Identifying risk factors. The case patient experienced bullying and reported a nonheterosexual orientation, both of which have been demonstrated as strong risk factors for NSSI.5 Female gender has also been identified as a risk factor for NSSI.3
In adolescent psychiatric samples, prevalence rates of NSSI were found to be as high as 60% for 1 incident of NSSI and around 50% for repetitive NSSI.6 NSSI coincides with other psychiatric comorbidities, including eating disorders, mood disorders (depression), anxiety disorders, posttraumatic stress disorder, and borderline personality disorder.3 In a study of 93 subjects, each of whom was a self-reported abuse survivor with a history of self-injury, 96% were in therapy for diagnoses that included posttraumatic stress disorder (73%), dissociative disorder (40%), borderline personality disorder (37%), and multiple personality disorder (29%).7
The experience of adverse childhood events also increases risk for NSSI. This includes parental neglect, abuse, or deprivation.6 Insecure paternal attachment and parental neglect are significant predictors for women, while childhood separation is a primary predictor for men.8 Indirect childhood maltreatment, such as witnessing domestic violence or increased parental critique, is also associated with NSSI.8 NSSI is also more prevalent among young people who identify with a subculture such as gothic or emo.6
Why they do it and how to help
In multiple studies aimed at identifying reasons for self-injury, converging evidence suggests that nearly all patients act with the intent of alleviating negative affect.9 Patients self-harm to regulate distress, anxiety, and frustration that they perceive to be intolerable.9 They may self-harm to generate feeling when emotionally empty or to avert suicidal intent.9 For others, self-harm is a way to communicate their distress.
How to proceed. After a physician identifies NSSI, the patient should be assessed for suicidality and medical severity of the injury.3 Factors associated with higher likelihood of suicidality in patients with NSSI include multiple self-injurious methods and locations, early age of onset, longer history of NSSI, recent worsening of the injuries, simultaneous substance use, and the perception that the patient is addicted to self-injury.10
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