DSM-5

Proposed Criteria

A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). (Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual's repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death.)

B. The individual engages in the self-injurious behavior with one or more of the following expectations:

  1. To obtain relief from a negative feeling or cognitive state.
  2. To resolve an interpersonal difficulty.
  3. To induce a positive feeling state.

Note: The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.

C. The intentional self-injury is associated with at least one of the following:

  1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.
  2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.
  3. Thinking about self-injury that occurs frequently, even when it is not acted upon.

D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.

E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.

F. The behavior does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury, trichotillomania [hair-pulling disorder], excoriation [skin-picking] disorder).

Differential Diagnosis

Borderline personality disorder

As indicated, nonsuicidal self-injury has long been regarded as a "symptom" of borderline personality disorder, even though comprehensive clinical evaluations have found that most individuals with nonsuicidal self-injury have symptoms that also meet criteria for other diagnoses, with eating disorders and substance use disorders being especially common. Historically, nonsuicidal self-injury was regarded as pathognomonic of borderline personality disorder. Both conditions are associated with several other diagnoses. Although frequently associated, borderline personality disorder is not invariably found in individuals with nonsuicidal self-injury. The two conditions differ in several ways. Individuals with borderline personality disorder often manifest disturbed aggressive and hostile behaviors, whereas nonsuicidal self-injury is more often associated with phases of closeness, collaborative behaviors, and positive relationships. At a more fundamental level, there are differences in the involvement of different neurotransmitter systems, but these will not be apparent on clinical examination.

Suicidal behavior disorder

The differentiation between nonsuicidal self-injury and suicidal behavior disorder is based either on the stated goal of the behavior being a wish to die (suicidal behavior disorder) or, in nonsuicidal self-injury, to experience relief as described in the criteria. Depending on the circumstances, individuals may provide reports of convenience, and several studies report high rates of false intent declaration. Individuals with a history of frequent nonsuicidal self-injury episodes have learned that a session of cutting, while painful, is, in the short-term, largely benign. Because individuals with nonsuicidal self-injury can and do attempt and commit suicide, it is important to check past history of suicidal behavior and to obtain information from a third party concerning any recent change in stress exposure and mood. Likelihood of suicide intent has been associated with the use of multiple previous methods of self-harm.

In a follow-up study of cases of "self-harm" in males treated at one of several multiple emergency centers in the United Kingdom, individuals with nonsuicidal self-injury were significantly more likely to commit suicide than other teenage individuals drawn from the same cohort. Studies that have examined the relationship between nonsuicidal self-injury and suicidal behavior disorder are limited by being retrospective and failing to obtain verified accounts of the method used during previous "attempts." A significant proportion of those who engage in nonsuicidal self-injury have responded positively when asked if they have ever engaged in self-cutting (or their preferred means of self-injury) with an intention to die. It is reasonable to conclude that nonsuicidal self-injury, while not presenting a high risk for suicide when first manifested, is an especially dangerous form of self-injurious behavior.

This conclusion is also supported by a multisite study of depressed adolescents who had previously failed to respond to antidepressant medication, which noted that those with previous nonsuicidal self-injury did not respond to cognitive-behavioral therapy, and by a study that found that nonsuicidal self-injury is a predictor of substance use/misuse.

Trichotillomania (hair-pulling disorder)

Trichotillomania is an injurious behavior confined to pulling out one's own hair, most commonly from the scalp, eyebrows, or eyelashes. The behavior occurs in "sessions" that can last for hours. It is most likely to occur during a period of relaxation or distraction.

Stereotypic self-injury

Stereotypic self-injury, which can include head banging, self-biting, or self-hitting, is usually associated with intense concentration or under conditions of low external stimulation and might be associated with development delay.

Excoriation (skin-picking) disorder

Excoriation disorder occurs mainly in females and is usually directed to picking at an area of the skin that the individual feels is unsightly or a blemish, usually on the face or the scalp. As in nonsuicidal self-injury, the picking is often preceded by an urge and is experienced as pleasurable, even though the individual realizes that he or she is harming himself or herself. It is not associated with the use of any implement.

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