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Stepping Out of the Shadows: Non-Suicidal Self-Injury as Its Own 
Diagnostic Category

Lindsay Cohen

Non-suicidal self-injury (NSSI) is the repetitive and intentional act of 
causing injury to one’s own body without suicidal intent. NSSI is an 
extremely prevalent and pervasive phenomenon, affecting between 
13.0 to 23.2% of individuals in the general population. There are 
significant negative outcomes that may result from engaging in NSSI 
including risk of serious physical injury, becoming addicted to the 
behavior, experiencing stigmatization and social rejection, and an 
increased risk for suicidality. There is also sufficient evidence in the 
literature supporting the distinction between NSSI and suicide as well 
as NSSI and Borderline Personality Disorder (BPD). Creating a distinct 
diagnosis of NSSI in the DSM has many positive clinical implications 
such as developing a tailored treatment for individuals who engage in 
such behaviors, stimulating further research about NSSI, improving 
communication regarding behaviors of self-injury, and bringing 
awareness to this widespread behavior. This article evaluates each 
of these benefits to demonstrate that NSSI deserves to be a distinct 
diagnostic entity in the DSM. 

Introduction

Mary, a 14-year-old female, spends most of her time with 
her friends and boyfriend, Steve. On Monday, Steve cancelled on her, 
claiming that he was sick and wanted to go home and sleep after school. 
On the way home from school, Mary saw Steve walking down the block 
holding another girl’s hand. When she arrived home, Mary ran through 
the kitchen, ignored her parents’ greeting, and went straight upstairs to 
her bedroom. She locked the door and took out the razor blade that she 
had hid in her bottom drawer. Mary knew that she was not supposed to 
cut her arms, but it seemed like the only way to escape from the horrible 
knot inside her chest. She held the razor blade to her arm and sliced 
deeply into her skin, watching the bright red line slowly materialize. 
Mary felt an immediate warm sense of release, as if all of her anger and 
pain were bleeding out of her. 



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Cohen

Non-Suicidal Self Injury (NSSI) is defined as the purposeful 
hurting of oneself without the conscious intent to die (Jacobson & 
Gould, 2007). The majority of individuals report that the function 
of NSSI, such as self-scratching or self-cutting, is to reduce tension 
and regulate     emotions, such as anxiety, depression, fear, or anger 
(Favazza, 1998; Nixon et al., 2002; Ross & Heath, 2003). As illustrated 
by Mary’s behavior in the case study, interpersonal difficulties often lead 
to NSSI. A study by Adrian, Zeman, Erdley, Lisa, and Sim (2011) found 
that interpersonal difficulties in the family and peer context increase 
the frequency and severity of NSSI through emotional dysregulation. 
Interpersonal influence, the use of self-injury to manipulate people in the 
environment, also has been found to contribute to NSSI (Klonsky, 2007). 
A minority of individuals assert that their motivations for engaging in 
NSSI are to arouse feelings when none exist and to terminate feelings of 
depersonalization (Jacobson & Gould, 2007; Klonsky, 2007). 

When the American Psychiatric Association composed the 
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition 
(DSM-5), NSSI was proposed for inclusion as its own diagnostic 
category. Ultimately, NSSI was added to Section III of the DSM-5 as 
a condition for further study, which means that criteria sets need to be 
further studied before NSSI can become an official diagnosis (In-Albon, 
Ruf, & Schmid, 2013). Given (a) the prevalence and pervasiveness of 
NSSI; (b) the problems that stem from engagement in such behaviors; 
(c) evidence in the literature distinguishing NSSI from both suicidality 
and Borderline Personality Disorder (BPD); and (d) the clinical utility 
of having NSSI as its own diagnosis, NSSI deserves to be a diagnostic 
category in the DSM. Furthermore, NSSI meets the criteria for a mental 
disorder according to the DSM-5.

Prevalence and Pervasiveness of NSSI

NSSI often starts during early adolescence, with an average 
age of onset of 12-14.  NSSI peaks in mid-adolescence and decreases 
into adulthood. Prevalence of NSSI in males and females is nearly 
equivalent, and it is unclear whether there are ethnic differences in its 
incidence (Jacobson & Gould, 2007). In their critical review of NSSI 
literature, Jacobson and Gould (2007) found that the lifetime prevalence 
of the behavior in the general population ranges from 13.0%- 23.2%. An 



12       Columbia Social Work Review, Volume V

Non-Suicidal Self-Injury

adolescent community study, which used the proposed criteria for the 
DSM-5, found the prevalence of NSSI to be 6.7% among adolescents 
(In-Albon et al., 2013). In the inpatient population, approximately 
21% of adults and 30%-40% of adolescents engage in NSSI (Hamza & 
Willoughby, 2013). 

