Non-Suicidal Self Injury in the DSM 5

As you likely already know, a draft of the DSM 5 came out Wednesday.
There’s a lot of interesting stuff to look through, but the part I had the biggest reaction to was the addition of Non-Suicidal Self Injury. Funny that this is what interested me, because in general research on self-injury bores me.

My initial reaction was entirely positive, but after some more thought I realized some potential problems. So, here’s a list of pros and cons.

Pros:
Too often people who self injure get stuck with the borderline personality disorder diagnosis who don’t meet the criteria only because they self injure. In the paper explaining the rationale for this addition (It’s a quick read. I recommend skimming through it if you’re at all interested) the authors mention that self injury occurs in many different disorders.

The specific wording in the title differentiates self injury from a suicide attempt. Hopefully this can help to cut down on some of the overreaction from practitioners about self injury.

Cons:
Does self injury really belong as its own disorder? Are there people who self injure on multiple occasions without any other diagnosis? Is there research on this? Seems strange to add a disorder that might only rarely be seen in isolation, increasing problems of co-morbidity.
But I understand that the way the DSM is set up, it has to be its own disorder or nothing at all. Possibly the benefits outweigh the negatives of added co-morbidity.
In the article (page 10-11) the authors justify self-injury as a separate phenomena by mentioning a longitudinal study showing that self injury decreased independent of other symptoms. This study was done only on patients with borderline diagnoses, not sure it is fair to generalize this to other patients especially because this new disorder plays a role to separate self injury away from only borderline personality disorder.

My largest problem is with section B: “The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.
This seems like a benign thing to add. Similar qualifiers are in every disorder.

Here’s the problem: The way it is written right now, I don’t meet the criteria for this disorder. I don’t have impairment or distress from the self injury, but I have a lot of that from the feelings leading up to the self injury.

Seems silly. No one would try to argue with me that what I do is self injury. I’ve even participated in a number of studies researching non-suicidal self injury. Those studies could easily be used to support inclusion of this diagnosis, wouldn’t make sense for their participants to not all qualify.

Instead, I feel section B should be written something like this: “The behavior, its consequences and/or feelings precipitating the behavior cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.”

The current writing reflects an unfortunate trend to treat self-injury as the problem rather than the reasons for self injury. Certainly many people feel guilt over their self injury, but this is not the case with everyone.
The authors touched upon a similar idea in their section, “Placement in the system: A Mood or a Behavior Disorder?” (Pages 8-9). Much of their argument leads towards placing it in mood disorders, with a side note of similarity towards impulse control disorders, so it seems strange for the mood component to be omitted from the impairment part of the diagnostic criteria.

33 thoughts on “Non-Suicidal Self Injury in the DSM 5

  1. Hi,

    I didn’t know about the DSM-V until you told me just now. So thanks for that and I am glad they are still open for public comment. I may have a comment or two for them.

    I must dash off to the beach right now and I will come back and have a better read of your post later today.

    Graffiti

    Reply
  2. Hi, i’m just some random person who found you via google search for more information on this proposed diagnosis. I haven’t given much thought to self-injury as a phenomenon in several years, but i’m really kind of floored by this proposal.

    I think you hit upon it right here:

    “The current writing reflects an unfortunate trend to treat self-injury as the problem rather than the reasons for self injury.”

    I think that what you just articulated above is something that people who have self-injured and have developed an awareness of their problem can quickly and intuitively grasp. While clinicians, in my experience, often simply cannot get past the self-injurious act.

    I will go further and say that oftentimes my therapy or, uh, shrinkage (What’s a session with a psychiatrist called?) became all about reducing the _clinician’s_ distress.

    Maybe the reason i’m so irritated by this proposed diagnosis is the slowness of these psychiatric researchers to catch on… I get the feeling they _think_ they’re being forward-thinking, when really they obviously only have a third of a clue. To me, it seems that they’re still mostly so freaked out by the idea that someone might do THAT to themself that they can’t think clearly. Because it is a symptom of something wrong. It’s a behavior. Since when does one behavior equal a disorder?

    (Well, eating disorders, is the answer to that last question. And i can’t figure out what the difference is between ED and SI. But, i don’t have any personal experience with ED.)

