NSSI "Wiki"

Welcome to the NSSI "Wiki" page! This page contains a brief summary of the most important things to know about NSSI.

Introduction
What is self-injury?

Self-harm or deliberate self-harm (DSH) is an umbrella term that refers to any self-inflicted behaviour regardless of intent (1). This can include culturally appropriate behaviours (e.g. tattoos, body piercings), risky and dangerous behaviours (e.g. reckless driving), self-destructive behaviours (e.g. hair pulling, drinking excessively, behaviours associated with eating disorders), and poisoning - whether meant as an attempt to end life or not - and/or a suicide attempt.

Non-suicidal self-injury also comes under this umbrella. Non-suicidal self-injury (NSSI), or self-injury, is the deliberate damage of body tissue without suicidal intent and for purposes not socially sanctioned (2). The term self-harm is typically used to describe both non-suicidal self-injury and suicide attempts. It is important to make a distinction between behaviours engaged with and without suicidal intent for a number of reasons:

1. The reason for the behaviors differ: suicide attempts are a way to escape life; NSSI is a way to cope with life;

2. The psycho-social factors associated with each behaviour can differ (3);

3. The behaviours often look different (e.g., in method, frequency, potential lethality)

4. The responses to each behaviour should differ

Talking About Self-Injury

Aside from distinguishing NSSI from self-harm, the way we talk about the behaviour itself is important. Traditionally, the discourse around NSSI has been grounded in a medical framework. That is, NSSI is seen as a symptom of an underlying condition that needs to be treated or ‘fixed’. The ultimate goal of treatment is seen as ‘curing’ someone of self-injury, where recovery is defined as a return to ‘normal’ functioning. Further, self-injury has been viewed from a deficit-based perspective. People who self-injure are seen to be lacking in a core skill such as emotion regulation or coping skills. This medical, deficit-based, backdrop can lead to NSSI, and the people who engage in the behaviour, as being further stigmatized and considered faulty in some way.

Language is important. It shapes our shared understanding of concepts and ideas, gives value to these (e.g. as good or bad), and when used inappropriately can perpetuate stereotypes and stigma. When stigmatising language around NSSI is used (e.g., people who self-injure are crazy), individuals can internalize that messaging (e.g., I am crazy), which leads to the individual feeling devalued, misunderstood, and less likely to seek support (4).

In recent years there has been a shift toward talking about NSSI in a non-stigmatizing, person-centred way, emphasizing that a person is not defined by their self-injury (5). When talking to someone who self-injures, adopt a respectful curiosity, showing a non-judgmental and genuine interest in what is going on for them (6). We suggest avoiding terms like ‘maladaptive’ and ‘contagion’ which suggest that someone is faulty in some way that is likely to spread to others (7,8).

Top Tips

Always be respectful when talking about NSSI, or people with a lived experience of NSSI
Poorly-considered language can exacerbate stigma among people who already feel highly stigmatised
Avoid language that defines a person by their behaviour (e.g., “cutter”; “self-injurer”)
Avoid language that is value-laden (e.g., good/bad; maladaptive), or propagates stigma (e.g., attention-seeking)
Use of appropriate language can foster open communication and facilitate support-seeking
Check out specific guidelines for members of the media in reporting on and writing about NSSI.

Following these principles, media guidelines have been developed to assist media in appropriate reporting of self-injury. These guidelines emphasize (9):

Avoid use of NSSI-related images and details within text, especially of NSSI wounds and methods/tools
Highlight efforts to seek treatment, stories of recovery, adaptive coping strategies as alternatives to NSSI, and updated treatment and crisis resources
Avoid misinformation about NSSI, by communicating peer reviewed and empirically supported material, including distinguishing NSSI from suicide
Present information neutrally; avoid exaggerated descriptions of NSSI prevalence and sensational headlines that include NSSI, especially the method of NSSI
Use non-stigmatising language and avoid terms that conflate person and behaviour (e.g. ‘cutter’)
Ensure that online article comments are responsibly moderated.