For individuals who have engaged in NSSI, the behavior is 
extremely pervasive. In a study that examined the frequency of NSSI 
over the lifetime, it was found that out of a sample of 171 people who 
had engaged in NSSI at some point during their lives, over 55% self-
injured at least once a week (Turner, Chapman, & Layden, 2012). The 
high prevalence of NSSI in the population and the pervasiveness of this 
behavior in individuals’ lives is a chief reason why NSSI is a behavior 
significant enough to be a distinct diagnostic category in the DSM.

Adverse Consequences of Engaging in NSSI

While NSSI provides relief from negative emotions in the 
moment, it can create long-term problems. First, NSSI may be a habit-
forming behavior. Individuals who engage in NSSI report difficulty 
in controlling the urge to self-injure. A person can become physically 
addicted to self-harm as a result of the involvement of the endogenous 
opioid system. This system regulates pain perception and levels of 
endorphins, which are released when the body is injured and result 
in a feeling of pleasure. Repeated activation of this system may lead 
to a tolerance effect whereby individuals who self-injure develop a 
decreased sensitivity to pain while self-injuring over time (Mental 
Health Foundation and Camelot Foundation, 2006; The Cornell Research 
Program on Self-Injury and Recovery, 2013). 

Social consequences, including peer rejection and stigmatization, 
are also important repercussions of NSSI (Favazza, 1998). Society’s 
negative views of self-injurious behaviors cause people to avoid 
individuals who engage in such behaviors.  Healthcare workers also 
possess stigma towards individuals who engage in NSSI, such as 
beliefs that people who self-injure are manipulative, attention seeking, 
untrustworthy, and uncooperative. Evidence suggests that this stigma 
may negatively impact services and treatment outcomes and lead to a 
growing sense of alienation amongst individuals who self-injure (Law, 
Rostill-Brookes, & Goodman, 2009). The stigma present in the general 



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Cohen

population, the stigma among healthcare professionals, and the self-
stigma that individuals possess towards themselves often discourage 
individuals from disclosing their NSSI behavior and seeking help. 
Resulting feelings of secrecy and the inability to reach out generate 
shame and guilt (Raymond, 2012). 

Another adverse consequence of NSSI is the risk of physical 
injury. Infection and scarring often result from NSSI. People sometimes 
inflict more harm upon themselves than was intended, which can lead 
to severe and potentially life-threatening injuries that may require 
medical attention and cause lasting disfigurement (Turner et al., 2012). 
Lastly, individuals who practice NSSI have an increased likelihood of 
suicidal behavior when compared to individuals who do not practice 
NSSI (Hamza & Willoughby, 2013). Studies of older individuals who 
engaged in NSSI in the past indicate a greater risk for subsequent 
suicidal behavior (Hawton & Fortune, 2008). According to Joiner (2005), 
increased engagement in NSSI raises an individual’s capacity for suicide 
via habituating the individual to the fear and pain linked with taking 
one’s own life. Increased frequency and greater time spent engaging in 
NSSI, using multiple methods to inflict NSSI, and engaging in NSSI 
alone are all associated with a greater risk of future suicidality (Hamza & 
Willoughby, 2013). These many adverse consequences demonstrate why 
NSSI is significant enough to warrant its own diagnostic category.

NSSI and Suicide as Distinct Concepts

NSSI is often wrongly viewed as a manifestation of suicidality. 
This has made it difficult for researchers, clinicians, and the general 
public to view NSSI as a valid and distinct entity. While in the past 
suicidality and NSSI were seen as two points on the same continuum, 
recently, research has found a high prevalence of NSSI in individuals 
who clearly distinguish this behavior from suicidality (Jacobson & 
Gould, 2007). This growing research base is forcing researchers and 
clinicians to rethink their perspective and to begin to view NSSI and 
suicidality as distinct concepts.

The major difference between NSSI and suicide attempts is the 
intent of the behavior. While NSSI is a maladaptive behavior, it is a form 
of coping, and coping is a confirmation of a desire to live, not a desire to 
die. Typically, when individuals engage in NSSI, they have cognitions 



14       Columbia Social Work Review, Volume V

Non-Suicidal Self-Injury

centered on temporary relief while individuals engaging in suicidal 
behaviors have cognitions of permanent relief via death. Additionally, 
people engage in NSSI more frequently and with more diverse methods 
compared with suicidal behavior (Jacobson & Gould, 2007). While 
NSSI is a risk factor for suicide, these are distinct behaviors that do not 
necessitate the presence of the other. This differentiation between NSSI 
and suicide supports the diagnostic validity of NSSI. 

