Please also see Proposal to the DSM-5 Childhood Disorder and Mood Disorder Work Groups to Include Non-Suicidal Self-Injury (NSSI) as a DSM-5 Disorder.
Rationale below added March 4th, 2010.
I. RATIONALE FOR THE DIAGNOSIS
A new disorder should be unrepresented or inappropriately represented in DSM-IV; have clinical value, improving accurate identification and/or treatment; and be prevalent, impairing, and distinctive.
A. Limited and Inappropriate Representation in DSM-IV
The closest representation in DSM-IV of the disorder we propose is criterion 5 of borderline personality disorder (BPD) (301.83): “Recurrent suicidal behavior, gestures, or thoughts or self-mutilating behavior.”
Research among both adult (Herpetz 1995) and adolescent (Nock et al. 2006) inpatients and both adult (Zlotnick et al. 1999) and adolescent (Jacobson et al. 2008) outpatients has shown that repeated self-injury co-occurs with a variety of diagnoses and that many individuals who engage in repeated self-injury do not meet criteria for BPD (see Table 1).
B. Clinical Implications
Two clinical problems arise from the current situation.
1. NSSI is commonly viewed as pathognomonic of BPD.
2. Broad similarities to suicide-attempt behavior (which, in the young, usually involves an overdose), perhaps reinforced by the explicit links in criterion 5, promote the view that self-injury with a sharp object is a form of attempted suicide.
Either of these conclusions is likely to lead to overly restrictive, expensive, and burdensome management, such as emergency evaluation and inpatient hospitalization or prolonged, frequent engagement in complex psychotherapies.
Evidence for this can be drawn from NCIPC (National Center for Injury Prevention and Control) data that show between 10% and 30% of those who contact a hospital for self-inflicted cut/pierce injuries are admitted as inpatients.
FIGURE 1 (CLICK HERE)
C. Distinctiveness and Differentiation from Attempted Suicide
While the set of symptoms and criteria that we propose are broadly similar to suicide attempts, in that they involve physical damage to the self, they are—unlike the existing criterion 5—associated with a variety of diagnoses and negative emotions. Evidence that supports discriminating between NSSI and attempted suicide includes:
1. It is generally observed that the behavior is initiated, not to result in death or as a mode of avoidance, but to bring relief from ill-defined tension and distress that will allow the patient to continue his/her predicted life.
2. Cutting with a sharp object has a very low lethality. In 2005, in the U.S., it accounted for only 0.4% of under-age-24 suicides and 0.6% of suicides at all ages (National Center for Injury Prevention and Control 2008).
3. Research that has compared youth who engage in superficial injury with those who have taken an overdose (Brausch & Gutierrez 2010; Madge et al. 2008; Muehlenkamp & Gutierrez 2004; Rodham et al. 2004) has consistently shown that the former are less likely to wish to die or to have a depressed mood. They exhibit greater self-esteem and better relationships with their parents than suicide attempters.
4. Experts such as Linehan and colleagues (2006), in a methodological study of the SASII diagnostic instrument, judged the great majority (87%) of events mediated by cutting or puncturing to have been nonsuicidal.
5. Incorrect conclusions about the behavior are apparent to the patients, and Kumar and colleagues (2004) noted that 88% of adolescents who cut reported that a nonsuicidal cutting incident was misinterpreted as a suicide attempt.
6. The definition we propose requires that injuries be superficial and frequently repeated. It can, therefore, be assumed that individuals who practice these behaviors are, by experience, aware of their non-life-threatening nature.
It should not be implied from the above that individuals with NSSI are immune to making suicide attempts. A sizeable proportion will do so at some time. The proportion is higher in clinical than in unreferred populations, in individuals who have tried a variety of NSSI methods, and in those who have engaged in a larger number of previous NSSI events (Brunner et al. 2007; Klonsky & Olino 2008; Lloyd-Richardson 2007; Nock et al. 2006; Zlotnick et al. 1997).
NSSI can be regarded as one of several disorders that are associated with elevated rates of suicidal behavior. We recommend that the accompanying text indicate that a history of multiple engagement in NSSI or using a variety of methods signals an enhanced, but not imminent, risk for attempted suicide.
D. Public Health Impact
The current representation of NSSI in DSM-IV has impacts on public health that go beyond the utilization of expensive treatment resources. It might also distort important surveillance and investigative procedures. Posner and colleagues (2007) reexamined adverse events reported to the FDA during the course of 25 adolescent antidepressant trials and found that 8% of the suicidal events reported by the pharmaceutical companies in trials of SSRI antidepressants would have been better classified as acts of NSSI.
Key benchmark and prevalence surveys (e.g., the Youth Risk Behavior Survey [YRBS], NHANES, NCS, etc.) cannot differentiate between suicidal and nonsuicidal self-injurious behaviors or between behaviors involving different methods. It is possible that the absence of this distinction contributes to the very high rate (9%–11%) of self-reported “suicide attempts” in high-school students that, in turn, can be translated into ratios of suicide attempts to completions of approximately 5,000:1 in girls and just under 500:1 in boys, far greater than is found in adults. The failure to differentiate NSSI from suicide attempts might also contribute to the unusual secular trends of suicidal phenomena. Over the past two decades, there has been a marked decline in suicide ideation and suicide itself, while the adolescent suicide-attempt rate has remained stable.