NICE Guidelines https://www.nice.org.uk/guidance/ng225
ISSS
Brausch, A. M., & Gutierrez, P. M. (2010). Differences in non-suicidal self-injury and suicide attempts in adolescents. Journal of youth and adolescence, 39(3), 233–242. https://doi.org/10.1007/s10964-009-9482-0
Staniland, L., Hasking, P., Boyes, M., & Lewis, S. (2021). Stigma and Nonsuicidal Self-Injury: Application of a Conceptual Framework. Stigma and Health, 6. 312-323.
Lewis SP. I cut therefore I am? Avoiding labels in the context of self-injury. Medical Humanities 2017;43:204.
Walsh
Hasking, P., & Boyes, M. (2018). Cutting Words: A Commentary on Language and Stigma in the Context of Nonsuicidal Self-Injury. The Journal of nervous and mental disease, 206(11), 829–833.
Hasking, P., Lewis, S.P. and Boyes, M.E. (2019), "When language is maladaptive: recommendations for discussing self-injury", Journal of Public Mental Health, Vol. 18 No. 2, pp. 148-152
Westers

Experiences of Self-Injury

Disclosure of self-injury

People can learn about another person’s self-injury in several ways including if they happen to notice signs of self-injury (e.g., seeing scarring, witnessing the person self-injure), being told by a third party, or when the person who has self-injured intentionally shares this information with them (1). When a person directly and willfully tells another person that they have self-injured this is considered to be “voluntary disclosure” of self-injury. Estimates of how many people have disclosed their self-injury voluntarily vary across studies, partly depending on the population being surveyed (2). Generally 40-50% of people who have self-injured have disclosed this to another person, amongst xxx. When people do disclose their self-injury they tend to tell people they have a personal relationship with rather than talking to professionals about their self-injury (2). Disclosures in personal relationships are often made in friendships and romantic relationships, though disclosures to parents and siblings are more common for younger people (2).

Mirichlis. (2024). Understanding Voluntary NSSI Disclosure [Doctoral thesis, Curtin University].
Simone, A., & Hamza, C. (2020).

Self-injury stigma

Stigma refers to the culmination of stereotype, prejudice, and disrimination (ref). Many behaviors, experiences, and identities are stigmatized. While self-injury stigma has been described by individuals with lived experience, researchers have only recently begun to investigate its manifestations and impacts (ref). It is argued that self-injury stigma is distinct from other forms of stigma because self-injury is a socially unacceptable behavior associated with mental illness that can leave visible marks. As such, self-injury attracts three forms of stigma: behavioral (related to act of harming oneself), physical (related to the physical and sometimes long-lasting marks caused by self-injury), and mental (representing the aspect of NSSI stigma that overlaps with mental illness stigma).

The NSSI Stigma Framework outlines four perspectives through which NSSI stigma manifests, with a fifth perspective being suggested in subsequent research. These perspectives represent how stigma is experienced and perpetuated. Additionally, the NSSI Stigma Framework identifies why self-injury is stigmatized, categorising manifestations of self-injury stigma into the domains outlined by Jones et al. (ref).

Self-injury Recovery

Historically, NSSI recovery has emphasised cessation of the behaviour. This, in many ways, aligns with traditional medical frameworks (Lewis & Hasking, 2020, 2021). Over the past few years, however, growing attention has been paid to understanding NSSI recovery from a lived experience perspective (e.g., Lewis et al., 2019; Lewis & Hasking, 2020, 2021, 2023). Efforts in this regard have pointed to the complexity of recovery and led to the development of a person-centred framework (see Lewis & Hasking, 2021). Consistent with its person-centred nature, the components of the framework will have varying levels of relevance to different people. In other words, recovery experiences vary and not all components will be relevant to a given person. Components can also differ in their salience for a person across time (e.g., one component may be more important early vs later in recovery).