    Please forgive me, i’ve been out of the online self-injury world for ten years and am looking to discuss this with _someone_, so i can get a good understanding of the issue before i formulate my scathing letter to the APA. Thanks for the link. I’ll read that next.

    By the way, this one made me smile: “I don’t have impairment or distress from the self injury…” (I once had a shrink ask if i felt a sense of “release” from the injury; i was like, uh, i don’t know, i don’t think so? He was visibly relieved, “That’s good.” He clearly felt something had been narrowly averted!)

    Reply
    • ” became all about reducing the _clinician’s_ distress.”

      Yes! I’ve had a lot of therapy like that.
      Some get so caught up in how it’s something culturally objectionable that they miss the fact that if the same injury had happened by accident it would be a non-issue.
      At this point in my life I know that’s a type of therapist to run away from fast, but when I was younger I wasn’t that assertive and wasted a lot of time.

      Reply
  3. Rereading my coment… ok, obviously, i know the difference between an eating disorder and self-injury. What i can’t figure out is why i have a problem with self-injury as a diagnosis when i don’t have a problem with an eating disorder as a diagnosis… but again, it might just come down to my lack of knowledge about eating disorders. However, i have known people who’ve dealt with an eating disorder. A couple of them would flip-flop between the SI and the ED; they could drop one but not both.

    Reply
    • I flip flop between ED and SI. can actively engage in ED behaviors, but SI doesn’t happen then. Similarly, if i’m using SI behaviors, there are few to no ED behaviors. I have an issue with ED as a diagnosis (though, this might just be for me. I don’t have an ED. no, that’s not true. I totally do.) but SI is a diagnosis I could totally deal with. I don’t know. Today was odd, if this makes no sense, tell me and i’ll try to clarify.

      Reply
  4. As for the minute specifics, my mind can’t wrap them around into a logical thought. However, as an overall remark, it is nice to see that they are taking a closer look at the whole issue of self harm. I think it is on the whole, misunderstood. I don’t feel misunderstood by my psychiatrist and therapist, but from my understanding, a great deal of other people have faced the shock and misunderstanding that self-harm is a suicidal expression. For some, yeah it could be a suicide attempt but those are very few between.

    I don’t know if it calls for it to be labelled a disorder on its own, but at least their taking a closer look at the truth behind self harm. It may take them awhile to really get it “right” but it’s better than ignoring it.

    Psyc – even if you don’t fit into the current model, it doesn’t mean you wouldn’t fit in it. I know that doesn’t sound right, but it’s like bipolar and me. I don’t fit the DSM 5 description for bipolar because I don’t have the mania. I do have anxiety, but technically, that isn’t how it is listed. My psychiatrist thinks that the anxiety is comparable enough to warrant a soft label of possible BP. I think as much as they try to put everyone into a category, there will always be exemptions to the rule.

    Reply
    • Oh I’m sure this current criteria wouldn’t stop anyone from diagnosing me with it. Most people seem to only loosely follow the criteria. They tend to not believe me about the lack of impairment or distress anyways, because it bothers them so much they figure it must bother me too.

      I’m a bit skeptical about the idea of anxiety being compared to mania, but I don’t know the whole situation so it’s really not fair for me to comment.

      It’s not so much that I need the diagnosis. My situation with diagnoses is a mess. I don’t really know what I really have. https://talesofacrazypsychmajor.wordpress.com/2009/02/22/starting-off/ If there even is a such thing as really having anything.

      It’s only a draft right now. I sent in similar comments to these in the DSM’s comments section. We’ll probably be stuck with whatever changes are made for most of my early career. It’d be nice if I’m not stuck dealing with too many problems in the design.

      Reply
  5. Hi
    Im not sure if “isolating” SI into its own dissorder is a good idea because bottom line how would that isolation improve treatment ?
    Ok so now we have non suicidal SI as a dissorder how would that improve treatment? ? SI as part of another dissorder (ie borderline or ED) Is treated with CBT or DBT (Even though I read that you are not a fan of DBT ) and meds.
    How would this seperation of SI change \improve treatment ?

    Reply
    • It could improve treatment if it helps to dispel misconceptions (such as only being for borderline personality, and being a failed suicide attempt) also being it’s own disorder can encourage research on it.

      But I agree, I’m a bit on the fence about it.

