Non-Suicidal Self-Injury in Adolescent Inpatients
An Understanding of NSSI
Research regarding adolescent development has sought to understand the cause of self-harming behaviors, such as suicide, eating disorders, substance abuse, and as of recently, non-suicidal self-injurious (NSSI) behavior. Adolescence is a critical period concerning the onset of self-harming behaviors, and the prevalence of NSSI among them ranges between 13 and 28 percent. Described as one of the most widely-spread and challenging clinical phenomena seen in adolescent inpatients, diagnoses of NSSI have more than tripled in the last ten-year period. However, there is much debate regarding the psychopathological meaning of NSSI, with two main controversial aspects: the relationship between NSSI and personality disorders and the relationship between NSSI and depression and suicide.1
Personality and NSSI
A large amount of empirical data suggests that there is a closer psychopathological association between NSSI and personality functioning,1 and more specifically, there has been a close link between NSSI and Borderline Personality Disorder (BPD). In DSM-IV, self-harm is a criterion of BPD; however, as it is controversial to diagnose a personality disorder prior to adulthood, the DSM-5 Childhood and Adolescent Workgroup is recommending the inclusion of a new diagnosis: Non-suicidal Self-injury (NSSI).1 The proposed diagnosis would apply to individuals who have engaged in intentional self-inflicted damage on five or more days in the last year, without suicidal intent.1 The new diagnosis may reflect upon the relationship between NSSI and adolescence, as well as reduce the automatic assumption that NSSI means BPD. From the Department of Pediatrics and Child and Adolescent Neurology and Psychiatry at the University of Rome, Mauro Ferrara and colleagues explored two objectives in their article “Non-Suicidal Self-Injury (NSSI) in Adolescent Inpatients: Assessing Personality Features and Attitude Toward Death:” first, describing characteristics of NSSI and related psychopathology functioning in a sample of adolescent inpatients, and second, to investigate whether depressive symptoms and attitude towards life and death differ between NSSI patients who have attempted suicide and those who have not.1
Ferrara and colleagues conducted a study of 52 adolescents with a history of NSSI who were consecutively admitted to the psychiatric inpatient unit at the University of Rome.1 The patients were administered three instruments, each required 50 minutes to complete. The first, the Deliberate Self-Harm Inventory (DSHI), measures non-suicidal deliberate self-harm in a self-reporting questionnaire. The DSHI measures frequency, age-of-onset, duration, date of last occurrence, and severity of 17 types of self-harming behavior.10 The second, the Children’s Depression Inventory (CDI) assesses the level of childhood depressive symptoms. The CDI contains 27 items, each consisting of three statements. For each item, the patient picks the one that best describes how they have felt over the past two weeks.11 With scores ranging from zero to 54, higher scores equal more severe depression.11 Third, the Multi-Attitude Suicide Tendency (MAST), measures an adolescent’s attitude towards life and death.
As a result, patients showed multiple types of self-harming behaviors and frequent actions of self-harm.1 The average onset of NSSI was 12.3 years, which indicated a long history of behaviors within the sample.1 Also, the patients manifested frequent and highly diverse forms of self-harm, which could indicate that adolescents with risk of psychopathology begin engaging in more severe forms of NSSI earlier.1 Regarding psychopathological features, Ferrara and colleagues stated that there was a strong link between BPD diagnosis and NSSI in their sample of adolescent patients, with 63.5 percent meeting criteria for the disorder.1 However, there was also a strong link between NSSI and other personality disorders, such as Histrionic Personality Disorder, Narcissistic Personality Disorder, and Passive-Aggressive Personality Disorder.1 On the other hand, there was not a strong link between depressive disorders and NSSI, although many patients did present depressive symptoms on the CDI. Ferrara and colleagues found that neither depressive symptoms nor attitudes toward life and death discriminate amongst patients with NSSI and patients with NSSI who attempt suicide.1 While no conclusions could be drawn regarding the role of depressive symptoms and attitude toward life and death, both are related to higher frequency and diversity of NSSI.1 Ferrara and colleagues stated that attitude toward life and death may help identify the gradual habituation of suicidal behaviors.1
Treatment of NSSI
Therefore, professionals who treat adolescent inpatients for NSSI should consider treatment options tailored to manage BPD features rather than depressive symptoms, as characteristics of non-suicidal self-harm line up more with features of BPD.1 Also, clinicians should evaluate internalizing disorders in association with NSSI, as well as emotional dysregulation and reduced attraction-to-life attitudes in order to assess suicide risk.1
 Ferrara, M.; Terrinoni, A.; and Williams, R. (2012, March 30). Non-Suicidal Self-Injury (NSSI) in Adolescent Inpatients: Assessing Personality Features and Attitude Toward Death. Child Adolesc Psychiatry Ment Health 6(12). doi: 10.1186/1753-2000-6-12. [PubMed]
 Favazza AR. The coming of age of self-mutilation. J Nerv Ment Dis. 1998;186:259–268. doi: 10.1097/00005053-199805000-00001. [PubMed]
 You J, Leung F, Fu K, Lai CM. The prevalence of nonsuicidal self-injury and different subgroups of self-injurers in Chinese adolescents. Arch Suicide Res. 2011;15(1):75–86. doi: 10.1080/13811118.2011.540211. [PubMed]
 Suyemoto KL, Macdonald ML. Self-cutting in female adolescents. Psychother. 1995;32:162–171.
 Olfson M, Gameroff MJ, Marcus SC. et al. National trend in hospitalization of youth with intentional self-inflicted injuries. Am J Psychiatry. 2005;162:1328–1333. doi: 10.1176/appi.ajp.162.7.1328. [PubMed]
 Van Der Kolk BA, Perry JC, Herman JL. Childhood origins of self-destructive behaviour. Am J Psychiatry. 1991;148:1665–1667. [PubMed]
 Shaffer D, Jacobson C. Proposed revisions: Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence. DSM-5 Development. Arlington, VA: American Psychiatric Association; 2009. Proposal to the DSM-5 childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-5 disorder.
 Gratz KL. Measurement of deliberate self-harm: preliminary data on the Deliberate Self-Harm Inventory. J Psychopathol Behav Assess. 2001;23:253–263. doi: 10.1023/A:1012779403943.
 Kovacs M. The Children’s Depression Inventory. Psychopharmacol Bull. 1985;21:995–998. [PubMed]
 Osman A, Gilpin AR, Kopper BA. et al. The Multi Attitude Suicide Tendency Scale: Further Validation with Adolescent Psychiatric Inpatients. Suicide Life Threat Behav. 2000;30(4):377–385. [PubMed] NSSI.