Old Problem: Historical Perspectives of NSSI
NSSI is defined as the direct and deliberate destruction of one’s own body tissue without suicidal intent, for purposes not socially sanctioned.1-3 Over the years, NSSI has been referred to by a range of other terms, including deliberate self-harm (DSH),4 self-mutilation,5 and parasuicide.6 However, these terms do not distinguish between suicidal and nonsuicidal self-injury, which has created confusion in the field and hindered understanding of the phenomenology, function, and treatment of nonsuicidal forms of self-injury specifically. By studying NSSI and suicidal self-injury separately, researchers have found that the two behaviors are distinct in terms of prevalence (NSSI is more prevalent), frequency (NSSI is engaged in more frequently), functions (motivations for NSSI are aimed at coping with the present in order to continue life, whereas motivations for suicidal behavior are focused on ending life), and medical severity (NSSI infrequently requires medical attention).4,7
Although the term NSSI is relatively new to the field, the phenomenon of self-harm has been reported for over 2000 years.5 Stories dating back to the 5th century BCE tell of a man who mutilated his entire body with a knife starting at his shins, and another who would “cry aloud ... and cut himself with stones.” At that time, self-harm was thought to be caused by demon possession, and thus exorcism was the appropriate intervention. Since Biblical times, numerous anthropological studies and clinical case reports have described a range of self-harming practices, with different perspectives hypothesizing varied causes for the behavior. For instance, psychoanalytic theories suggested that self-mutilation resulted from anger at another turned inward, attempts to avoid suicidal impulses, or reactions to one’s sexual drive by providing sexual gratification or punishing the self for sexual urges.5 Contemporary clinical reports have also suggested a range of motivations for self-injury (discussed later in this chapter), including tension reduction and communication with others.
Despite the long-documented history of self-injury, systematic research on the behavior only dates back a few decades, with dramatic growth in the past 10 years. A Web of Science search of publications related to “self-harm,” “self-injury,” or “self-mutilation” resulted in relatively few publications (<100) prior to the 1980s (see Figure 15.1). However, the number of articles focused on self-injury has increased steadily from around 60 publications per year in 1991 to almost 600 per year in 2013. The purpose of this chapter is to review the current state of knowledge about NSSI, highlight significant gaps in our understanding of NSSI, and recommend the types of NSSI research needed to move the field forward.
15 Nonsuicidal Self-Injury
Figure 15.1 Publications per year on self-injury.