Reviews

Non-suicidal self-injury (NSSI) and suicidal:

Criteria differentiation
Joanna HalickaB–D, Andrzej KiejnaA
Department and Clinic of Psychiatry, Wroclaw Medical University, Poland

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;
D – writing the article; E – critical revision of the article; F – final approval of the article

Advances in Clinical and Experimental Medicine, ISSN 1899–5276 (print), ISSN 2451–2680 (online) Adv Clin Exp Med. 2018;27(2):257–261

Address for correspondence

Joanna Halicka
Abstract
E-mail: [email protected] There are 2 types of basic self-destructive behavior: suicide and non-suicidal self-injury (NSSI). Currently,
more and more researchers point out significant disorders which are NSSI behavior. This phenomenon is not
Funding sources
None declared
new; NSSI seemingly has always been present in society, and certainly in approx. 10% of the population
worldwide in recent times. Despite the enormous scale of the phenomenon, so far it has been overlooked and
Conflict of interest marginalized. They were considered transient behavior, typical of adolescence, a part of youthful rebellion.
None declared Current research indicates that the disorder affects the adult population in almost equal measure. It is only
in the latest diagnostic classification – Diagnostic and Statistical Manual of Mental Disorders, Fifth edition
(DSM-5) by American Psychiatric Association – that has considered NSSI a separate class of behavior. Up to
Received on August 22, 2016 now, it was classified as a prelude to suicide or an element of personality disorders. NSSI is more commonly
Reviewed on October 2, 2016
Accepted on October 25, 2016 associated with disturbing behavior and suicide attempts.
Key words: non-suicidal self-injury, suicide, suicide attempt

DOI
10.17219/acem/66353

Copyright
© 2018 by Wroclaw Medical University
This is an article distributed under the terms of the
Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
258 J. Halicka, A. Kiejna. Criteria differentiation of NSSI and suicide

Introduction Methods
There are 2 types of basic auto-destructive behavior: Using the Scopus, PubMed, EBSCO, Google Scholar, and
suicide and non-suicidal self-injury (NSSI). There are Web of Science databases, medical literature on the topics
a number of distinguishing criteria, but the main one is of suicide and NSSI were searched and 12 differentiation
the intention of death. criteria were created between the self-destructive behav-
According to World Health Organization (WHO), sui- iors suicide and NSSI.
cide is a multidimensional phenomenon, resulting from the
interaction between biological, psychological, genetic, and
environmental factors.1 According to the definition, suicide Results
is the deliberate termination of life, and legal definition is
extended with the statement that the death is a result of the NSSI is commonly although incorrectly called suicide
direct or indirect action or negligence of the victim, who fully attempts. This misuse of the term occurs just as frequently
realizes the effect of their actions.2 in clinical practice and entails improper treatment of the
NSSI has been defined by the International Society for patient. Therefore, it is important to tell these phenomena
the Study of NSSI as the deliberate, self-inflicted destruc- apart. So far in Polish literature, there have been no articles
tion of body tissue without suicidal intent and for purposes on the distinction between these behaviors. Below there
not socially sanctioned. NSSI can be divided due to its fea- are the 12 determinants by means of which NSSI can be
tures and forms. The features are positive reinforcement, distinguished from suicide attempts.
addition of desired stimulus, or negative reinforcement Table 1 explains the differences between a suicide at-
or subtraction of unwanted stimulus. NSSI is expressed tempt and NSSI (author’s own work, after Walsh, 2006).
in various forms from relatively mild, such as scratching, The fundamental criterion for distinguishing between
plucking hair or interfering with wound healing, to rela- non-suicidal self-destructive behaviors and suicide is the
tively severe forms, such as cutting, burning or hitting.3 intention of death.5 According to Shneidman, suicide in-
The Diagnostic and Statistical Manual of Mental Disor- volves not so much the desire to kill the body, but the wish
ders, Fifth Edition (DSM-5), published in the year 2013,4 to end one’s own consciousness.6 NSSI, in turn, has 2 func-
qualifies NSSI as a separate entity, among the disorders tions. One of them is negative reinforcement and removing
requiring further research. The proposed criteria for DSM- unwanted stimuli, i.e., dismissing unpleasant emotional
5 include the following: states.5,6 The most common categories of unpleasant emo-
– intentional self-inflicted injury performed with the tional states declared by NSSI are fear, sadness, shame or
expectation of physical harm, but without suicidal guilt, tension, anxiety or panic, frustration, and contempt.
intent, on 5 or more days in the past year; The share and severity of these emotions varies individu-
– the behavior is performed for at least 1 of the following ally.6 The other function of NSSI is positive reinforcement
reasons: – to boost a desired stimulus, i.e., to provide stimulation by
• to relieve negative thoughts or feelings; experiencing strong emotions and get rid of the feeling of
• to resolve an interpersonal problem; emptiness, which takes place in the vast minority of cases.7
• to cause a positive feeling or emotion; Babikier and Armond suggest a different division of func-
– the behavior is associated with at least 1 of the following: tions of NSSI: functions related with managing and sur-
• negative thoughts or feelings, or interpersonal prob- viving, functions related with ego and proper experience,
lems that occur immediately prior to engaging in and functions connected with punishing oneself and be-
NSSI; ing a victim.8 NSSI is a way of coping and it is a means
• preoccupation with NSSI that is difficult to resist; of surviving, as it reduces tension and fear, helps to man-
• frequent urge to engage in NSSI; age anger and it is applied to avoid or focus on pain in
– the behavior is not socially sanctioned and is more order to control it. An individual copes with unbearable
significant than nail biting or picking at a scab; feelings to distract oneself from fear and tension, and to
– the behavior causes clinically significant distress or pay attention to other, more attainable behaviors, such
impairment; as self-harm. The functions of NSSI related with ego in-
– the behavior does not occur exclusively in the context clude reinforcement of a sense of control, intensification
of another disorder and cannot be accounted for by of a sense of reality and breaking the states of dissociation.
another mental or medical disorder. The pain that accompanies NSSI is often an important ele-
ment of the process of regaining the sense of self-control
and integration of an individual. Another function of NSSI
Objectives is creating opportunities to take care of oneself. In some
individuals, the period following NSSI is the only moment
The aim of the study was to differentiate between the when they allow themselves to feel relieved and experi-
self-destructive behaviors NSSI and suicide. ence physical care. On the other hand, coping with one’s
Adv Clin Exp Med. 2018;27(2):257–261 259

