Nonsuicidal self-injury is characterized by deliberate self bodily harm in the absence of intent to take one’s own life. Such injuries may cause substantial bruising, bleeding and skin damage and are often associated with powerful negative emotions such as stress or anxiety. Most often, such self-injury is not preceded by substantial precontemplation and occurs impulsively. Methods of self-injury include cutting, stabbing, severe scratching, and burning of the skin, most often found on the nondominant limb. Other methods include inserting sharp objects under the skin, hair pulling, and carving words or symbols into the skin. Cutting tends to be the most common of self-injuries, estimated as being present in 70% to 90% of individuals engaging in nonsuicidal self-injury. Cuts are often deep enough to cause bleeding and are characterized by a series of parallel lines frequently located over the volar aspect of the upper extremities.
Nonsuicidal Self-Harm—Superficial Cutting. Deliberate tissue injury without suicidal intent often manifests as superficial cutting, burning, and deep scratching in adolescents, as seen in this patient (Photo contributor: Christopher L. Stark, DO.)
Nonsuicidal Self-Harm—Deep Cutting. Cutting to the degree that repair is required is likely to be nonsuicidal; however, some would argue this level of injury is a prelude to suicide attempt. (Photo contributor: Christopher L. Stark, DO.)
Nonsuicidal Self-Harm—Soft-Tissue Foreign Body. Hairpin inserted under the skin in an adolescent. Insertion of sharp objects under the skin, another form of nonsuicidal self-harm, suggests an increased level of distress compared to superficial cutting. (Photo contributor: Lawrence B. Stack, MD.)
Nonsuicidal Self-Harm—Abdominal Foreign Body. Insertion of a foreign body into the abdominal cavity is common among institutionalized persons and is often done to avoid specific situations as opposed to true self-harm. (Photo contributor: R. Jason Thurman, MD.)
Patients who repeatedly exhibit nonsuicidal self-injury and use multiple methods over their lifetime are at greater risk for a suicide attempt.
Management and Disposition
The initial approach to the patient with nonsuicidal self-injury should address the patient’s immediate safety as well as their associated injuries. Many superficial injuries may be easily repaired at the bedside, but the clinician should also consider the possibility of additional modes of self-harm such as ingestion. A thorough medical screening exam should be performed prior to psychiatric evaluation.
Nonsuicidal self-injury is highly associated with risk for future suicide attempts, and psychiatric stabilization is paramount.
Physical injuries occurring from self-injury should be managed as any patient presenting with trauma with the caveat that ...