The main components of this framework are:

Realistic Expectations and Setbacks: Given its nonlinear nature, there may be setbacks (e.g., instances of NSSI) during recovery; these are expected and normal.
Normalizing Thoughts and Urges: Thoughts about, and urges, to self-injure are also a normal part of the process. These may never fully go away but will abate in frequency and intensity.
Self-efficacy: People develop efficacy to resist urges and find alternatives to replace self-injury.
Finding Alternatives: Recovery involves finding new ways to respond to NSSI urges and to meet the need(s) of NSSI.
Identifying Strengths: All people who self-injure have strengths that can be drawn upon and fostered in recovery.
Addressing Underlying Adversities: NSSI occurs in a context and a person’s unique adversities (e.g., mental health difficulties, trauma) merit attention.
Addressing and Accepting Scarring: Scarring from self-injury may be a concern (e.g., being stigmatised, feeling shame). Support may be needed to promote scar acceptance.
Navigating Disclosures: People may wish to share their lived experience at different time points; they should do so only when they are ready but may need support when making this choice.
Self-acceptance and Self-compassion: While working on recovery, self-acceptance and self-compassion can be cultivated.
Resilience and Meaning-making: People develop resilience and can find meaning in their lives by navigating through the above components

Whereas some models of recovery suggest a stepwise progression, the person-centred framing of NSSI recovery emphasises a non-linear process. Thus, recovery is bound to ebb and flow (e.g., setbacks may occur). The non-linearity of the framework also means that the process itself may not have an ‘end-point’ and may continue ongoingly. Finally, a core tenet of this framework is that all people have strengths and that as people chart their own recovery path, they can build resilience, acceptance, and forge meaning in their lives (Lewis & Hasking, 2021, 2023).

1. Lewis, S. P., Kenny, T. E., Whitfield, K., & Gomez, J. (2019). Understanding self‐injury recovery: Views from individuals with lived experience. Journal of Clinical Psychology, 75(12), 2119-2139.

2. Lewis, S. P., & Hasking, P. A. (2020). Rethinking self-injury recovery: A commentary and conceptual reframing. BJPsych bulletin, 44(2), 44-46.

3. Lewis, S. P., & Hasking, P. A. (2021). Self‐injury recovery: A person‐centered framework. Journal of Clinical Psychology, 77(4), 884-895.

4. Lewis, S. P., & Hasking, P. A. (2023). Understanding self-injury: A person-centered approach. Oxford University Press.

The Functions of NSSI

People engage in NSSI for many different reasons, meaning it serves distinct functions for different people and within the same person. Research has shown that people first begin engaging in NSSI and continue doing so for a variety of intrapersonal (i.e., automatic) and interpersonal (i.e., social) reasons (1, 2; see Table 1). People who engage in NSSI report doing so for intrapersonal reasons much more often than for interpersonal reasons (3,4). Research has repeatedly shown that the most common function of NSSI is to lessen the intensity of negative internal states, including feelings of shame, guilt, anger, and sadness (2, 5, 6). Yet, some people report engaging in NSSI to end feelings of emotional numbness, to punish themselves, and as an alternative to acting on suicidal urges, all of which are self-reinforcing (5, 6, 7).

Contrastingly, interpersonal or socially reinforced functions describe NSSI reasons that facilitate help-seeking and/or an escape from undesired social situations (2, 8). For instance, it may act as a way of communicating pain, indicating toughness, and keeping others who cause harm away (e.g., bullies, abusers; 9, 10). NSSI may also act to increase connectedness or in-group affiliation with peers (5,11).

Table 1. Examples of Intrapersonal and Interpersonal Reasons for NSSI (5, 9)

Intrapersonal (Automatic) Functions of NSSI

Screenshot 2025-05-22 at 12.58.08 PM.png

Interpersonal (Social) Functions of NSSI

While NSSI functions are often categorized as intrapersonal or interpersonal, it is worth noting that no function is purely interpersonal or purely intrapersonal (12). Though intrapersonal functions for NSSI are more common than interpersonal functions, many people report engaging in NSSI for the first time for social reasons (4, 9). For example, a person may begin self-injuring to feel more connected with peers who engage in NSSI but continue to do so to help them cope with negative emotions. Therefore, people’s reasons for engaging in self-injury are not limited to one particular interpersonal or intrapersonal function, and their reasoning can change over time (9, 12).

