Introduction to self-harm in adolescents
Summary
Non-suicidal self-injury (NSSI) is a direct and deliberate damage of one's body surface, without lethal intent. It is distinct from suicide attempts because although they involve self-inflicted bodily harm there is no intention of causing death. Its recurrence may be related to an increased risk of suicide.
It is important to know its key features, understand its functionality, its risk factors and its triggers in order to offer specialized help to adolescents and young people who present them.
Non-suicidal self-injury (NSSI) is a direct and deliberate damage of one's body surface, without lethal intent. It is distinct from suicide attempts because although they involve self-inflicted bodily harm there is no intention of causing death. Its recurrence may be related to an increased risk of suicide. Its incidence continues to be higher in young people with a previous history of mental health issues, but in recent decades at the international level, in adolescents of the general population of all cultures and countries, an increase in its prevalence has been observed.
Although these are behaviors without suicidal intent, there are currently numerous studies that link a high recurrence of this type of behavior with an increased risk of suicide.
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Its for this reason that this article gives the keys to understanding what non-suicidal self-harm is and what its functionality may be, with the aim of addressing an issue that, in addition to being a mental health problem in itself, can be a risk factor for suicidal behavior.
What do we understand about non-suicidal self injury and in what context do we observe it?
What do we understand by non-suicidal self-injury and in what context do we observe it?
Non-suicidal self-injury (NSSI) is a direct and deliberate destruction of one's body surface, without lethal intent. Therefore, it involves self-inflicted bodily harm, with no intention of causing death.
Currently NSSI is receiving a lot of interest from journalists, scientists, teachers and educators, parents, etc., partly due to the increase in the incidence of these behaviors by young people and adolescents, and because of the concern and anguish that the behavior generates in the people around these young people and adolescents.
Although NSSI is not yet a psychiatric disorder, the Diagnostic and Statistical Manual of Mental Disorders (DSM), in its fifth version (APA, 2013) has included it as a diagnosis that requires further study.
The definition of the concept has been changing over the last decades, which means that some of the published studies are not entirely comparable, since they start from a different conceptualization, and this entails methodological problems.
Currently, most studies are already carried out with the definition proposed by the latest version of the DSM, which clearly differentiates non-suicidal self-harm from other types of behaviors harmful to health and from other behaviors that imply a certain suicidal intentionality.
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Thus, DSM 5 defines non-suicidal self-harm based on 6 criteria, which are the following (adapted from DSM 5, Psychiatric, 2013)
1. In the past year, the individual has sustained, for 5 or more days, intentional damage to himself / herself on the surface of his / her body, of a type that is likely to induce bleeding, bruising, or pain (for example, cutting, burning, stabbing, hitting, rubbing excessively), with the expectation that the injury will only lead to mild or moderate physical harm (i.e. there is no suicidal intent)
2. The individual engages in self-injurious behavior with one or more of the following expectations:
Get relief from a negative feeling or cognitive state
Solve an interpersonal difficulty
Induce a positive feeling state
3. Intentional self-harm is associated with at least one of the following criteria:
Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, general distress or self-criticism, which occurs in the period immediately before the act of self-harm
Before getting into the act, there will be a period of preoccupation with the intended behavior that is difficult to control
Thinking about self-harm that occurs frequently, even if you don't act on it
4. The behavior is not socially sanctioned (eg, body piercing, tattoo, part of a religious or cultural ritual) and is not restricted to scratching a scab or biting nails.
5. The behavior or its consequences cause clinically significant annoyance or interference with interpersonal, academic, or other important functions.
6. The behavior does not occur exclusively in psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive behavior. The behavior is not better explained by another mental disorder or medical condition (eg, psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypical movement disorder with self-harm, trichotillomania [hair pulling disorder], excoriation [skin scratching disorder.
In the field of Mental Health, non-suicidal self-harm has traditionally been considered a behavior associated with a serious mental disorder, such as schizophrenia, Tourette's syndrome, severe intellectual disability or serious neurological syndromes.
Also traditionally, NSSI have been one more symptom within Borderline Personality Disorder (BPD), being one of the established diagnostic criteria.
In these disorders, self-injurious behaviors have been understood as a type of behavior aimed at reducing anxiety (whether carried out consciously or unconsciously by children or adolescents) or as a form of self-stimulation that is observed in these cases severe mental disorder.
However, at present ANS, although it continues to be observed in serious mental illnesses, and its prevalence has not changed in these cases, it is also observed in boys and girls of the general population, that is, without established mental pathologies.
This does not mean, however, that the young people who carry out these behaviors do not have any significant distress or psychological difficulties, but the contrary.
Do adolescents without mental health disorders self harm?
Do adolescents without mental disorder self-harm?
In recent decades, an increase in the prevalence of non-suicidal self-harm has been observed in young people and adolescents, without an established psychiatric disorder.
When the first scientific articles on the subject were published (early 1980s) they reported a prevalence of 0.4% (percentage of cases in a population) (Pattison ME, 1983), but current international studies observe prevalences far higher.
Thus, in studies published in the last 10 years, prevalences of 17% in China, 18% in India, 20% in New Zealand, 21.7% in Finland, 17.1% in Sweden, 30.7% in Belgium, 25.6% in Germany, 23.2% in the United States, or 11.4% in Catalonia, to give a few examples, although in different studies the data are quite heterogeneous, depending on the collection instruments of data or the type of prevalence studied (vital prevalence or last year) (Muehlenkamp, Claes, Havertape, & Llenos, 2012).
In general and internationally, it is considered that between 13 and 45% of adolescents have self-injured at some point in their life and in Europe there is talk of a vital prevalence of 27.6% (Brunner et al., 2014).
