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EDITORIAL  
Year : 2018  |  Volume : 60  |  Issue : 3  |  Page : 259-260
Nonsuicidal self-injury: Implications for research and management


Professor of Psychiatry, WBMES and Consultant Psychiatrists AMRI Hospitals, Kolkata, West Bengal, India

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Date of Web Publication16-Oct-2018
 

How to cite this article:
Singh OP. Nonsuicidal self-injury: Implications for research and management. Indian J Psychiatry 2018;60:259-60

How to cite this URL:
Singh OP. Nonsuicidal self-injury: Implications for research and management. Indian J Psychiatry [serial online] 2018 [cited 2018 Nov 19];60:259-60. Available from: http://www.indianjpsychiatry.org/text.asp?2018/60/3/259/243390




Self-injurious behavior or deliberate self-harm (DSH) in adolescents and young adults is an area of growing concern. Reports from clinics and emergency rooms are pointing to the increase in incidence. However, there are very few studies from India. Many of the people presenting with acts of self-harm do not have suicidal intent, and this has prompted the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)[1] to propose a category of Nonsuicidal Self-Injury (NSSI) as a “Condition for Further Study” to encourage further research in this area. DSM-5 Proposed Criteria for NSSI requires an individual to engage in intentional self-inflicted damage to the surface of his/her body, on 5 or more days in the last 1 year, with the expectation that the injury will lead to only mild or moderate physical harm. The individual engages in such a behavior either to get relief from negative feelings, to resolve interpersonal difficulties, or to induce a positive feeling.[1]

Learning theories have been used to explain the maintenance of NSSI in individuals. Positive reinforcement may come in the form of emotional relief obtained from the act or the attention and importance it generates. Negative reinforcement results from reduction of unpleasant emotions or avoiding distressing thoughts.[1] Social learning theories put forward an explanation as to how recent highlighting of self-injurious behaviors in the media and songs could explain the increasing trend of self-injurious behavior among youth. According to self-punishment hypothesis, individuals may choose to engage in self-injury as a means of affect regulation and as a vehicle for punishing oneself for wrong deeds. Social signaling hypothesis explains these behaviors as “means of communication” or “cries for help.” According to “Altered Pain Hypothesis,” these individuals have higher threshold for pain responsiveness, which makes them engage repeatedly in such acts, which others would find “painful.”[2] Individuals engaging in NSSI have also been found to have poor tolerance to distress, higher arousal in response to stressful events, poor verbal communication, and social problem-solving skills.[2]

One of the major problems in conducting research in suicide and related behaviors is the confusing array of related terminologies. DSH refers to attempts to injure oneself irrespective of the intent behind the act. The term “parasuicide” is frequently used interchangeably. Nonfatal suicidal behavior is another term, which denotes a nonlethal “deliberate” act of self-injury, in which a person may or may not have the intent to die. NSSI, on the other hand, clearly mentions “lack of intent” to die at the time of committing the act.[3] Gandhi et al.[4] in their review of 38 Indian studies on self-injurious behavior found a major confusion in interpreting the prevalence of such behaviors due to overlapping use of related terminology. They found only one community study, which strictly adhered to the internationally accepted definition of NSSI, and reported a lifetime prevalence of 31% in a sample of emerging adults.[5] Another study carried out among 1571 male and female school and college students in India found the prevalence of NSSI to be 33.8%.[6] These figures are higher than the pooled prevalence of NSSI of 17.2% among adolescents and 13.4% among young adults from nonclinical samples from studies in various countries.[7] Whether the figures in India are actually higher than the global estimates or whether the rates could be elevated in Indian studies due to inclusion of milder forms of self-injury such as skin-picking, hair-pulling, or tattooing remains to be determined. Further community-based studies are also essential to determine diagnostic and clinical approaches, which take our cultural and religious factors into consideration.

The position of NSSI in the broader spectrum of suicidal behavior remains to be ascertained. According to some researchers, its ability to regulate emotions can serve as a protective factor against completed suicide.[8] However, in the opinion of others, NSSI could increase the risk of future suicide attempts.[9] Research efforts in India are also required to find out whether the sociodemographic profile as well as risk and protective factors of NSSI are distinct from that of individuals who make lethal suicide attempts. Since preliminary research findings have reported higher NSSI in India and its association with increased hospitalization and suicide, it is a potential candidate for further research.



 
   References Top

1.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.  Back to cited text no. 1
    
2.
Nock MK. Self-injury. Annu Rev Clin Psychol 2010;6:339-63.  Back to cited text no. 2
    
3.
Nock MK, Favazza A. Non-suicidal self-injury: Definition and classification. In: Nock MK, editor. Understanding Non-Suicidal Self-Injury: Origins, Assessment, and Treatment. Washington, DC: American Psychological Association; 2009. p. 9-18.  Back to cited text no. 3
    
4.
Gandhi A, Luyckx K, Maitra S, Claes L. Non-suicidal self-injury and other self-directed violent behaviors in India: A review of definitions and research. Asian J Psychiatr 2016;22:196-201.  Back to cited text no. 4
    
5.
Kharsati N, Bhola P. Patterns of non-suicidal self-injurious behaviours among college students in India. Int J Soc Psychiatry 2015;61:39-49.  Back to cited text no. 5
    
6.
Bhola P, Manjula M, Rajappa V, Phillip M. Predictors of non-suicidal and suicidal self-injurious behaviours, among adolescents and young adults in urban India. Asian J Psychiatr 2017;29:123-8.  Back to cited text no. 6
    
7.
Swannell SV, Martin GE, Page A, Hasking P, St John NJ. Prevalence of nonsuicidal self-injury in nonclinical samples: Systematic review, meta-analysis and meta-regression. Suicide Life Threat Behav 2014;44:273-303.  Back to cited text no. 7
    
8.
Brunner R, Parzer P, Haffner J, Steen R, Roos J, Klett M, et al. Prevalence and psychological correlates of occasional and repetitive deliberate self-harm in adolescents. Arch Pediatr Adolesc Med 2007;161:641-9.  Back to cited text no. 8
    
9.
Hamza CA, Stewart SL, Willoughby T. Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model. Clin Psychol Rev 2012;32:482-95.  Back to cited text no. 9
    

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Correspondence Address:
Dr. Om Prakash Singh
AMRI Hospitals, Dhakuria, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_396_18

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