1. Klonsky, E. D., Glenn, C. R., Styer, D. M., Olino, T. M., & Washburn, J. J. (2015). The functions of nonsuicidal self-injury: Converging evidence for a two-factor structure. Child and Adolescent Psychiatry and Mental Health, 9(44), 1-9. https://doi.org/10.1186/s13034-015-0073-4

2. Nock, M. K. (2009). Why do people hurt themselves?: New insights into the nature and functions of self-injury. Current Directions in Psychological Science, 18(2), 78-83. https://doi.org/10.1111/j.1467-8721.2009.01613.x

3. Kim, H., & Hur, J. (2022). What’s different about those who have ceased self-injury? Comparison between current and lifetime nonsuicidal self-injury. Archives of Suicide Research, 27(2), 718-733. https://doi.org/10.1080/13811118.2022.2064256

4. Tatnell, R., Kelada, L., Hasking, P., & Martin, G. (2014). Longitudinal analysis of adolescent NSSI: The role of intrapersonal and interpersonal factors. Journal of Abnormal Child Psychology, 42, 885-896. https://doi.org/10.1007.s10802-013-9837-6

5. Klonsky, E. D., & Glenn, C. R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the inventory of statements about self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31(3), 215-219. https://doi.org/10.1007/s10862-008-9107-z

6. Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M. (2018). A meta-analysis of the prevalence of different functions of non-suicidal self-injury. Journal of Affective Disorders, 227, 759-769. https://doi.org/10.1016/j.jad.2017.11.073

7. Rallis, B. A., Deming, C. A., Glenn, J. J., & Nock, M. K. (2012). What is the role of dissociation and emptiness in the occurrence of Nonsuicidal self-injury? Journal of Cognitive Psychotherapy, 26(4), 287-298. https://doi.org/10.1891/0889-8391.26.4.287

8. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226-239. https://doi.org/10.1016/j.cpr.2006.08.002

9. Lewis, S. P., & Hasking, P. A. (2023). Understanding self-injury: A person-centered approach. Oxford University Press.

10. Nock, M. K. (2008). Actions speak louder than words: An elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Applied and Preventive Psychology, 12(4), 159-168. https://doi.org/10.1016/j.appsy.2008.05.002

11. Muehlenkamp, J., Brausch, A., Quigley, K., & Whitlock, J. (2012). Interpersonal features and functions of nonsuicidal self-injury. Suicide and Life-Threatening Behavior, 43(1), 67–80. https://doi.org/10.1111/j.1943-278x.2012.00128.x

12. Taylor, P. J., Dhingra, K., Peel-Wainwright, K. M., & Gardner, K. J. (2024). The functions of nonsuicidal self-injury. In E. Lloyd-Richardson, I. Baetens, & J. L. Whitlock (Eds.), The oxford handbook of nonsuicidal self-injury (pp. 89-106). Oxford University Press.

Estimated Prevalence

NSSI usually begins during early to mid-adolescence (1). In non-clinical samples, approximately one in five adolescents report engaging in NSSI at least once (2,3). Among emerging adults (18-29 years), this increases to 42% (4). Commensurate with this, NSSI appears particularly common among college students (5). Recent results suggest that up to one quarter of college students have engaged in NSSI (6). Prevalence among adults aged over 30 years, averages 20% (4). Less work has explored NSSI among younger children. A recent meta-analysis of NSSI among pre-adolescents (before the age of 13 years) estimated a rate of 6.25% among community-based youth, and 37.38% among clinical samples (7). In clinical samples, rates of NSSI are higher, although estimates vary significantly based on study design, population studied, and lack of reliable epidemiological data (8).

