Evidence-Based Reviews

Risk factors for nonsuicidal self-injury: A review of the evidence

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Understanding the differences in risk for adolescents and adults can help inform treatment.



Nonsuicidal self-injury (NSSI) is the direct and deliberate destruction of body tissue without intent to die.1 Common forms of NSSI include cutting, burning, scraping/scratching skin, biting, hitting, and interfering with wound healing.2 Functional theories suggest that NSSI temporarily alleviates overwhelming negative emotions and can produce feelings of relief, resulting in a reinforcing effect.3

NSSI has been shown to be a risk factor for future suicide attempts.4 A 2018 study found that NSSI is associated with an increased risk of subsequent suicidal ideation (odds ratio [OR] 2.8), suicide plan (OR 3.0), and suicide attempt (OR 5.5).5 NSSI is also associated with individuals who had suicidal ideation and formed a suicide plan, and individuals who had a suicide plan and attempted suicide (ORs 1.7 to 2.1).5 Another study found that 70% of adolescents who engage in NSSI have attempted suicide during their lifetime, and 55% have multiple attempts.6

Given the overlap between suicide attempts and NSSI, performing a thorough suicide risk assessment (which is beyond the scope of this article) is crucial. This article describes the static and dynamic risk factors for NSSI in adolescents and adults, which can help us perform a suicide risk assessment and allow us to formulate an appropriate treatment plan that includes safety-based interventions.

Risk factors for nonsuicidal self-injury in adolescents

NSSI risk factors for adolescents

From developing sexual identity and undergoing puberty to achieving increased independence from their parents and developing a sense of autonomy, adolescents undergo many biological, psychological, and social changes before reaching adulthood.7 Data suggest that NSSI often begins in adolescence, with a typical onset at age 13 or 14.3 Community studies show that one-third to one-half of adolescents in the United States have engaged in NSSI.8,9 Previously, NSSI during adolescence was associated with 3 major diagnostic categories: eating disorders, developmental disabilities, and borderline personality disorder (BPD).10 However, recent data suggest that NSSI is also common outside of these categories. Here we describe static and dynamic risk factors for NSSI in adolescents (Table 111-42). Table 211-42 summarizes the studies of NSSI in adolescents that we reviewed.

Nonsuicidal self-injury in adolescents: Select studies

Static risk factors

Female adolescents and adults engage in NSSI at higher rates than males. The difference is larger in clinical populations compared to the general population.11

A large portion of research about NSSI has been conducted in studies in which the majority of participants were White.12 Most studies report a higher prevalence of NSSI among non-Hispanic White youth,13 but some suggest other ethnic groups may also experience high rates of self-harm and NSSI.13-15 Several studies have demonstrated high rates of self-harm among South Asian adult females compared with White adult females, but this difference may be less pronounced in adolescents.14 One study in the United Kingdom found that White females age 10 to 14 had higher rates of self-harm compared to South Asian females,14 while another found that risk and rates of self-harm in young South Asian people varied by city and country of origin.15 Young Black females15 and young Black males13 also may be at an increased risk of self-harm. One review found that Black females were more likely to self-harm than Asian or White groups.15

Several studies suggest that sexual minority adolescents (SMA) (eg, lesbian, gay, bisexual, transgender, queer) are at greater risk for NSSI than heterosexual adolescents.16 SMA have been shown to engage in a significantly greater frequency of NSSI and more types of NSSI than heterosexual adolescents.16 Furthermore, on the Inventory of Statements about Self-Injury, SMA self-reported using NSSI for intrapersonal functions (eg, for affect regulation, antisuicide, self-punishment) significantly greater than their heterosexual peers; however, there were no significant differences between the 2 groups on interpersonal functions (eg, autonomy, interpersonal boundaries, peer bonding, sensation-seeking).16

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