Treating Nonsuicidal Self-Injury

Abstract

Nonsuicidal self-injury (NSSI) evaluation and treatment are critical for comprehensive patient care. A thorough assessment of nonsuicidal self-injury(NSSI) following DSM-5-proposed criteria is critical in understanding and treating NSSI and should be informed based upon past and current self-harm behaviors, including self-injury methods, frequency, severity, and intent, along with a comprehensive suicide risk assessment. After NSSI is diagnosed, patients should be offered proper management of co-occurring psychiatric illnesses, if applicable, enhanced by an 8 – 12 week trial of cognitive behavior therapy (CBT) focusing on NSSI. Cognitive strategies to be used include Socratic questioning, keeping thought records, and addressing self-derogatory and distorted beliefs about NSSI. Behavioral strategies include contingency management, behavioral activation, and addressing environmental factors maintaining NSSI. In adolescents, individual CBT work might be supplemented with family-based therapy. Dialectical strategies (acceptance and distress tolerance) and skills training (focus on improving emotion regulation, problem-solving, interpersonal, and communication skills) can be used to enhance CBT, but in some cases DBT can be cost prohibitive. If adequate psychotherapy trials are ineffective, a pharmacotherapy trial of emerging drug therapies for NSSI, e.g. naltrexone, N-acetylcysteine, or topiramate to enhance supportive psychotherapy would be recommended. We would encourage patients to continue effective treatment for at least 6 months and would continuously assess for self-harm urges and behaviors. Psychoeducation and adequate treatment of comorbid conditions should be provided on an ongoing basis along with attention to physical self-care and regular exercise.