In Spain, very little data is available on children under 18 years of age, but the data is similar to those in Europe.
Therefore, the data from epidemiological research allow us to affirm that it is a phenomenon that has increased in recent years, and that it goes beyond the barriers of serious mental illness and extends among adolescents and young people of the general population. in all countries and cultures.
Is there a difference between teenagers who self-harm who have a mental health problem?
When adolescents with some type of psychiatric or psychological disorder are studied, the incidence of NSSI is much higher, for several reasons.
In the first place, this behavior can be another symptom within a mental disorder that occurs together with other symptoms, but in which self-harm is an inherent symptom and, therefore, very relevant to the patients diagnosis and treatment. This is the case with Borderline Personality Disorder (BPD).
BPD is a personality disorder that is defined by a dysfunctional pattern of thinking, emotions and behaviors, due to various alterations related to mood instability, impulsivity, problems with one's own identity and also the propensity to perform ANS.
Second, non-suicidal self-injury can also be seen in adolescents with other disorders (in addition to BPD) as an accompanying symptom, which may or may not be associated with this disorder. In these cases, it has been observed that, in adolescents with eating disorders, depressive or anxiety disorders, self-injurious behavior occurs occasionally or occasionally (not always) and occurs in different ways, usually as a mechanism to reduce anxiety, to express discomfort socially, etc.
And finally, another reason that could explain the high incidence of ANS in the clinical population is contagion.
An unavoidable fact among adolescents with psychiatric pathology, whatever it may be, is admission to specialized healthcare facilities (inpatient units, day hospitals, etc.).
This fact has proven advantages, such as access to specialized treatment and professionals, benefits of group treatments with other adolescents who have the same problems, among others. But it can also have, in some cases, the aforementioned drawback of the possible contagion of these and other pathological behaviors.
At what age does this problem start and how does it evolve?
NSSI usually begins between the ages of 11 and 13 (Whitlock J, 2014). This data is explained by the fact that adolescents are a population of great vulnerability to NSSI, especially due to the high impulsivity and emotional reactivity that characterize this vital stage.
Which adolescents are more prone? Risk factors
Some psychological variables have been identified that, when present, are risk factors for the development of ANS.
Some of these variables are dysfunctional personality traits, and specifically unstable personalities, with high emotional reactivity, with a tendency to impulsive behaviors, or with a tendency to develop excessively subjective and / or egocentric points of view.
Dysfunctional personality traits, in general, refer to an enduring pattern of internal experience and behavior that deviates markedly from the individual's cultural expectations. This pattern manifests itself in the areas of cognition, affectivity, interpersonal functioning, and impulse control.
In adolescence, personality problems can be difficult to diagnose, and require the intervention of a clinical specialist, since in this period the personality is in the process of formation and structuring, and also the adolescent crises themselves can lead to some non-pathological alterations in personality, which could be confused with dysfunctional (pathological) traits.
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Does gender have an influence?
Traditionally, self-harm has been considered a predominantly female phenomenon. There are many studies on prevalence and incidence that support this consideration (Vega, Sintes, Fernández et al., 2018)
However, there are also recent studies that qualify those from older studies, and some research indicates minor differences in incidence according to sex and / or gender.
Another widely demonstrated aspect is the use of different methods to carry out non-suicidal self-harm, in boys and girls.
While girls are more likely to cut, scratch, and use methods that involve bleeding, boys are more likely to hit and burn themselves.
Does the environment influence it? Adverse life experiences
More verified data indicates high incidence, among boys and girls who injure themselves, of experiences that involve bullying, mistreatment or abuse during childhood.
However, studies that show this association indicate that there is a shared risk between both factors (NSSI and abuse), although it does not mean that having suffered abuse is the cause of self-injurious behavior.
Why do young people self-harm?
One of the most relevant aspects for professionals who study the phenomenon is to be able to determine what sense or "motivation" the adolescent has when performing this behavior.
Several authors have approached the study of the functionality of these behaviors, that is, of the role that the behavior fulfills in the mental and social functioning of the adolescent.
Like all human behaviors that are maintained over time, or that even tend to increase, it is clear that such behavior must be reinforcing or "useful" for the functioning of the person, although said utility is detrimental in the long run term or have negative consequences. Therefore, young people who self-injure obtain something "positive" for them when they do so, even if the "positive" is only to avoid the occurrence of some event or internal experience that they consider more unpleasant or difficult to bear. The problem is that this supposed "benefit" is short-term (in the medium and long term there is no benefit), it entails risks for physical and psychological health, the quality of relationships, etc.
One of the authors who have studied the functionality of the NSSI the most are Nock and Klonsky (Klonsky & Glenn, 2009).
These authors have observed that non-suicidal self-harm would fulfill two types of functions, some that are related to intrapersonal (more individual) motivations and others that are more interpersonal (or social).
In each of this type, there would be different functions. The authors propose, among the intrapersonal ones, the reduction of some internal state (emotion, thought) that the person experiences as negative. For example, some teens self-harm to reduce the feeling of emptiness they experience, or a state of intense anxiety. Sometimes they try to stop the recurrence of negative thoughts.
Among interpersonal functions, the aforementioned authors describe the possibility of avoiding unpleasant interpersonal situations, or obtaining attention, affection, or approval from their social environment.
These types of functions, of a more social nature, are the ones that often generate more problems in school and family settings, because for adolescents for whom the NSSI perform functions of this type, the response of the social environment in their behavior has a great influence in its evolution and prognosis.
In addition, when the interpersonal function predominates, contagion, imitation, phenomena can occur, which in the school environment is a challenge for educators and counselors.
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