Non Suicidal Self Injury (NSSI): The Paradigm of Suicide

Longitudinal research indicates that NSSI predicts suicide attempts in adolescents. The high concurrence between suicide attempts and NSSI can be best understood in the view of NSSI increasing the risk for suicidal tendencies. There have been reports of suicide due to excessive fear of contracting COVID-19 from India as early as 12 February 2020, even when the infection was not spread across the country (Goyal et al., 2020).    

 

The connection among NSSI and suicide attempts is labyrinthine and nuanced and there is a general understanding that there is an overlap among nonsuicidal and suicidal self-injury. Adolescents who engage in NSSI do not intend to end their own lives, nor do they perceive that their injuries will result in death (Andover & Gibb, 2010). These behaviours may be engaged in because of a desire for relief from a distressing affective state; COVID-19, for example.

 

NSSI is more prevalent as compared to suicide, involves different methods (for example, cutting and burning, rather than behaviours involving firearms, hanging, or self-poisoning), and results in bodily harm that is less medically severe and that causes less lethal damage, compared with suicide attempts. 

 

A growing body of literature now proposes that NSSI is an especially important risk factor for suicidal behaviour. As per Klonsky et al, established risk factors for suicide such as BPD, depression, anxiety and impulsivity are now deemed less important to be associated with a history of suicide attempts as compared to NSSI.

 

Joiner (2005), in exploring the possibility for an acquired capability for suicide, hypothesises that to commit suicide, a person must overcome the fear and pain associated with killing oneself. NSSI may be one way to become desensitised to the fear and pain of suicide.   

 

Behaviours associated with NSSI that are expected to decrease pain and fear associated with suicide are not enough to lead to suicide unless they lead to perceived burdensomeness (i.e., feelings that one is a strain on others) and social isolation, as per Joiner’s Theory of Acquired Capability.

 

Another theory suggests the existence of a third variable to explain the co-occurrence of NSSI and suicidal behaviours. The existence of a diagnosable psychiatric disorder (Jacobson, Muehlenkamp, Miller, & Turner, 2008), a higher level of psychological stress (Brausch & Gutierrez, 2010), and biological markers such as serotonin system dysfunction (Sher & Stanley, 2009) have been suggested as possible third variables. 

 

Hamza, Stewart, & Willoughby (2012) integrate aspects of the previously discussed theories exploring the link between NSSI and suicidal behaviours. The Integrated Model states that NSSI may uniquely and directly predict suicidal behaviour in persons who are currently engaging in only NSSI behaviours but are also demonstrating greater levels of depression, hopelessness, and negative self-esteem.    

 

The level of intrapersonal distress felt by the individual moderates his or her relationship between NSSI and suicidal behaviour. Thus, persons who are experiencing greater psychological distress are at increased risk to engage in suicidal behaviours. The Integrated Model also views an indirect path from NSSI to suicidal behaviour, similar to descriptions in Joiner’s theory.    

 

This indirect link is moderated by acquired capability and suicidal desire. The severity of NSSI behaviours (cutting versus hair pulling) moderates the link between NSSI and acquired capability, with persons engaging in more severe forms of NSSI having a stronger link between the two and being more likely to engage in suicidal behaviour. The link between NSSI and suicidal behaviour is also moderated by suicidal desire. Suicidal desire will be higher in persons endorsing higher feelings of burdensomeness and social isolation.   

 

Viewed in this context, NSSI may represent a unique risk factor for suicide as it is strongly associated with emotional and interpersonal distress, which increases the risk for suicidal ideation and (or) desire, and desensitises people to the pain associated with SIBs, which increases the capability to act on the suicidal desire.   

 

NSSI presents a two-fold risk when it comes to suicide risk; it elevates suicidal ideation and the ability to act on the very ideation itself. NSSI tends to occur more frequently than suicidal behaviours. It is imperative to understand that the COVID-19 outbreak hence possesses a potential novel risk of an increase in behaviours related to NSSI.

 

Written By:

Khushi Boken

Jesus and Mary College, University of Delhi

Intern, Brain Behaviour Research Foundation of India 

 

REFERENCES:

Hornor, G. (2016, May/June). Nonsuicidal Self-Injury. Journal of Pediatric Health Care, Volume 30 Number 3.

https://www.jpedhc.org/article/S0891-5245(15)00227-8/pdf#:~:text=According%20to%20the%20DSM%2DV,intent%20within%20the%20past%20year

 

Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal self-injury: what we know, and what we need to know. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 59(11), 565–568.

 

Singh O. P. (2018). Nonsuicidal self-injury: Implications for research and management. Indian journal of psychiatry, 60(3), 259–260.