Table 1. Criteria for differentiation of direct self-destructive behaviors

Criterion Suicide NSSI
Primary intention intention to die preservation of life, destruction of the body
escape from mental pain and transformation into
General intention escape from mental pain and consciousness
physical pain
managing and surviving (e.g., reduction of tension
and fear), functions connected with ego, functions
Functions reduction of tension, a sense of relief
connected with proper experience, punishing oneself,
providing stimulation
Potential death high degree of mortality low degree of mortality
Number of methods used usually one usually many (the number increases over time)
Chronicity rarely often
Mental pain persistent, unbearable discontinuous
Cognitive narrowing high, suicide seen as the only solution low or none
Hopelessness and helplessness constant, occupies a central place variable, does not dominate
Consequences in terms of the
discomfort intensifies after suicide attempt discomfort decreases after NSSI
recognition of discomfort
psychotic disorders (schizophrenia), affective personality disorders, addictions, eating disorders,
Associated disorders
disorders, alcohol abuse, anxiety disorders posttraumatic stress disorder
Main issue depression, mental pain unbearable negative image of ego

experience is expressed by experiencing again the feelings are emotionally wrecked, and hit themselves when expe-
and traumas which had been denied previously, as well riencing nervousness. Others cut their skin when experi-
as by manifesting toward oneself their own experiences. encing anxiety and burn themselves under nervousness.
Punishing oneself is also a significant function of NSSI, The scope of relations between the form of self-harm and
most frequently related with a negative image of oneself the type of emotion is nearly infinite.15
created in the period of childhood or under the influence Another issue that tells these types of behavior apart is
of a traumatic experience.8 the frequency of their occurrence. NSSI episodes in one
NSSI and suicide attempts also differ by their mortal- person take place much more often than suicide attempts.
ity rate, which results from the nature of the forms of Most people attempting suicide do it neither frequently
self-destruction. The most common methods of suicide nor repeatedly. Suicide attempts are usually made once
in Poland are hanging oneself – 75.04%, jumping from or twice in a  lifetime, in one’s most stressful period
a height – 7.11%, poisoning – 4.49%, and jumping in front of life.15 However, the number of NSSI episodes is approx.
of a vehicle – 2.27%.9 Suicide attempts are fatal in 10–20% 20–100 times over the course of several years.11 The fre-
of all cases, while other self-destructive behavior ends in quency of NSSI among teenagers may reach up to 20–30
death in 0.6% of cases and are most often caused by cutting episodes per year. 5
an artery.5,10,11 However, according to Whitlock et al., NSSI The differences between the types of aggressive behav-
usually takes the form of: scraping the skin – 51.6%; beating ior are also seen in the level of psychological pain, which,
– 37.6%; cutting – 33.7%; bruising – 24.5%; cutting symbols like cognitive narrowing, is higher for suicidal behavior
in the skin – 14.9%; scratching wounds – 13.5%; piercing than NSSI.5 According to Ringel’s concept, around 80%
with sharp objects – 12%; and plucking hair – 11%.12 A gen- of suicides are related to the narrowing of consciousness,
eral review of the literature shows that the most common which, apart from anger inhibition and directing it at one-
methods of NSSI include cutting the skin, hitting oneself, self and suicidal thoughts, is an element of pre-suicidal
scratching wounds, bruising, and biting.6,8 Thus, suicide syndrome. The narrowing of consciousness occurs when
and NSSI involve different methods. an individual does not perceive alternative forms of solving
Another point of distinction between self-harm behavior a problem (tunnel vision). Suicide attempts are preceded
is the number of methods used. Those making suicide at- by dichotomous thinking, where the alternative is death.
tempts use the same method when making another suicide Hopelessness and helplessness in the face of mental pain
attempt.13 Most people repeatedly attempt suicide by drug are more often experienced by future suicides than NSSI,
overdose.6 In contrast, 78% of people who practice non- who do not declare their lack of control over pain; on the
lethal self-injurious behavior use more than 1 method.14 contrary, NSSI helps them maintain a sense of control.16
The use of more methods is related mainly to preferences. NSSI is not characterized by dichotomous thinking. Peo-
Many people using NSSI say they use a variety of meth- ple engaged in NSSI are usually rather disorganized than
ods depending on their mood. For example, some people limited in terms of their way of thinking. They do not
engaged in NSSI claim that they cut their skin when they limit their life to all-or-nothing attitudes. They consider
260 J. Halicka, A. Kiejna. Criteria differentiation of NSSI and suicide

themselves to be capable to make life choices. One of those of premature death among patients.23 In addition, the risk
choices is the decision to harm themselves. of a suicide attempt is increased by 30% in those patients
Research on suicide has long identified a sense of both suffering from schizophrenia who have symptoms of de-
hopelessness and helplessness as essential component of pression.24 Depressive disorders and alcohol abuse are