Differentiating NSSI from BPD

Some clinicians argued that NSSI is primarily a function of 
BPD. However, while NSSI and BPD are frequently comorbid, they also 
frequently occur independently–a point that is largely misunderstood 
and overlooked. A growing number of adolescents do not meet the 
diagnostic criteria for BPD, are nonetheless distressed, exhibit NSSI, and 
are in need of help. In a recent study by In-Albon et al. (2011), it was 
found that 80% of the adolescents with NSSI did not fulfill the criteria 
for BPD. Results from a study conducted by Glenn and Klonsky (2013) 
indicate that the comorbidity of NSSI with BPD is comparable to that 
of BPD with mood and anxiety disorders. Substantial overlap has been 
found between NSSI and depressive disorders, anxiety disorders, Post 
Traumatic Stress Disorder, Conduct Disorder, and substance misuse 
disorders (Jacobson & Gould, 2007; Wilkinson & Goodyer, 2011). In 
addition, many individuals who engage in NSSI have no associated 
psychiatric diagnoses (Wilkinson & Goodyer, 2011). Thus, while NSSI 
and BPD do commonly overlap, NSSI is distinct from BPD, as evidenced 
by its frequent presence in the absence of symptoms of BPD. 

Misconceptions about the relationship between NSSI and BPD 
lead to the assumption that NSSI does not have clinical significance 
beyond the context of BPD.  Many studies have found that, on its own, 
NSSI is linked with clinical impairments such as depression, anxiety, 
suicidality, emotion dysregulation, and loneliness (Glenn & Klonsky, 
2013; Wilkinson & Goodyer, 2011). The fact that NSSI frequently occurs 
independently of BPD and has clinical significance outside the scope 
of BPD, provides compelling evidence that NSSI is, in fact, a distinct 
condition that is not simply a symptom of BPD.



   Columbia Social Work Review, Volume V       15

Cohen

Clinical Utility of Including NSSI as a Diagnosis in the DSM

Creating a distinct diagnostic category for NSSI has significant 
clinical benefits. In the absence of an accompanying psychiatric 
diagnosis, there currently exists no place to record NSSI. It is especially 
difficult to provide treatment to individuals without a formal diagnosis 
within today’s healthcare system, which will not pay for services 
provided to individuals without a diagnostic label. To ensure insurance 
reimbursement in the current healthcare system, many individuals are 
misdiagnosed with other psychiatric disorders without meeting the 
full criteria. If NSSI were an official diagnosis, insurance companies 
would reimburse for the treatment of NSSI, and the primary objective 
of psychotherapy could be treatment of NSSI (In-Albon et al., 2013). 
Imparting DSM status to NSSI will help individuals who engage in 
such behaviors to receive appropriate treatment before they begin to 
demonstrate suicidality. 

The presence of an NSSI diagnosis would provide a research-
based definition that would prevent clinicians and researchers from 
confusing NSSI with BPD or suicidal behavior.  Furthermore, it would 
enhance inter-professional communication and communication between 
professionals and patients regarding this behavior (In-Albon et al., 2013). 
The presence of a separate diagnostic category would encourage NSSI 
research, particularly on NSSI-specific treatments. Unfortunately, there 
is scant research about the treatment of NSSI, probably in large part 
because it has not been its own diagnostic entity. Most research studies 
look at the treatment of NSSI under the umbrella of BPD and suicidality. 
In this regard, dialectical behavior therapy (DBT) has been found to 
reduce the frequency and severity of NSSI. DBT was originally designed 
to treat BPD, and its use has been expanded to treating adolescents with 
suicidal tendencies (Linehan et al., 2006; Washburn, Gebhardt, Styer, 
Juzwin, & Gottlieb, 2012). As discussed above, NSSI is distinct from 
BPD and suicidality, and therefore, approaches specific to NSSI must 
be studied. Last, creating a distinct diagnostic category for NSSI would 
elevate the visibility of this behavior, bringing awareness to the issue and 
ensuring that clinicians treat it seriously (Wilkinson & Goodyer, 2011). 
All of these clinical benefits present further support for the addition of 
NSSI as a disorder in the DSM.



16       Columbia Social Work Review, Volume V

Non-Suicidal Self-Injury

Does NSSI Meet all the DSM Requirements of a Mental Disorder?

