Inside the Mind: A Glimspe into Sufferers of Non-Suicidal Self-Injury

CONTENT WARNING: This article discusses and depicts images related to non-suicidal self-jury and self-injurious behaviors. This can be triggering for some readers. Please be advised when reading this article.

Introduction

How would you describe self-injurious behavior? How seriously should self-injurious behaviors be taken? Is self-injury just a temporary means to escape from deeper emotional suffering? What is really happening in the minds of the sufferers of self-injury? 

Non-suicidal self-injury, clinically known as NSSI in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is commonly associated with psychological and psychiatric disorders, including but not limited to Major Depressive Disorder (MDD), Borderline Personality Disorder (BPD), and Intermittent Explosive Disorder (IED) [1]. This type of self-injury is the intentional harm or destruction of one’s body without suicidal intention (i.e. cutting the wrists, burning the skin, stabbing the skin, banging their head on a wall, etc.) [2]. 

Contrary to conventional belief, non-suicidal self-injury can occur without any pre-existing mental conditions [2]. Misinterpretations made by the public eye, like “It’s just a phase” or “They’re just doing it to get attention”, result in frequent misdiagnosis at a clinical level. For example, self-harm has previously been misidentified as teenage stress, misuse of alcohol, or just a symptom of another condition, resulting in a lack of treatment in developing young adults [3]. These widespread misconceptions surrounding NSSI can be extremely invalidating to those with the disorder, undermining the severity of this condition and creating harmful stereotypes about NSSI as well as the individuals who suffer from it [4]. In particular, in the United States alone, NSSI is prevalent in adolescents as early as 13 years old, and about 10% of teens and 35% of young adults have been clinically diagnosed with NSSI [4]. These rates of younger generations reporting NSSI make this a topic in need of emphasis before it develops into a more serious and threatening long-term consequence, such as suicidal behavior [2]. It is critical to recognize the importance of those diagnosed with nonsuicidal self-injury, to examine the differing factors of NSSI behavior, and to identify the proper approaches to intervention or recovery by exploring the neuroscience behind this psychological condition. 

What is Non-suicidal self-injury? 

Let us discuss the specifics of NSSI disorder by examining some of the behaviors and symptoms within it. NSSI is characterized as repetitive and intentional damage to one’s own body that is not considered socially acceptable, such as getting a piercing or tattoo [1]. In most cases, these self-inflicted injuries can appear on the hands, wrists, stomach, and thighs [5]. It should be noted that those living with NSSI do not have control over their urges or thoughts to self-harm, nor do they harm themselves with the intention to die, marking this as one of the distinctions between NSSI and suicidal behavior and ideation [1].

 Historically, NSSI was recognized as a symptom of BPD, where individuals also display symptoms of unstable self-image, issues with interpersonal relationships, and much more [1]. However, more recent research has distinguished NSSI from self-injurious behaviors exhibited in those with other psychiatric conditions [2]. Compiled independent studies, also known as meta-analyses, have predicted that NSSI is also present in nonclinical populations (those who have not received a diagnosis). It is estimated to be in about 17.2% of adolescents, 13.4% of young adults, and 5.5% of adults, suggesting a significant gap between clinical and nonclinical populations [6]. This gap could be reflective of the stigmatization of self-injury, which manifests into medical bias or lack of motivation to seek professional help because self-harm was previously viewed as a symptom of a larger condition. On the other hand, those who suffer from NSSI may be discouraged from seeking help due self-harm serving as a coping mechanism to induce relief from negative emotions; thus, positive associations are formed between the behavior and the relief it provides for the individual [1]. 

Why Do People Injure Themselves? 

The idea behind inducing self-inflicted pain is complex. Those who suffer from nonsuicidal self-injury often experience difficulties with emotional distress, depression, anxiety, and emotional dysregulation [2]. Individuals who experience NSSI have reported seven main reasons for self-harm: emotional relief, self-punishment, dissociation, interpersonal influence, peer bonding, sensation seeking, and assertion of interpersonal boundaries [7]. To highlight these key rationales underlying the functions of NSSI, the motivations can be further categorized into intrapersonal and/or interpersonal functions [4]. 