depression and suicidal behavior.17–19 The feeling of help- placed second and third, respectively.1 Suicidal behaviors
lessness, which involves the lack of hope, refers to the loss are also largely related to anxiety disorders. The risk of sui-
of control.18 People who feel helpless believe that they cide is further increased if anxiety and personality disor-
have no real influence or real control over their situation. ders are observed collectively.25 Other important disorders
They are convinced that there is nothing they could do to associated with suicide are affective disorders. The risk
change or improve their lives. Such cognitive pessimism of suicide in these patients is around 30–40%.26 Through-
is very characteristic of “surrender”, which is part of sui- out the course of life, suicidal behavior affects an average
cide. The feeling of helplessness of people committing of 4% of people with mood disorders and 8% of those with
suicide is well illustrated by Beck’s triad of depression.17 bipolar disorder.1
In this perspective, people with suicidal tendencies think: By contrast, NSSI are often linked to destructive mental
“I am angry, the world is a hostile place and the future disorders, such as alcohol and drug abuse, eating disorders
is unchangeable.” and personality disorders, and are observed in patients
On the other hand, helplessness and hopelessness are not suffering from posttraumatic stress disorder (PTSD).27,28
characteristic of people hurting themselves. Such people Up to 79% of those suffering have experienced violence
usually do not have a sense of lack of control over their or rejection in childhood.28 Up to 50% of cases of self-
physiological pain, which de facto conditions this sense destructive behaviors are associated with alcohol abuse.1
of control. Control resulting from NSSI is the opposite In the context of substance abuse and addictions related
of hopelessness. The future is not seen as a great suffering, to self-destructive behaviors, in its therapy it is necessary
because NSSI reduces emotional tension. An individual’s in the first place to deal with the substance abuse, which is
psychological discomfort and crippling pessimism are the base for other self-destructive behaviors. The next step
temporary. Their suffering lacks a sense of permanence, is to deal with the self-harm which derives from the ad-
which is typical of a suicidal crisis. dictions and substance abuse. Amongst the aforementioned
Muehlenkamp and Gutierrez made a comparative study behaviors, addictions and substance abuse are the easiest to
of teenagers engaged in NSSI.20 Their research showed overcome, which is caused by the fact that for a self-harming
that people engaged in self-injury without suicidal inten- individual it is hard to function without self-harm, and at
tions were characterized by a lower rate of hopelessness, the same time self-harm seems the mildest means of self-
stronger future-orientation, more developed motivation destruction that enables the individual’s existence.10
to live as compared to people undertaking a suicide at- The source of the problems of people with suicidal ten-
tempt. These results confirm the hypothesis that the level dencies fluctuates around depression, sadness and rage
of emotional pain varies depending on the type of self- due to the primary source of pain. Maltsberger showed
destructive behavior. that suicides are caused not only by sadness, isolation and
The difference is also observed in terms of psychological loneliness, but also include an element of “murderous ha-
consequences. After a failed suicide attempt, a person usu- tred”.29 This hatred is directed both inward and outward.
ally experiences a worsening of mood, the feeling of fail- Help for those making suicide attempts is to rely on find-
ure associated with the fact they failed to commit suicide ing and reducing the original source of pain. Shneidman
successfully. NSSI, on the other hand, is done to reduce emphasizes that the task of the therapist is to add a third
tension, and as a result, a person usually experiences relief component to the dichotomous thinking in people with
and an improved frame of mind.5 suicidal tendencies, one that reduces the risk of a suicide at-
Research indicates that some disorders accompany sui- tempt.6 Finding the source of unbearable suffering should
cide attempts, while others are associated with NSSI. Ap- be the first element in working with people at risk of sui-
proximately 90% percent of suicides are associated with cide. The more accurate the clarification of the source, the
at least 1 psychiatric disorder.21 The risk of committing more efficient the therapeutic work.
suicide over a lifetime is 30.2% for the general population In contrast, research shows that the source of the prob-
of the mentally ill.2,21 These are mainly depressive dis- lem in NSSI is a distorted body image.6 The feeling of be-
orders, addictions, cluster B personality disorders, and ing cut off from the body or hatred toward the body leads
schizophrenia. 24 Schizophrenia is associated with the to NSSI. The key question in the treatment of the source
highest elevated risk of suicide. About 40–50% of schizo- of self-injury should be: “What are the sources of such
phrenia patients have suicidal thoughts at some point in a relationship with one’s body?” and “Why do you keep
life, and 4–13% commit suicide, making it a leading cause trying to inflict harm on your body?”
Adv Clin Exp Med. 2018;27(2):257–261 261

