Bringing the pain to the surface. An overview of non suicidal self-injury (NSSI). A presentation by Jesse S. Esqueda, Psy.D., Engage Psychological Services

1. An overview of nonsuicidal self-injury
(NSSI)
Jesse S. Esqueda, Psy.D.
Engage Psychological Services

2. • Formally Defined by the International Society for the Study of Self-Injury
as, “The deliberate, self-inflicted destruction of body tissue without
suicidal intent and for purposes not socially sanctioned.” (ISSS, 2007)
• Sometimes referred to as self-injurious behavior or self-harm.
• Most familiar types of NSSI behaviors include cutting or branding,
however studies have shown over 16 unique types of NSSI behaviors.
(Whitlock, Eckenrode, et al., 2006)
• One critical component of self-injury to understand is the intent of the
harm. Often times NSSI behaviors are confused with suicidal behaviors.
What is Nonsuicidal Self-Injury (NSSI)?

3. Myth Fact
1. Self-injury alone indicates acute
stress and distress. While there is
comorbidity, self harm does occur
without another diagnosis.
2. While prevalence and reporting of
self-harming behaviors is highest
among adolescent females, this type
of behavior is seen across ages and
genders.
3. The severity of the actual wound has
little to do with the amount the
person is suffering.
1. You must be mentally ill to engage in
self harm.
2. Cutting and other self-injurious
behaviors are really an adolescent,
female issue.
3. If the wounds/cuts are not that bad,
then its not that serious.
Common Myths about Self Harm

4. • NSSI behaviors are seen across the spectrum; the behaviors are not
limited by education, age, race, sexual orientation, socioeconomic status,
or religion. However, self-injury occurs more often among:
• Adolescent females
• Bisexual females
• People with a history of physical, sexual or emotional abuse.
• Individuals raised in families that discouraged expression of negative
emotions (anger, sadness).
• Those with a co-occurring disorders, particularly: substance abuse, major
depression, anxiety disorders (particularly OCD), bipolar, and personality
disorders.
Who typically self-injures?

5. • Most available data and studies are on adolescents and young adults.
• In a recent decade long study, researchers found a 28% increase in
adolescents presenting to the hospital in study for self-injurious
behaviors (Boyce, Oakley-Browne, & Hatcher, 2001).
• Among US and Canadian high school students, recent studies consistently
show a 13-24% prevalence rate. (Laye-Gindhu; & Schonert-Reichl, 2005;
Muehlenkamp & Gutierrez, 2004; Muehlenkamp & Gutierrez, 2007; Ross &
Health, 2002)
• Among US University students, a recent study showed a lifetime
prevalence rate of 17%. (Whitlock et al., 2006)
• Interestingly, among the college aged population, 44% of those
reporting NSSI behaviors did not show symptoms of DSM classifiable
disorders. (Gollust, Eisenberg, & Golberstein, 2008)
How common is NSSI?

6. • Early onset NSSI is common as young as age 7 (CRPSIR,
2014)
• Self-injurious behaviors most often begin in middle
adolescence between the ages of 11 and 15 (Yates,
2004).
• However, almost 40% of college students who reported
engaging in NSSI behaviors stated they began after age
17 (Whitlock et. al, 2006).
When do these behaviors start?

7. • Like all aspects of the human condition, the duration of NSSI behaviors
vary greatly.
• For some, it is a single act, for others it is a long standing coping strategy
that can last for months and years.
• For many, the pattern of NSSI behaviors is cyclical rather than linear
(CRPSIR, 2014).
• For individuals with repeat NSSI who abstained from the behavior for the
past year and are commited to avoid that coping strategy, 79% reported
stopping all NSSI within 5 years of starting and 40% within one year
(Whitlock, et. al., 2006)
What is the typical course of NSSI?

8. • Overall, self-injury should be viewed as a maladaptive coping strategy.
• The reasons for NSSI are numerous, but individuals commonly report
they practice it as a way to deal with: Overwhelming sadness, anxiety,
emotional numbness, stress/pressure reduction, to feel in control, and to
distract from other feelings (Klonsky, 2007; DiLazzero, 2003).
• Studies are now looking at NSSI behaviors as having addictive qualities.
When looking at NSSI as addiction, researchers have found that the
Endogenous Opioid System (EOS) is activated. Activation is caused by
physical pain and can lead to an increased sense of comfort temporarily
(Walsh, 2005).
• Over time, repeated activation of the EOS can cause a tolerance effect,
allowing those who self injure to feel less pain over time (Walsh, 2005).
Why do people self-injure and why do
they continue?

9. • Within hospitals and institutions, self-injurious behavior has followed
epidemic like patterns (Taiminen et. al., 1998).
• Within non-clinical populations, there has been significant anecdotal
support provided by school nurses, counselors and social workers
suggesting a “fad” quality (Purington et al., 2010).
• One belief is that youths may engage in these behaviors as a way to
connect with other peers in their social group.
• Also, the access to stories and news reports regarding self injury have
increased which may also contribute to the “contagious” effects
(Whitlock, Purington & Gershkovich, 2009).
The contagion of NSSI behaviors.

10. • Due to the seemingly increase in prevalence of NSSI among school aged
youth, it is now considered appropriate to create a self-injury protocol for
each campus.
• Currently, it is suggested that protocols for schools include the following:
1. Identify self-injury
2. Assess self-injury
3. Designate point persons for following steps.
4. Create guidelines for how parents are contacted
5. Create plan with parents, students and other to manage
behaviors.
6. Become familiar with outside resources and when to use.
7. Educate students and staff about self-injury.
What can be done at the school level?

11. • Self-injurious behaviors often occur on arms, fists, and forearms opposite
the dominant hand.
• Also, it is common for individuals who self-injure to wear inappropriate
dress for season (consistently wearing long sleeves or pants in summer),
constant use of wrist bands / coverings, unwillingness to participate in
events / activities which require less body coverage (such as swimming or
gym class), and frequent bandages.
• In regards to cutting specifically, David Rosen, MD, MPH, an expert in
teenage and young adult health stated, “The most typical cuts are very
linear, straight line, often parallel like railroad ties carved into forearm,
the upper arm, sometimes the legs.”
What to look for.

12. Prevention Treatment
Overall, the goal is to help those
engaging in NSSI to learn new, healthy
coping strategies. This can be achieved
through:
• Individual and Group therapy
• Dialectical Behavior Therapy (DBT)
• Family Therapy
• Medication management to address
depressive and anxiety symptoms.
• Enhance capacity to cope and regulate
emotions.
• Increase social connectedness
• Have interventions aimed at youth to
be less about raising knowledge and
more about increasing awareness
about underlying factors.
• Focus on increasing staff and student
capacity to recognize distress.
• Promote healthy help-seeking
behaviors.
Action steps.