Intrapersonal functions derive from a form of self-regulation in order to cope with negative emotions. Those who suffer from NSSI commit these acts in place of healthier coping mechanisms, such as talking with a friend and/or family, or seeking help from a licensed professional [8]. Self-harm provides alleviation from overwhelming feelings of anxiety or distress via integration of the brain’s reward processing pathways [9]. This behavior is then reinforced by the positive feeling of relief that the individual feels following self-injurious acts, creating a repetitive and habitual cycle [10]. Even further, disassociation, which can be characterized as an “out-of-body experience”- disruption of emotion, perceptions, and identity- tends to appear in individuals with a lack of understanding of their own emotional states and a lack of impulse control in stressful situations [8, 11]. In turn, they are able to gain a sense of control over emotional states and feelings through acts of NSSI. On the other hand, about half of those who self-injure report acting out of aggression towards themselves in an act of self-punishment [9]. This effort of self-punishment serves as a way to control emotions of shame, guilt, or self-hatred, which manifest internally, as opposed to the external experiences that result in the use of NSSI as self-regulation [8]. 

Conversely, interpersonal functions of self-harm have an influence on the person’s social life and their surrounding community [10]. Those who suffer from NSSI have continuous difficulty effectively expressing their emotions with others, and they tend to perceive and interact with the world in a vengeful and dominating way in an attempt to influence the behaviors of others [8]. In previous psychological studies, acts of NSSI have been shown to strengthen or improve an individual’s social relationships with their friends or family [12]. This could be because adolescents are engaging in self-injurious behavior to “fit-in” with a social group (peer-bonding), or, as a result of their actions, are receiving more social support from their friends and family [12]. Although interpersonal functions can be associated with increase in interpersonal relationships and social support, the opposite is true as well. Most individuals who suffer from NSSI feel as if they have little to no social support or people to relate to [13, 8]. For instance, some adolescents report that their reason for engaging in self-harm is as a last resort for help when all other attempts have failed [10]. Their hope is that someone will notice their struggles without having to communicate them verbally, which could make them feel vulnerable and, unfortunately, embarrassed [10]. So, while interpersonal functions of NSSI may be motivated by social gain, they can also be utilized as a social cue towards family and friends, indicating the person’s need for help. 

While these functions provide insight into the behaviors behind NSSI, they still remain in need of further, more in-depth research. An individual suffering from NSSI is not confined to fall within only one of these functions; in fact, it is entirely possible for them to fall within multiple. Studies have shown that symptoms of depression, characteristics of BPD, and suicidal ideation are more evident in intrapersonal functions opposed with intrapersonal functions, whereas symptoms of anxiety and a history of suicide attempts have appeared with intrapersonal and interpersonal functions [8]. Nevertheless, other studies have associated NSSI with various types of emotional dysregulation conditions, suggesting symptoms of depression are apparent in interpersonal and intrapersonal functions [14, 8]. 

The Neurobiology Behind NSSI 

On the outside, NSSI may appear entirely behavioral, but recent studies involving functional magnetic resonance imaging (fMRI) have been able to identify specific brain regions associated with this condition. In a meta-analysis, prominent structures, the frontal gyrus, rostral anterior cingulate cortex (rACC), and the amygdala, were shown to be hyperactive in individuals with NSSI. Both of these regions have key roles in the reward system, most notably in emotional production (rACC) and emotional judgment (frontal gyrus); therefore, individuals suffering from NSSI begin to equate self-harm with emotional regulation and elation, further emphasized by the hyperactivation of these regions in the reward system. [15, 16]. The rACC and amygdala are also considered part of the limbic system, widely regarded as the central emotional processing system in the brain. Studies have shown increased activation and neural connectivity in the ACC when images of self-harm were displayed to patients, suggesting a mediatory role of NSSI in distressing or emotionally overwhelming situations. Both of these regions have key roles in the reward system, most notably in emotional production (i.e. the limbic system) and emotional judgment (i.e. the frontal gyrus); therefore, individuals with NSSI are making positive associations with acts of self-harm which are being fed by the reward system (i.e. “If I do this, I will feel better”) [5, 15]. Other studies have shown increased activity as well as increased neural connectivity in the ACC when self-injury-related images were displayed to individuals, which suggests a mediatory role of NSSI in distressing or emotionally overwhelming situations [14, 17, 18]. Conversely, other studies have found decreased neural connectivity from the medial orbitofrontal cortex to the limbic system, which aids in the expression of positive emotions such as pleasure or joy [5]. This may explain the “rewarding” feeling NSSI presents to those who self-harm, as decreased neural connectivity in the region of the brain dealing with positive emotions points to the notion that self-harm slowly starts to become the “only” option for someone to expel negative emotions and experience positive ones. 