Summary and discussion 8. Babiker G, Arnold L. Autoagresja, mowa zranionego ciała. Gdańsk:
Gdańskie Wydawnictwo Psychologiczne; 2003.
9. Serwis policja.pl. www.policja.pl
As it has been shown, suicides and NSSI differ in many 10. Walsh B, Rosen P. Self-Mutilation: Theory, Research and Treatment. New
respects. These differences are primarily qualitative. These York, NY: Guilford Press; 1988.
behaviors are caused by other factors, they have a different 11. Conterio K, Lader W. Bodily Harm: The Breakthrough Healing Program
for Self Injurers. New York, NY: Hyperion Press; 1998.
intent and serve different functions. NSSI and those mak- 12. Whitlock JL, Eckenrode J, Silverman D. Self-injurious behaviors in a
ing a suicide attempt also suffer different consequences college population. Pediatrics. 2006;117:1939–1948.
and psychological after-effects.5 One should also pay atten- 13. Berman AL, Jobes DA, Silverman MM. Adolescent Suicide: Assessment
and Intervention. 2nd ed. Washington, DC: American Psychological
tion to the coexistence of these self-destructive behaviors; Association; 2006.
NSSI often precedes a suicide attempt, as the individual 14. Whitlock J, Muehlenkamp J, Eckenrode J, et al. Nonsuicidal self-inju-
embraces the notion of self-destruction, to start later us- ry as a gateway to suicide in adolescents and young adults. J Adolesc
Health. 2013;52:486–492.
ing more and more destructive methods. NSSI youths are
15. Nock MK, Kessler RC. Prevalence of and risk factors for suicide
3 times more likely to experience suicidal thoughts and attempts versus suicide gestures: Analysis of the National Comor-
attempt suicide.11 Long-term NSSI often precedes suicide, bidity Survey. J Abnorm Psychol. 2006;115:616–623.
even though the individual showed no intention of death 16. Kubiak A. Mechanizm radzenia sobie z napięciem u osób podejmujących
nawykowe samouszkodzenia. 2013. [Unpublished doctoral thesis.]
at first.30 17. Beck AT, Rush, AJ, Shaw BF, Emery G. Cognitive Therapy of Depression.
Recent years have brought a lot to the understanding New York, NY: Guilford Press; 1979.
of NSSI. Both NSSI and suicide attempts are phenom- 18. Seligman MEP. Helplessness: On Depression, Development, and Death.
San Francisco, CA: W.H. Freeman; 1975. (Paperback reprint edition,
ena of enormous magnitude. NSSI involves 7–14% of the W.H. Freeman; 1992.)
population worldwide6 and applies to 15–28% of young 19. Milnes D, Owens D, Blenkiron P. Problems reported by self-harm
people,27,30 and on average begins between 12 and 14 years patients: Perception, hopelessness and suicidal intent. J Psychosom
Res. 2002;53:819–822.
of age. 31,32 However, according to WHO data, suicide is
20. Muehlenkamp J, Gutierrez PM. Risk for suicide attempts among ado-
one of the 20 most common causes of death among the lescents who engage in non-suicidal self-injury. Arch Suicide Res.
total population and represents one of the most common 2007;11:69–82.
causes of death among young people.33 Further research 21. Harris EC, Barraclough B. Suicide as an outcome for mental disorders.
A meta-analysis. J Psychiatry. 2007; Mar;170:205-28.