DSM-5 Working Definition for a Mental Disorder

 The DSM-5 working definition defines a mental disorder as 
“a syndrome characterized by clinically significant disturbance in an 
individual’s cognition, emotion regulation, or behavior that reflects a 
dysfunction in the psychological, biological, or developmental processes 
underlying mental functioning” (American Psychiatric Association, 
2013, p. 20). Additionally, mental disorders cannot be an expectable or 
culturally accepted response to stress or loss or socially deviant behavior 
that is primarily a conflict between the individual and society (American 
Psychiatric Association, 2013).
 NSSI is a disturbance in behavior that involves repetitive self-
injuring. This behavioral pattern reflects an underlying psychological 
dysfunction, which centers on difficulties regulating emotions as well as 
preoccupation with self-injury and urges to self-injure (In-Albon et al., 
2011; Klonsky & Glenn, 2008). There are possible biological correlates, 
such as altered serotonergic function and endogenous opiate function, 
which may increase an individual’s chance of engaging in NSSI by 
affecting responses to stress and levels of pain tolerance (Jacobson & 
Gould, 2007). This behavior pattern is also associated with significant 
distress as evidenced by all of the problematic consequences that result 
from engaging in NSSI. It is important to note that NSSI is associated 
with levels of distress and impairment comparable to levels seen in 
individuals diagnosed with other Axis I disorders (Selby et al., 2012). 
Furthermore, it is not an expectable or culturally sanctioned response to 
stress or loss. Therefore, NSSI fulfills the criteria of a mental disorder 
according to the DSM-5.

Benefit versus Harm of Creating an Independent Diagnosis

 In proposing the creation of a separate diagnostic category for 
NSSI, it is important that the potential benefits of doing so outweigh 
the potential harms. The creation of NSSI disorder has many benefits, 
including motivating new research and improving patient care through 
more targeted diagnosis and treatment (Selby et al., 2012). In addition, 
the creation of this new diagnostic category would help to further 
distinguish behaviors of suicidal intent from behaviors of self-injury. 

http://www.psychologytoday.com/basics/cognition
http://www.psychologytoday.com/basics/emotion-regulation


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Cohen

The misclassification of NSSI as suicidal in nature, which is commonly 
reported by adolescents, leads to inappropriate and potentially 
unnecessary responses such as hospitalization.  Clearly differentiating 
NSSI from suicide would result in decreased hospital admissions for 
individuals engaging in NSSI (Glenn & Klonsky, 2013). 

A possible disadvantage of creating this new diagnosis is 
the potential for increased stigmatization of self-injurious behaviors 
(Zetterqvist, Lundh, Dahlstrom, & Svedin, 2013). While this is possible, 
individuals who engage in NSSI already experience stigma. Creating 
a new diagnosis will likely bring increased attention and awareness 
to the condition in the community at large. A second disadvantage is 
that by defining the condition as “non-suicidal,” people may begin to 
perceive NSSI as less severe or important, decreasing the significance of 
treatment. However, it is also likely that the presence of an independent 
diagnostic category for NSSI will increase awareness, leading to 
improved assessment and treatment (Wilkinson, 2013). Thus, the 
potential benefits of creating a diagnosis of NSSI greatly outweigh the 
potential harms, further strengthening the case for the creation of a 
distinct diagnostic category for NSSI. 

Conclusion

Recently, NSSI has gained attention in regards to its legitimacy 
as a diagnosis in the DSM. As discussed above, there are many reasons 
why NSSI deserves to be a distinct diagnostic entity: (a) the prevalence 
and pervasiveness of NSSI is extensive; (b) many problematic outcomes 
stem from engagement in NSSI; (c) NSSI is distinct from suicidal 
behaviors; (d) there is significant research indicating that NSSI is often 
present in individuals not diagnosed with BPD; (e) there is considerable 
clinical utility to having NSSI as its own diagnosis; and (f) NSSI meets 
the standards for a mental disorder according to the DSM-5. While more 
research is needed regarding the specific diagnostic criteria, there is no 
reasonable doubt that NSSI should be a diagnosable disorder.

The addition of NSSI as a diagnosis in the DSM has immense 
implications for the field of social work. This change in diagnosis 
would largely impact the work of clinical social workers that work with 
adolescents in psychiatric settings, as this is the population most likely to 
present with NSSI. It will bring awareness to and stimulate new research 
regarding NSSI, which will increase social workers’ understanding of the 



18       Columbia Social Work Review, Volume V

Non-Suicidal Self-Injury

disorder. Additionally, establishing a diagnosis of NSSI will encourage 
research regarding NSSI-specific treatments. This will increase social 
workers’ competence in regards to diagnosis and treatment, resulting 
in improved patient care. According to the NASW Code of Ethics “the 
primary mission of the social work profession is to enhance human 
well being” (National Association of Social Workers, 2008). Creating an 
independent diagnostic category for NSSI in the DSM would be a crucial 
step in fulfilling this goal.

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