw a family tree
        • Mother's name and age
        • Father's name and age
        • Children they have together and ages
        • Children they have with other partners and ages
        • Who lives with the child
        • Who lives in the home that the child visits
      • Parental drug/alcohol concerns
      • Parental mental health/mental retardation
      • Parental involvement with law enforcement
      • Exposure to domestic violence
      • Parental child maltreatment history as a child
        • Sexual abuse/physical abuse/emotional abuse/neglect
          • Did you receive treatment?
        • Involvement with child protective services as a child
      • Parental concerns of sexual abuse/physical abuse or neglect for this child
      • Involvement with child protective services for the child or child's siblings
      • Mental health/behavioral/developmental concerns for the child
      Any teen who reports engaging in NSSI behaviors must be linked with appropriate mental health services. If the teen is already linked with mental health services, the PNP must ensure that the therapist is aware of the NSSI and feels comfortable addressing the problem. Although no treatment for NSSI can be considered evidence-based, some treatment modalities show promise. A modification of dialectical behavioral therapy for adolescents has been found to decrease both NSSI and other symptoms of BPD (
      • Fleischhaker C.
      • Bohme R.
      • Sixt B.
      • Bruck C.
      Dialectical behavioral therapy for adolescents: A clinical trial for patients with suicidal and self-injurious behavior and borderline symptoms with a one-year follow-up.
      ). Cognitive behavioral therapy has also been found to decrease NSSI symptoms (
      • Taylor L.
      • Oldershaw A.
      • Richards C.
      • Davidson K.
      Development and pilot evaluation of a manualized cognitive-behavioral treatment package for adolescent self-harm.
      ). Emotionally focused family therapy may be helpful in the treatment of NSSI given the existing scientific evidence for family-based interventions for other adolescent and child disorders (
      • Schade L.
      Non-suicidal self-injury: A case for using emotionally focused family therapy.
      ). If the psychosocial history reveals a history of trauma exposure, trauma exposed care is necessary.
      • Gonzales A.
      • Bergstrom L.
      Adolescent non-suicidal self-injury interventions.
      discuss stages in patient recovery from NSSI: limit setting for safety (initially inpatient care or close caregiver supervision but gradually transitioning to the patient himself or herself); developing self-esteem; discovering why the NSSI took place and what role it served for the patient; realization by the patient that he or she can choose whether or not to self-injure; replacing NSSI with other coping skills; and a period in which the patient is able to maintain an NSSI-free state.
      Adolescence can be a difficult developmental period. PNPs must be alert to the development of behavioral and mental health disorders, including NSSI. It is crucial for PNPs to possess a thorough understanding of their patient's behavioral/mental health history, including any family history of mental illness. A patient's psychosocial assessment, including screening for child maltreatment, can provide vital insight into their health and well-being. Identification of a familial psychosocial concern and linking the family with appropriate resources can prevent the development of NSSI and other behavioral/mental health concerns. Prompt identification of NSSI coupled with appropriate intervention can result in cessation of the behavior, failure of progression to suicidal behavior, and improved emotional health for the adolescent.

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      Biography

      Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.

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