E. Impact on Research
The failure to distinguish between NSSI and suicide attempts impacts research activity. The establishment of NSSI as a discrete entity would clarify this distinction and act as a stimulus to innovative research.
F. Distinctive Clinical Features
1. Prevalence
Although there have been many reports of prevalence, the base populations have varied in their nature and representativeness, and most have failed to discriminate between any and repeated incidents or have failed to specify the timeframe for the incidence being reported. These requirements have been met in the German Heidelburg Schools Study (Brunner et al. 2007), in which the prevalence of repeated incidents (4 or more per annum) was 4%, while 7% had engaged in the behavior at least once. Having engaged in the behavior 4 or more times also discriminated between those with and without significant comorbidity. In a large, representative sample of adults, Briere and Gil (1998) reported a 6-month prevalence of any engagement in the behavior of 4%.
2. Impairment
Clinical reports on NSSI note that negative feelings such as shame, disappointment, and guilt secondary to engaging in self-injury are common (Briere & Gil 1998). Anecdotal evidence suggests that, although an immediate sense of relief follows engagement in NSSI, feelings of shame and guilt often follow. Some adolescents with NSSI eventually stop going to school because of embarrassment or harassment.
Medical complications occur and can result in infection at the site of injury. DiClemente and colleagues (1991) reported that over one quarter of the sample of adolescents who self-injured shared cutting instruments, thus putting them at risk for contracting infectious diseases, including HIV.
3. Natural History
Age of onset: Hospital contact rates (CDC 2009) (see Figure 2) show that contacts for injury from a sharp object commence at 10 to 15 years old, peaking in the late teens (these data cannot be used to differentiate between initial and recurring events). Hospital admissions show a more striking but similar path, starting at ages 12 to 14, peaking at ages 15 to 19, and then declining until ages 25 to 29.
Retrospective, clinical, and community studies indicate that the first episode most commonly occurs between the ages of 10 and 16. Herpertz (1995), in a retrospective study of 54 predominantly female psychiatric inpatients who had engaged in repeated self-injury, found that most had the onset of their condition in adolescence, with onset after early adulthood being very unusual.
The only published longitudinal data derive from the McLean Study of Adult Development that followed 299 participants who met criteria for BPD (Zanarini et al. 2005). At baseline, 81% of the participants reported engaging in NSSI at some point during the 2 years before joining the study. This rate had fallen to 26% at 6-year follow-up. Given the similar findings from different samples and methods, it appears that NSSI commences around puberty, peaks in mid-adolescence, and then decreases on into adulthood, independent of other symptoms.
FIGURE 2 (CLICK HERE)
II. RATIONALE FOR INDIVIDUAL CRITERIA
A. Name of the Condition
The term self-mutilation is used in the existing borderline-personality-disorder listing. The word mutilation signifies either the physical loss or loss of use of a body part. As proposed, NSSI involves the self-infliction of superficial damage without consequent loss of power or anatomy.
The term self-harm is widely used and is applied to both suicide attempts and non-suicidal injuries, as well as, at its broadest, to behaviors or attitudes that carry a risk of harmful consequences, such as gambling or substance abuse. It was agreed that it would be advantageous to use a term free of such broad connotations.
Non-suicidal self-injury is the term most commonly chosen by researchers and practitioners working in this area.
B. Number of Episodes
There is general agreement that qualifying for the disorder should require more than a single episode.
Ideally, the threshold value for past incidents within a specified period of time would be determined empirically by examining a range of frequencies against the likelihood of repetition or some other disabling feature of the condition. We have not found data that can provide that information.
We examined the frequency required for inclusion as a case in different research studies. With rare exceptions, this ranges from 4 to 6.
Some support for this comes from Dulit and colleagues (1994), who, examining self-injury in a large group of consecutive patients with BPD, found that patients who had self-injured more than 5 times were more likely to be in treatment and were more likely to meet criteria for an additional psychiatric diagnosis.
In light of the above, we propose a less sensitive 5 events in the last year as a threshold that is in line with current practice.
C. Psychological Contingencies
All studies into prior feeling states and motivation have found that negative reinforcement (removal of aversive feelings, tension reduction) is the most commonly reported reason to engage in NSSI. Forms of positive reinforcement (including to elicit attention from others and to experience physical sensations associated with the event) are also commonly cited as important factors (Chapman & Dixon-Gordon 2007; Favazza 1998; Herpertz 1995; Kumar et al. 2004; Laye-Gindhu & Schonert-Reichl 2005; Lloyd-Richardson et al. 2007; Nixon et al. 2002; Nock & Prinstein 2004, 2005; Ross & Heath 2003).
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