      P.S CBT and DBT and medications are not the only treatment options. Just the ones that get shoved down people’s throats most commonly. I get the impression you’re one of the lucky ones to have not had an awful experience with them as you don’t have the bitterness towards them a lot of us do.

      Reply
      • From what I understand
        CBT and DBT work on behaviour changing through cognative work (that is going deep into the thaught process of SI)

        Reply
      • I’ve got a serious beef with the idea of “creating” a disorder just to prevent mental health professionals from misusing a particular diagnosis. Why not instead clarify the criteria for borderline personality disorder?

        I echo Just A Gal’s question (How will this diagnosis improve treatment?) and am hoping to see it addressed by mental health professionals, somewhere, sometime soon.

        Reply
  6. Hello Major,
    It seems for some reason the DSM no longer likes the romans and their numerals, wonder why that is?

    I think you make a good point and I agree with it to include the feelings precipitating the event.

    My view also would be a problem with the concept of non-suicdal self injury. As I have written on my blog I see the two as quite separate psychological processes with obviously two quite separate goals. If ones goal is to suicide then the goal of cutting self is clear. These are distinct from the 8 self injury goals which are not to kill self. So self injury is by definition not a suicidal act but an act to injure self and not to kill self.

    As a consquence in my view it should be a disorder of its own.

    If a client is doing self injury that is not severe then I ask them what is the problem? For instance a woman recently said she was bulmic and upon enquiry she stated that she purged about once a fortnight. That is going to cause very little physical damage but it certainly did distress her that she did it. thus the problem is not the purging but her distress about that piece of behaviour.

    Is some one is to do self harm that is not causing moderate to significant physical damage then to my mind there is not a self harm problem.

    Graffiti

    Reply
    • I’m not sure what’s going on with the roman numerals situation. I’ve seen many people comment on it but no explanation. Maybe they realized that roman numbers are silly?

      I agree that I don’t have a self harm problem, but I guess it’s tricky because feelings that are very closly tied in with the self injury are a problem. Separating the two out isn’t so easy.

      Reply
    • Graffiti, first of all i thoroughly appreciate that you, as a therapist, are seeking opinions on and discussing this subject. I wish more mental health professionals would seek to understand their patients as you are doing. I also commend you for your level-headed attitude.

      I question just a couple of your points…

      “[T]hus the problem is … her distress about that piece of behaviour.”

      Being distressed about a self-injurious act seems to me a normal, healthy reaction. I’d be more concerned about the person who treats it nonchalantly.

      “Is some one is to do self harm that is not causing moderate to significant physical damage then to my mind there is not a self harm problem.”

      I’m not sure what you mean by “a self harm problem” here. Do you mean, for example, that you would not use the proposed self-harm diagnosis in this treatment? Or that you would not consider the self-harm a main focus of your treatment?

      I have known enough people who’ve self-injured that, to me, a category like “people who self-injure” isn’t a very informative one…

      – There are people who’ve tried it once or several times, and then never seek help or talk about it again. (I’ve got noticeable self-inflicted scarring, and so sometimes people randomly bring up the topic with me, usually when drunk or on a Greyhound bus.)

      – There are people who become addicted to self-injury, to the point that they don’t know how to get through a day without it. For them, the injury may be a central issue that needs to be directly addressed.

      – There are people who are suicidal at the same time; the suicidality and self-injury, though separate things, are both ways of alleviating distress. (This was me at nineteen. I never used to tell anyone about the self-injury or my overdoses… if i woke up the next morning, i just went about my life. For me, the injury was not a central issue, but rather a manifestation of my depression and emotional immaturity.) Or, as i mentioned before, people with comorbid SI and ED, who can quit one but not both.

      – There are people who are desperate for someone to take their distress seriously and reveal their injuries in this context.

      I have a problem with lumping all these people into one category. Diagnostically, i don’t even think i like my own categories, since they still focus more on the nature of the behavior than the ultimate cause. But i am not a mental health professional, and i’m sure my observations don’t fit within any therapeutic framework. I am interested in your perspective as a trained therapist.

      Hey, Psych Major, sorry i’m blathering all over this thread. Please let me know when i start getting too repetitive!

      Sarah

      Reply
      • Yes S,

        You could say that suicide and self harm both alleviate distress however the post event outcomes are very different.

