To highlight its pathological significance, nonsuicidal self-injury was for the first time categorized as a distinct condition in the 2013 edition of the American Psychiatric Association's diagnostic manual, DSM-5. Rather than being an official diagnosis, however, the problem appears in a section of the publication entitled “Conditions for Further Study,” which lists behaviors or issues that merit further research. The new entry emphasizes that self-injury is not associated with one particular mental illness and may constitute a stand-alone problem. For example, some people might be diagnosed with major depressive disorder and nonsuicidal self-injury to distinguish that person from someone who is depressed but does not harm himself or herself.
Coping and Changing
Despite numerous attempts to determine why people deliberately hurt themselves, no one is certain of the answer. When asked why they do it, individuals most commonly say their actions help them suppress or release negative emotions, such as anxiety, anger or depression. Psychiatrist Leo Sher, then at Columbia University, and Columbia psychologist Barbara Stanley concluded in 2009 from their review of biological research that self-injury releases opiatelike chemical messengers in the brain known as endorphins. The release leads to a euphoric state that reduces pain and offers reprieve from emotional distress, supporting the reason most self-injurers give for their behavior. This state may also explain why people such as Alice say they feel as if they are being good to themselves. A smaller percentage of afflicted individuals report that the pain helps to snap them out of an emotional numbness, that they want to punish themselves for wrongdoing or that they are using their injuries to get attention from others.
Based on the endorphins hypothesis, some researchers have examined whether naltrexone—a drug used to treat alcohol dependence that blocks the release of these hormones in the brain—might limit this self-destructive behavior by reducing its palliative properties. So far, however, the results of studies of the effectiveness of this and other medications for the condition have been unconvincing.
For now an approach called dialectical-behavior therapy, developed by psychologist Marsha M. Linehan of the University of Washington, offers the best hope for patients. In this therapy—which was initially designed for people with borderline personality disorder, 80 percent of whom self-injure—clients learn how to better tolerate stress and reduce negative feelings, among other coping strategies. The approach combines emotion-regulation techniques used in cognitive-behavior therapy with mindfulness training, which emphasizes acceptance and living in the moment. At least five well-designed studies show that dialectical-behavior therapy reduces rates of self-injury in individuals and lowers the number of suicide attempts and episodes of substance abuse in people with personality disorders.
Although its effectiveness in people with other psychological problems remains unsubstantiated, the treatment is an excellent starting point for the Alices of the world who need less harmful ways to take care of themselves.