Brianna J. Turner, Andrew C. Porter, Christina L. Robillard. (2024). Average ages of onset and time to transition between self-injurious thoughts and behaviors: Retrospective evidence from two developmentally distinct samples, Journal of Affective Disorders, 363, 465-473,
Moloney F, Amini J, Sinyor M, Schaffer A, Lanctôt KL, Mitchell RH. Sex Differences in the Global Prevalence of Nonsuicidal Self-Injury in Adolescents: A Meta-Analysis. JAMA Netw Open. 2024;7(6):e2415436. doi:10.1001/jamanetworkopen.2024.15436
Xiao, Q., Song, X., Huang, L., Hou, D., & Huang, X. (2022). Global prevalence and characteristics of non-suicidal self-injury between 2010 and 2021 among a non-clinical sample of adolescents: A meta-analysis. Frontiers in psychiatry, 13, 912441. https://doi.org/10.3389/fpsyt.2022.912441
Liu R. T. (2023). The epidemiology of non-suicidal self-injury: lifetime prevalence, sociodemographic and clinical correlates, and treatment use in a nationally representative sample of adults in England. Psychological medicine, 53(1), 274–282. https://doi.org/10.1017/S003329172100146X
Kiekens, G., Bruffaerts, R., Claes, L., Hasking, P., & Kessler, R. (2023). A longitudinal investigation of non-suicidal self-injury persistence patterns, risk factors, and clinical outcomes during the college period. Psychological Medicine, 53, 6011-6026.
Hasking et al., (R&R). The Relationships Between Sporadic and Repetitive Non-Suicidal Self-Injury and Mental Disorders Among First-Year College Students: Results from the World Mental Health International College Student Initiative. Psychological Medicine. 14 January 2025
Liu, R. T., Walsh, R. F. L., Sheehan, A. E., Cheek, S. M., & Sanzari, C. M. (2022). Prevalence and Correlates of Suicide and Nonsuicidal Self-injury in Children: A Systematic Review and Meta-analysis. JAMA psychiatry, 79(7), 718–726. https://doi.org/10.1001/jamapsychiatry.2022.1256
Muehlenkamp, Jennifer J., and Victoria Tillotson, 'Overview and Epidemiology of NSSI in Clinical Samples', in Elizabeth E. Lloyd-Richardson, Imke Baetens, and Janis L. Whitlock (eds), The Oxford Handbook of Nonsuicidal Self-Injury, Oxford Library of Psychology (2024; online edn, Oxford Academic, 23 Feb. 2023), https://doi.org/10.1093/oxfordhb/9780197611272.013.8

Male/Female Gender Differences

Self-injury appears to be more common among women than men in North America and Europe (1). Differences in prevalence are especially pronounced in clinical samples, which estimate female patients are 1.5 to 1.8 times more likely to self-injure than male patients (2). Self-injury is also much more common among incarcerated women than incarcerated men (3). This gender disparity in rates of self-injury can be partially explained by women’s higher levels of psychological distress compared to men (4), a population-level phenomenon which can be attributed to a complex interplay of individual and sociocultural influences (5). However, gender disparities in self-injury prevalence vary geographically; rates of self-injury do not significantly differ between men and women in Asia (1). The factors influencing cultural and geographic differences in gender disparities are not well established.

Evidence for gender differences in self-injury characteristics or clinical presentation is limited and mixed. It appears that men and women are largely similar in their reported reasons for self-injuring, with reducing tension, releasing anger or frustration, and self-punishment being the most common functions (6,7). There may be patterns of difference in the methods and locations of self-injury, with women more likely than men to scratch, rub, or pinch themselves and self-injure on their stomach or legs, and men more likely than women to self-injure on their chest (8). Women may also experience more self-injury urges (8) and greater versatility of self-injury functions than men (6), which may be indicators of more clinically severe self-injury.

However, there is insufficient evidence to draw conclusions about male/female differences in self-injury presentation. Most English-language self-injury research over the past century has focused on the experiences of young women (9). Self-injury is likely underreported among men due to gender-based stereotypes which impact help seeking and bias interpretation of self-injuring behaviours (10). For example, clinicians and men themselves may not recognise their behaviours as self-injury, such as punching walls when upset which is generally interpreted as an act of aggression despite conforming to clinical definitions of self-injury.

Moloney et al (2024) Sex Differences in the Global Prevalence of Nonsuicidal Self-Injury in Adolescents A Meta-Analysis
Muehlenkamp & Tillotson (2023) Overview and Epidemiology of NSSI in Clinical Samples. Oxford Handbook of Nonsuicidal Self-Injury.
Winicox (2023) Prisons. Oxford Handbook.
Lutz et al. (2023) Why is nonsuicidal self-injury more common among women?
Hyde & Mezulis (2020) Gender Differences in Depression: Biological, Affective, Cognitive, and Sociocultural Factors
Lutz et al. (2024) Gender Similarities and Differences in the Functions of Non-Suicidal Self-Injury
Tofthaugen et al. (2021) Men who self-harm—A scoping review of a complex phenomenon
Victor et al. (2018) Characterizing gender differences in nonsuicidal self-injury: Evidence from a large clinical sample of adolescents and adults
Millard (2013) Making the cut: The production of ‘self-harm’ in post-1945 Anglo Saxon psychiatry
Inckle (2014) Strong and Silent: Men, Masculinity, and Self-injury