on the various types of self-destructive behavior is needed 22. Rosa K. Młodzież podejmująca próby samobójcze. Charakterystyka
for a full understanding of the problem and to determine socjologiczna. Przegl Lek. 2007;1:24–30.
the appropriate directions of therapeutic work. Incorrect 23. McGirr A, Renaud J, Bureau A, Seguin M, Lesage A, Turecki G. Impul-
sive-aggressive behaviors and completed suicide across the life
diagnosis of self-destructive behavior can cause inefficient cycle: A predisposition for younger age of suicide. Psychol Med.
therapeutic work, and even intensify the severity of the 2006;38(3):407–417
disorder occurrence. 24. Radomsky ED, Gretchen JJ, Mann, Sweeney JA. Suicidal behavior in
patients with schizophrenia and other psychotic disorders. Am J Psy-
chiatry. 1999;156:1590–1595.
References 25. Sareen J, Afifi TO, McMillan KA, Asmundson GJ. Relationship between
household income and mental disorders: Findings from a popula-
1. World Health Organization: WHO. http://www.who.int/topics/sui- tion-based longitudinal study. Arch Gen Psychiatry. 2011;68(4):419–
cide/en/ 427.
2. Putowski M, Piróg M, Podgórniak M, Zawiślak J, Piecewicz-Szczęsna 26. Bostwick JM, Pankratz SV. Affective disorders and suicide risk: A reex-
H. Analiza epidemiologiczna występowania samobójstw w Polsce w amination. Am J Psychiatry. 2000;157:1925–1932.
latach 2000-2013. Probl Hig Epidemiol. 2015;96(1):264-268. 27. Kerr PL, Muehlenkamp JJ, Turner JM. Nonsuicidal self-injury: A review
3. Gratz KL, Conrad SD, Roemer L. Risk factors for deliberate self-harm of current research for family medicine and primary care physicians.
among college students. Am J Orthopsychiatry. 2002;72:128–140. JABFM. 2010;23(2):240–259.
4. American Psychiatric Association, ed. Diagnostic and Statistical Man- 28. Yates, TM. The developmental psychopathology of self-injurious
ual of Mental Disorders. 5th ed. Washington, DC: American Psychiat- behavior: Compensatory regulation in posttraumatic adaptation.
ric Association; 2013. Clin Psychol Rev. 2004;24(1):35–74.
5. Walsh B. Treating Self-Injury: A Practical Guide. New York, NY; Guil- 29. Maltsberger JT. Suicide Risk. The Formulation of Clinical Judgment.
ford Press; 2006. New York, NY: University Press; 2013.
6. Shneidman E. Definition of Suicide. New York, NY: John Wiley & Sons; 30. Cooper J, Biddle L, Owen-Smith A, et al. Suicide after deliberate self-
1985:202–213. harm: A 4-year cohort study. Am J Psychiatry. 2006;162(2):297–230.
7. Whitlock J, Muehlenkamp JJ, Eckenrode J. Variation in non-suicid- 31. Ross S, Heath NL. A study of the frequency of self-mutilation in a com-
al self-injury: Identification and features of latent classes in a col- munity sample of adolescents. J Youth Adolescence. 2002;31:67–77.
lege population of emerging adults. J Clin Child Adolesc Psychol. 32. Whitlock J, Knox KL. The relationship between self-injurious behav-
2008;37:725–735. ior and suicide in a young adult population. Arch Pediatr Adolesc
Med. 2007;161:634–640.
33. Nock M, Prinstein MA. Functional approach to the assessment of
self-mutilative behavior. J Consult Clin Psychology. 2004;2(5):885–890.