Additionally, studies have found activation in the medial prefrontal cortex, the inferior frontal gyrus, and the insula in individuals with NSSI, which have been known to integrate emotional processing and decision-making [14, 15]. The medial prefrontal cortex deals with self-referencing processing, or how an individual perceives themselves, as well as emotional dysregulation; on the other hand, the inferior frontal gyrus processes social interaction and emotional regulation, and the insula helps link emotional perception to a particular situation or experience [14, 15]. Those who experience NSSI are more likely to have a negative perception of themselves, which links to the activation seen in the medial prefrontal cortex [19]. 

NSSI's common comorbidity with depression or anxiety might create a strong bias in believing common stress-reward neurotransmitters like serotonin or dopamine are primarily involved. While these neurotransmitters do play a part in mood regulation and reward function, there is little support for their management in those who engage in NSSI [17]. Studies have revealed that the neurobiological rationale behind self-harm is likely due to the fact that patients suffering from NSSI have a lower overall baseline of endogenous opioids, known for their addictive qualities, their reward function, and their involvement in the perception of pain. [17, 20]. These low levels of endogenous opioids, such as iβ-endorphin or met-enkephalin, can be replenished and released through acts of NSSI in stressful situations, and their addictive qualities can then enforce this behavior, consequently reinforcing the cycle of self-injury [17].  

Approaches and Interventions 

Having covered the psychopathology and neurobiology of non-suicidal self-injury, what are the options for seeking treatment? Below is a list of various treatment options and approaches for someone struggling with NSSI (Table 1) [21]. 

Conclusion

Perhaps you notice someone with unexplained markings or bruises on their body, and their responses are evasive or passive. It is not our place to make judgments or assumptions about their experiences or struggles; a situation like this should be approached by directing the individual to professional help for treatment and providing them with a safe environment. 

Overall, NSSI remains a topic for more in-depth research to better understand its characteristics, motivation, and biological elements. Future research may guide the development of interventions that will help identify early behaviors associated with NSSI [5]. These interventions can then be implemented in therapeutic practices, such as school counseling services, in order to reach a broad spectrum of susceptible populations. This could aid in overall prevention of development of NSSI in early adolescents, and with help from the techniques listed above, they can work towards a better awareness and understanding of their mental health as well as identify and integrate healthier coping mechanisms [5].

If you or someone you know are struggling with issues pertaining to self-harm, please reach out to a professional for further information and help.

Resources: 

• CRISIS Text Line: Text HOME to 741741 to connect with a volunteer Crisis Counselor

• S.A.F.E Alternative (Self-Abuse Finally Ends): 1-800-DONT-CUT or 1-800-366-8288 

• Healthy Mind Philly (Local to Philadelphia)

• Tuttleman Counseling Services (Temple Employees and Students) 

• HelpGuide.Org

• Substance Abuse and Mental Health Administrations (Minorities and Marginalized Groups) 

• The Trevor Project  (LGBQT+) 

• Family Urgent Response System (Foster Care) 

• National Alliance on Mental Illness (Minorities) 

*If you are concerned about your specific insurance, you can reach out to a representative by the number located on your insurance card to ask about specific mental health providers offered by your plan. 

References

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https://www.mayoclinic.org/diseases-conditions/self-injury/diagnosis-treatment/drc-20350956