Populations at higher risk of self-injury

People with psychiatric diagnoses

Though some people who self-injure have no associated mental health condition, self-injury is much more common among people with psychiatric diagnoses and is associated with a range of different conditions. This includes mood, eating, anxiety, personality, behavioural, and psychotic disorders (1). Borderline Personality Disorder is the diagnosis most strongly associated with self-injury, since self-injury is one of its DSM-5-TR diagnostic criteria; an estimated 50-90% of people diagnosed with Borderline Personality Disorder have self-injured (1). Rates of self-injury are also high among people with panic disorder, PTSD, and binge-eating/purging subtype eating disorders (1).

Muehlenkamp & Tillotson (2023) Overview and Epidemiology of NSSI in Clinical Samples. Oxford Handbook of Nonsuicidal Self-Injury.

LGBTQIA+ people

Individuals who identify as LGBTQIA+ are at much higher risk of self-injury than their cisgender heterosexual peers (1). Self-injury prevalence appears to be particularly high among transgender, non-binary, and other gender diverse young people and among bisexual women (2). Applications of Minority Stress Theory (4) and the Gender Minority Stress and Resilience Model (3) explain that this higher incidence of self-injury can be attributed to the psychological impact of stressors related to societal homophobia and transphobia (1). Distress associated with gender dysphoria can also be a trigger for self-injury (5).

Zullo, Rogers, Taliaferro (2023) NSSI Among Sexual and Gender Diverse Youth. Oxford Handbook of Nonsuicidal Self-Injury.
Liu et al. (2019) Prevalence and correlates of non-suicidal self-injury among lesbian, gay, bisexual, and transgender individuals: A systematic review and meta-analysis
Meyer 2003
Testa et al., 2015
Hird et al. (2024) Trans Young People’s Experiences of Nonsuicidal Self-Injury

People who have experienced abuse or trauma

Childhood abuse and neglect are well-established risk factors for self-injury, particularly emotional and sexual abuse (1,2). Traumatic experiences in adulthood, including sexual assault, can also contribute to the initiation of self-injury (3). There are many potential pathways linking trauma and self-injury. Trauma can be defined as an experience which overwhelms one’s ability to cope (4), and self-injury is often a means of coping with overwhelming distress. Research in neurobiology and child development describe the long-term impacts of trauma and how these can create vulnerability for self-injury (5,6). Individuals describe self-injuring to escape dissociation, intrusive memories, and other trauma symptomatology; to punish themselves in response to trauma-related shame; and to deter further abuse (6).

Calvo et al. (2024) Childhood maltreatment and non-suicidal self-injury in adolescent population: A systematic review and meta-analysis
Serafini et al. (2023) Early Childhood Trauma and Nonsuicidal Self-Injury. Oxford handbook of nonsuicidal self-injury.
Watters & Yalch (2022) Relative effects of sexual assault and other traumatic life events on self-harm
Herman (1992) Trauma and Recovery
Kaes et al. (2021) Advancing a temporal framework for understanding the biology of nonsuicidal self- injury: An expert review
Smith, Kouros, Meuret (2014) The role of trauma symptoms in nonsuicidal self-injury.

People in prisons

People incarcerated in prisons and other forms of detention are at significantly higher risk of self-injury compared to the general population (1). Rates of self-injury tend to be highest in maximum-security settings. Contributing factors include high levels of suffering and low access to positive coping methods, isolation from social support systems, and low availability of professional mental health support. Self-injury can also be a means of influencing the environment in a setting where individuals are stripped of power and subjected to extreme adversity, for instance self-injuring in order to be moved from solitary confinement to a hospital facility.

Winicov (2023) Oxford handbook chapter

NSSI in the DSM

Nonsuicidal Self-Injury is included in the 2024 update of the Diagnostic and Statistical Manual Fifth Edition (DSM-5-TR) in the category “Other Conditions That May Be a Focus of Clinical Attention”, with classifications for “Current Nonsuicidal Self-Injury” and “History of Nonsuicidal Self-Injury” (source link 1). This means that it is not yet a verified psychiatric diagnosis but may become one with further research. Nonsuicidal Self-Injury Disorder was initially included in the 2013 edition of the DSM-5 as a “Condition for Further Study” (source link 2).

