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New Disorder: NSSI Disorder in DSM-5

In the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM),8,9 NSSI was included exclusively as a symptom of borderline personality disorder (BPD) and combined with “suicidal behavior, gestures, or threats, or any self-mutilating behavior” (regardless of suicidal intent). This classification implied that NSSI was unlikely to occur in those without BPD, was only clinically significant to the degree that it occurred within the syndrome of BPD, and was not meaningfully distinct from suicidal behaviors.

For the past few decades, researchers have argued that NSSI should be classified as a separate clinical syndrome,4,7,10 and recent evidence supports this argument. First, NSSI frequently occurs outside of BPD: rates of NSSI exceed rates of BPD in many samples,11,12 and NSSI co-occurs with a number of disorders other than BPD, including other personality disorders,13 as well as a range of major Axis I disorders, such as mood, anxiety, eating, and substance use disorders.11,13 Second, NSSI on its own leads to clinical impairment, apart from its association with other major psychiatric diagnoses. For instance, one study found that 12% of adolescents hospitalized for NSSI did not meet criteria for a major DSM disorder, indicating that NSSI alone can lead to significant impairment.11 Third, research has found important differences between NSSI and suicidal self-injury;4,14 collapsing these two behaviors into a single category leads to confusion and inappropriate clinical care (e.g., unnecessary hospitalization).7

Based on this growing evidence, there has been an important shift in the classification of NSSI in the most recent edition of the DSM. Specifically, in

DSM-5,* 1 a new NSSI disorder appears as a “condition requiring further study.” This designation is assigned to clinical phenomena when “there is insufficient evidence to warrant inclusion ... as official mental disorders” but for which “future research is encouraged” (p.783). The proposed DSM-5 NSSI disorder criteria were formulated based on existing research on the phenomenology, frequency, and function of NSSI (Table 15.1). The creation of specific NSSI disorder criteria has a number of positive implications for the field, including providing a clear and consistent definition of NSSI for research, distinguishing NSSI from BPD and suicidal behavior to improve accurate diagnosis and clinical care, and recognizing NSSI as its own clinical phenomenon for funding research aimed at treating and preventing the behavior. One argument against a separate NSSI disorder is concern that it would pathologize individuals, particularly adolescents, who may only briefly engage in the behavior. Criterion A of the proposed NSSI disorder partly addresses this concern by requiring a frequency threshold of 5 or more days of NSSI engagement in the past year.

Table 15.1 Proposed DSM-5 criteria for nonsuicidal self-injury disorder1

(A) In the past year, an individual has engaged in 5 or more days of self-injurious behavior (e.g., cutting, burning) that was severe enough to cause tissue damage but without suicidal intent.

Note. The absence of suicidal intent has either been stated by the individual or inferred from the repeated engagement in the behavior that the individual knows will not result in death.

  • (B) An individual engages in intentional self-injury 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

Note. The desired response is experienced during or shortly after engaging in self-injury. The individual’s repeated engagement in the act may suggest dependence.

  • (C) The self-injurious behavior is associated with one or more of the following:
  • (1) Interpersonal difficulties or negative feelings or thoughts occurring immediately prior to the self-injurious act.
  • (2) A period of preoccupation with the behavior precedes the act.
  • (3) NSSI urges occur frequently even if not acted upon.

(D) The behavior is not socially sanctioned (e.g., tattooing, part of a religious or cultural ritual) and not restricted to nail biting or picking a scab.

(E) The behavior or its consequences cause significant distress or impairment in important areas of functioning.

(F) Intentional self-injury does not occur exclusively in a state of psychosis, delirium, or intoxication, and cannot be accounted for by another mental or medical disorder.

Limited Data: What We Know and What We Don't What Is the Prevalence of NSSI?

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