        Regarding self harm problem. If some one cuts self with a knife deliberatley and it is not a suicidal act then technically it would be diagnosed as a psychological problem. However if the cuts are not dangerous and not excessively mutilative then I would see no reason to ‘treat’ any problem unless it was reported by the person as distressing. If they did not find it distressing then in my view there is no problem that is meant to be fixed.

        I think we agree that self harm and suicide are two different things and thus people can be only self harming, or only suicidal, or suicidal and self harming. thus the new DSM title is a nonsense as all self harming is not suicidal

        Graffiti

        Reply
  7. Hey,
    i don’t “Self-Injure”….i “Self-Mutilate”……..at least according to my current Shrink, who believes the fromer description is too “soft”. Whatever….go figure, eh? i guess i also don’t “Binge and Purge”, i “Scarf and Barf”….sigh.

    Sorry if this was too graphic…welcome to my world of therapy.

    Reply
  8. Me too. And makes me think of much worse damage than i have ever done to myself, and that is including stiches and staples. i think, if it’s okay with you, i will take this quote with me to my next appointment. Although i’m sure he must be aware of it, that doesn’t mean he knows i am…thanks!

    Reply
  9. Ha! Wouldn’t that be a riot if i learned something about the Psychiatric world pertaining to me before he did…what a riot!
    Thanks! Loving your blog!

    Reply
  10. Hello Everyone!

    I have never posted on any of these boards before but I have been waiting for this diagnosis to come out. I am a previous non-suicidal self-injuerer who was also struggling with many family issues. They gave me a diagnosis of minor depressive disorder at first, but after 2 months of telling my story they figured I had enough motivation of my own to get back on my feet on my own. Although they were correct, I strongly feel that I needed professional help to assist me in kicking my habits of SI. I have been “clean” for about 5+ years now and am currently an undergraduate in Psychology.

    I am surprised that so many of you are against this addition to the DSM-5. (Maybe they replaced the roman numerals for a more “modern” look. :) Not sure about that change either.) To me SI and ED are very much the same. Both can be practiced on many different terms. (I also have experience with ED by the way.)

    Whether a person has an additional disorder or not, I feel that their SI behaviors need to be addressed. A psych. can not just dismiss the behavior based on the ‘severity’ or lack there of. Any SI act can progress. It’s extremeley tough to quit cold turkey.

    SI is very much an addictive behavior. If it weren’t for my abusive alcoholic/drug abusing father – who amazingly remembered to check my arms every time I left or came back home, I’m not sure that I would have stopped by now.

    I would LOVE to see rehab centers put up for SI just as they treat ED and substance abuse.

    I am truly very shocked there are so many negative reviews to this, especially from those who were previous SI. How is SI not an addictive behavior? Why can’t we treat it as we would other addictions: ED, substance abuse, gambling, etc.

    Thank you for the great discussions and point of views!

    Reply
  11. You asked, “Are there people who self injure on multiple occasions without any other diagnosis?” Yes, there are. I was one of them.

    I don’t have much else to say because I don’t have any experience with psychiatrists or therapists or anything of the sort.

    But I do think that when the self-injurious behavior becomes addictive, that’s when it should definitely be considered a problem in its own right. Because then it becomes more like, as Amanda said, an ED, substance abuse, gambling, etc. At that point, the problem really is in the behavior, and not necessarily in other aspects of emotional and mental health.

    Reply
    • I’ve never heard of this before and know the research this diagnosis is based on was not done on people without co-morbid diagnoses. I’m very curious what your motivations for self-injuring are if you don’t mind sharing. What do you think causes it for you? What function is it serving? What changes do you feel in yourself as a result of it?

      Reply
      • Well, for one thing, I said “was” because I’m not doing it anymore. I stopped about a month ago. Of course, I’ve gone that long before and returned to it, but only briefly, and anyway I don’t intend to let that happen again.

        Motivations are a little tricky. I’m still not entirely sure myself. The best I can do is list some examples, because it varies. I know that the first time I did something I knew hadn’t been a good idea (evidenced by how I hid it) I had been upset because people were arguing in the house. I don’t know why that bothers me so much, I really don’t. People argue, it’s normal. But anyway, that just had me on edge. Other times, it was out of habit. Like scratching (which is what it was at the time) was just a way to wind down. Other times, I would self-injure when I was unusually nervous about something. For example, before starting my first year of college, or heading off to class and for whatever reason feeling weird about it. I think that it was also a response to stress, like when I was working on a paper or studying for an exam after having procrastinated for a while. But that case could also have been to deal with being mad at myself for putting it off for so long. Cutting was a quick way to get past that. Because generally, I have trouble letting mistakes go.

