Radhika J. Kothadia, MD PGY-3 General Psychiatry Resident Prisma Health/University of South Carolina School of Medicine Columbia, South Carolina
Kaustubh G. Joshi, MD Associate Professor of Clinical Psychiatry Associate Program Director, Forensic Psychiatry Fellowship Department of Neuropsychiatry and Behavioral Science University of South Carolina School of Medicine Columbia, South Carolina
Richard L. Frierson, MD Alexander G. Donald Professor of Clinical Psychiatry Vice Chair for Academic Affairs Program Director, Forensic Psychiatry Fellowship Department of Neuropsychiatry and Behavioral Science University of South Carolina School of Medicine Columbia, South Carolina
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Transgender and gender nonconfirming (GNC) youth are at a particularly high risk for NSSI; 30% to 45.5% of transgender adolescents report self-injury.17 Factors shown to distinguish transgender/GNC youth who engage in NSSI from those who do not include having a mental health problem, depression, running away from home, substance use, lower self-esteem/greater self-criticism, experiencing transphobia victimization, and having more interpersonal problems.18,19 Among transgender/GNC youth, those whose biological sex is female are more likely to report NSSI than those whose biological sex is male (ie, transgendered adolescent males are more likely to report NSSI than transgendered adolescent females).18,19
Most forms of childhood maltreatment have been associated with NSSI. In a recently published review, Liu et al20 found that childhood maltreatment (including sexual abuse, physical abuse, emotional abuse, and physical neglect) was associated with an increased risk for NSSI. However, conflicting evidence suggests that when confounders are removed, only childhood emotional abuse was directly associated with NSSI.21 Current evidence is modest for childhood emotional neglect as a risk factor for NSSI.20
Increasing research is investigating the biological processes that may be implicated in NSSI. Some studies suggest that endogenous opioids,22 monoamine neurotransmitters,22 and the hypothalamic-pituitary-adrenal (HPA) axis23 may play a role in NSSI. Compared to healthy controls, adolescents engaging in NSSI have been shown to have lower pain intensity (P = .036), higher pain thresholds (P = .040), and lower beta-endorphins (endogenous opioid hormones involved in mediating stress and pain) (P = .002).24 There may be alterations in the HPA axis among adolescents who engage in NSSI, more specifically stronger cortisol awakening responses.23 Both functional and standard MRI have been used to study the neurobiology of NSSI. One study demonstrated differences in functional connectivity between brain areas linked to neuroregulation of emotions in adolescents who engage in NSSI,25 while another found volume reduction in the insula of these adolescents, which suggests a possible neurobiological reason for impulsivity and the increased risk of suicidal behavior.26
Dynamic risk factors
Research has repeatedly shown bullying is a risk factor for NSSI.27 One study found that younger children who were victimized reported significantly more NSSI than older children.28 New data suggest that perpetrators of bullying are also at risk for deliberate self-harm behavior (SHB), which this study defined as a behavior that is intended to cause self-harm but without suicidal intent and having a nonfatal outcome.29 Victims of cyberbullying also are at a greater risk for self-harm, suicidal behaviors, and suicide attempt.30 To a lesser extent, cyberbullying perpetrators are at greater risk for suicidal behaviors and suicidal ideation.30 Bullying is a risk factor for NSSI not only in adolescence, but also in adulthood. Lereya et al31 found that victims of bullying in childhood and early adolescence were more likely to have mental health problems (including anxiety and depression) and more likely to engage in SHB—which this study defined as hurting oneself on purpose in any way—as adults.
The effects of internet use on adolescents’ mental health also has been investigated. A recent review that explored the relationship between all types of internet use (general use, internet addiction, social media, self-harm websites, forums, etc) and SHB/suicidal behavior found that young people with internet addiction, high levels of internet use, and a tendency to view websites with self-harm or suicidal content were at higher risk of engaging in SHB/suicidal behavior.32 This study did not use a specific definition for SHB or suicidal behavior.32
