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“When you make peace with yourself, you make peace with the world.”

–Maha Ghosananda


  • Examine origins of NSSI behavior

  • Explore how to assess patients with NSSI behavior

  • Find out how to prevent escalation of patients with NSSI behavior

  • Define de-escalation practices for patients with NSSI behavior

  • Explore differences between patients with NSSI behavior and patients with suicidal ideation

Non-suicidal self-injury (NSSI) behavior is defined as deliberate behavior that results in a self-inflicted injury and the destruction of body tissue without a conscious suicidal intent. NSSI involves deliberately mutilating the body—for example, by cutting or burning. Individuals who engage in NSSI repeatedly inflict shallow yet painful injuries to their body and skin. NSSI behavior causes significant distress and often interferes in academic, interpersonal, and other important areas of normal life.


NSSI behavior was previously described as self-mutilation, self-inflicted violence, self-injurious behavior, or self-directed violence (Agüero, Medina, Obradovich, & Berner, 2018).

The DSM-5 identifies the criteria for NSSI in its section for conditions requiring further study. It describes NSSI behavior as five or more days of intentional self-inflicted injury to one’s body likely to cause bleeding, bruising, or pain (American Psychiatric Association [APA], 2013). Individuals who engage in NSSI express no suicidal intent. They are aware the behavior will not result in death. The DSM-5 further defines NSSI behavior as being conducted to obtain relief from negative feelings such as depression, anxiety, or distress; to resolve an interpersonal difficulty; or to induce positive feelings. Table 12.1 lists types of behaviors associated with NSSI.

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TABLE 12.1 Behaviors Associated With NSSI



Cigarette burns

Self-embedding objects


Ingesting objects

Biting self

Skin picking

Hair pulling

Stabbing self

Head banging

Ingesting toxins

Striking self

Excessive rubbing with evisceration of tissue

NSSI is usually inflicted with a knife, needle, razor, or other sharp instrument. For example, someone who engages in NSSI might use a razor to cut or scratch their skin or embed a sharp object such as a sewing needle under the skin. Injuries are generally superficial but may deepen with repetition. NSSI can begin with relatively benign practices such as hair-pulling but escalate—for example, to intentional self-burning, scalding, or biting (Mental Health Foundation & Camelot Foundation, 2006) or to the ingestion of objects or toxic substances. This can lead to accidental suicide. Employing multiple methods of injury is associated with more severe psychopathology, including suicide attempts (APA, 2013).


At least 80% of NSSI behavior involves stabbing or cutting the skin with a sharp object (Greydanus & Shek, 2009; Hawton, Zahl, & Weatherall, 2003; Idig-Camuroglu & Gölge, 2018).

NSSI should be distinguished from behaviors such as tattooing or body piercing. In other words, NSSI is the deliberate, non–life threatening, self-inflicted bodily injury or disfigurement of a socially unacceptable nature ...

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