Several arguments have been made for the inclusion of NSSI as a standalone diagnostic category. Recently, the perspectives of people with lived experience has been explored i. Results from this line of research has illuminated both potential advantages and disadvantages (Lewis et al., 2017; Lengel et al., 2025). Among the main advantages identified are: potential improvements in the awareness and understanding of NSSI, reductions in stigma, increased comfort to disclose and seek support for NSSI, and facilitation of and improvements in treatment. In contrast, people with lived experience also see potential disadvantages. These include worsening of NSSI stigma, NSSI becoming a central focus at the expense of considering people’s other concerns (e.g., underlying mental health difficulties), and concerns about how a diagnostic category of NSSI may be used and whether it is even needed.

Notably, DSM diagnoses for self-injury have been proposed several times in the past. Deliberate Self-Harm Syndrome was proposed by Kahan and Pattison in 1984, Repetitive Self-Mutilation Syndrome by Favazza and Rosenthal in 1990, and Deliberate Self-Injury Syndrome by Muehlenkamp in 2005. In 2009, Shaffer and Jacobson proposed Nonsuicidal Self-Injury as a DSM-5 diagnosis, leading to its current inclusion.

Self-injury is also included in the diagnostic criteria for Borderline Personality Disorder in the DSM-5-TR. To receive the diagnosis, someone must endorse five out of nine possible criteria, one of which is: “Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior” (source link 3).

DSM-5-TR source link 1
DSM-5-TR source link 2
[lived experience sources]
Kahan J, Pattison EM (1984) Proposal for a distinctive diagnosis: the deliberate self-harm syndrome (DSH). Suicide Life Threat Behav 14:17–35
Favazza AR, Rosenthal RJ (1990) Varieties of pathological self-mutilation. Behav Neurol. 3:77–85.
Muehlenkamp JJ (2005) Self-injurious behavior as a separate clinical syndrome. Am J Orthopsychiatry. 75:324–333.
Shaffer D, Jacobson C (2009) Proposal to the DSM-V Childhood Disorder and Mood Disorder Work Groups to include non-suicidal self-injury (NSSI) as a DSM-V disorder.
DSM-5-TR source link 3
DSM-5-TR source link 4
Lengel, G. J., Ammerman, B. A., Bell, K. A., & Washburn, J. J. (2024). The potential impact of nonsuicidal self-injury disorder: Insights from individuals with lived experience. Qualitative Research in Medicine & Healthcare, 8, 12631.
Lewis, S. P., Bryant, L. A., Schaefer, B. M., & Grunberg, P. H. (2017). In their own words: Perspectives on nonsuicidal self-injury disorder among those with lived experience. The Journal of nervous and mental disease, 205(10), 771-779.

DSM-5 Criteria for Nonsuicidal Self-Injury Disorder

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).

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.

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 developmental disorder [intellectual disability], Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury, trichotillomania [hair-pulling disorder], excoriation [skin-picking] disorder).

Theoretical Models of NSSI

Four Function Model

The four function model asserts that NSSI serves four functions: automatic negative reinforcement, automatic positive reinforcement, social negative reinforcement, and social positive reinforcement (1).

Automatic negative reinforcement occurs when one self-injures to avoid, reduce, or distract from an unwanted emotional state (1). This function suggests that NSSI can be a method of regulating emotions. This function is the most commonly endorsed by individuals who engage in NSSI (52.9%). Those who endorse this function are more likely to report higher feelings of hopelessness and past suicide attempts (1).

Automatic positive reinforcement occurs when one self-injures to induce a desired emotional state (e.g. the desire to feel something or self-punishment) (1). Those who endorse this function are more likely to report symptoms of major depressive disorder and posttraumatic stress disorder (PTSD). Additionally, these symptoms are associated with feelings of emptiness and detachment (1).

Social negative reinforcement occurs when one self-injures to avoid an unpleasant situation or task (1). This function is endorsed less often than the automatic functions.

Social positive reinforcement occurs when one self-injures to gain something (e.g. care or attention) from others (1). Those who endorse this function have also reported awareness of a greater number of self-injury occurrences carried out by friends.