        I think that sometimes it served to give a simple, physical representation of feeling somehow off. Like I felt that something was a little bit wrong, but like I said, I haven’t been diagnosed with any disorder. But that only came to mind after I had read about self harm (because for a little while, a few months, I didn’t know what to call what I was doing. This was when it was scratching, not cutting. I just figured it was something odd, so I looked it up when I started college, on my wonderful high speed internet.) I think that in most of those cases I described though, it served to get past little things, rather than dwelling on them. But really, that doesn’t make sense logically, because it just creates something bigger to “get past”. Which leads me to changes…

        In the short term, it was comfort, relief, etc. But that would lead into negative things, like “Really, why did you just do that?” I started having something to hide, which made me a little less comfortable around people. But now I’m trying to get past that too. It might not be all that obvious where the scars I have came from. And even if it is, well… it’ll be hot next summer, and I plan on wearing more comfortable clothes then. And there are just annoying things now, like the random thought of wanting to cut, for no particular reason. Or looking at people’s arms, expecting to someday spot some scars or something. Those things bug me because I didn’t always think that way. Hopefully that’ll stop at some point.

        This may not be what you wanted to know. Or it may be more than what you wanted to know. I wasn’t really sure, so I just gave it a try. Hope that helps.

        Reply
        • The things you are saying sound pretty typical of a lot of people who self injured at one point. I’m not sure if your situation really fits what I meant by a peson who self injures but does not have other diagnoses. I was thinking about if a person sees a clinician for an evaluation could they be diagnosed with self-injury and nothing else? Obviously no one can diagnose you over the internet but if you had seen a clinician it’s possible you might have been diagnosed with an anxiety or mood disorder. Anything is possible though and I don’t know you. I guess my feelings are that most people don’t self-injure and that for those that do there is some reason why they do. Often the reason is related to anxiety or depression. So the disorder in isolation does not make sense to me if another disorder is already the cause.

          Reply
          • You are correct in that it doesn’t make sense to diagnose one thing when there is already a cause for it. But say the diagnosis is depression.. that’s nice.. but the cause of the depression is actually what you’re after. Too many people nowadays think that you can just diagnose something, throw some medicine on top, and cure it. A person who self injures and goes to a clinician to be diagnosed with depression is not then cured of their self injuring tendancies. People are not so simple that you can classify them and treat each incident the same. (So sad to me that we still need to emphasize this to people.) It’s so sad that ‘this generation’ of psychologists/psychaitrists think this way. Every situation is unique, that should still be Psych 101. And yes, you need SOME kind of guidelines, some kind of starting point. But that’s all it was supposed to be, a starting point. Self injuring DOES need to be diagnosed seperately, many things need to be diagnosed seperately; because too many of the psychs now, only go by the book. So if the DSM doesn’t write it out for you, nobody will help these people in the way they need to be helped. The smaller issues won’t ever be touched. So you are right that a diagnosis of a ‘symptom’ shouldn’t “really” exist.. but there is always that one bad egg in the box.

            And if an extra diagnosis can make these bad eggs focus on people with their full attention..let it be in the DSM.. Why do you really want to be a psychologist/socialworker/counselor/etc. ?

            Always remember that reason.

            Reply
  12. The addition of self-harm to the DSM 5 as a distinct disorder is nonsense! In my opinion the DSM 4 is a waste of space and the revisions make it worse. I self-harmed (cutting, banging head, punching self) for a short period many years due to a traumatic life event. The major function of these behaviours for me, was to regulate my emotions i.e avoid the pain I was feeling at the time. I engaged in many other behaviours that technically would not have been classed as ‘self-harm’ but were essentially the same, as they had the same function (avoiding feeling distress and thinking about the life event). These included excessive swimming, running till my legs hurt, and dating men I had no interest in. Should these also be included in the DSM as distinct disorders? self-harm could be replaced with ‘excessive swimming disorder’! For me this was equally harmful, probably more so as had a greater effect on my functioning in all areas.

    Reply

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