CC BY
3NON-SUICIDAL SELF- INJURIOUS BEHAVIOR IN
ADOLESCENTS (LITERATURE REVIEW)
Abdullaeva V.K.
Tashkent Pediatric Medical Institute https://doi. org/10.5281/zenodo. 10688733
Abstract. The article is devoted to the analysis of literary data on the main types andforms of self-harmful behavior, causes and mechanisms of occurrence, and differences from other forms of self-destructive behavior in adolescents. Non-suicidal self-harm behavior in adolescents is the result of the interaction of social, personal, and psychopathological factors. Non-suicidal self-injurious behavior may represent a relatively distinct behavioral pattern that exists outside the suicidal context, warranting further exploration of the relationship between suicidal and parasuicidal behavior.
Keywords: non-suicidal self-harm behavior, self-injurious behavior, adolescents
The World Health Organization considers childhood and adolescence to be one of the most important periods in the life of every person because it is at this stage that behavioral functions are formed that have a decisive impact on health status now and in the future [6]. During adolescence, major neurological and biological changes occur, relationships with the opposite sex develop, problems arise in learning and other activities, and independence in behavior arises. It is no coincidence that in recent years there has been a significant increase in attention to the issues of non-suicidal injuries [5, 24].
The phenomenological closeness of suicidal and self-harmful behavior is noted by many experts [1, 11]. Self-harm behavior is often associated with actions aimed at damaging one's own body but without suicidal intent. In addition, other specifics of self-harmful behavior go far beyond the scope of clinical practice and psychopathology, and define a complex range of psychological problems that reflect ontogenetic characteristics, cultural significance, and social selection of sanctioned methods and forms of self-harm [12, 13]. For modern researchers, self-injurious behavior is a group of behavioral phenomena, both clinical and preclinical levels, indicating probabilistic suicidal risk and psychological problems associated with emotional regulation and understanding of emotions, anxiety, hostility, and neuroticism.
Recently, we often have to deal with the problem of non-suicidal self-harm behavior in adolescents. Although this model of behavior was previously characteristic of adolescence, it raises serious concerns among both parents and specialists. Unfortunately, research related to this issue, explaining the essence and mechanisms of non-suicidal self-harm behavior, is extremely insufficient.
According to E.V. Zmanovskaya [4], deliberate self-harm or self-poisoning (self-harm behavior - intentional and conscious harm to oneself, self-injurious behavior) is becoming a common form of parasuicidal behavior among adolescents. The thesis is that self-harm behavior is a manifestation of a mental disorder, mainly borderline personality disorder [23, 41], as well as manifestations of depression, hyperkinetic disorder, schizophrenia, and autism spectrum disorders, eating behavior, as well as the causes of substance abuse [2, 3, 7, 9, 13, 22, 26, 34, 35, 36, 40, 43]. At the same time, this phenomenon in today's reality can be a follow of fashion trends, the manifestation of protest and demonstrative behavior [11, 19].
Non-suicidal self-harm (parasuicide, self-harm, suicidal gesture), as one of the types of auto-aggressive behavior, is now widespread among adolescents and young people. The definition of this phenomenon can be called deliberate, direct self-harm without fatal consequences, i.e. in the absence of suicidal intentions, the main goal of which is to reduce psychological discomfort. The most common are self-cuts, and to a lesser extent - blows, cauterization, scratching, etc. [38]. Currently, English-language literature uses the term self-injurious to define individuals who commit non-suicidal self-harm without having a real intention to commit suicide. According to B. Walsh [46], "self-injury is the intentional infliction of bodily harm on oneself, which has a low probability of death, is socially unacceptable in nature, and is carried out to reduce and/or cope with psychological distress." M. Nock [38] defines such actions as carried out deliberately, with a clear understanding of the physical or psychological consequences and damage of varying severity.
Among the variations of self-harmful non-suicidal behavior described in the scientific literature, the following forms are known: severe biting of nails and around the nail folds, lip biting; hair pulling, possibly in combination with trichophagia (hair eating); biting hands and other parts of the body (lips, tongue); scratching and/or scratching healthy areas of skin; scratching wounds, ulcers, stitches, birthmarks; self-cutting; self-burns; hitting limbs and/or head on objects and beating oneself; injections with improvised means; swallowing batteries, pins [16]. The expanded definition of self-harmful behavior given by V.D. Mendelevich includes harm to the body through eating disorders, excessive interest in tattoos and piercings, abuse of psychoactive substances and medications, various obsessive actions in the form of eating inedible products (paper, nail polishes, etc.) [10].
N.P. Pishchulin considers auto-aggression in the structure of a model of maladaptive behavior that arises as a result of frustration. He said that people who are unable to adapt to a changed social situation adequately use irrational ways of reacting: they become aggressive, stubbornly adhere to the usual (non-adaptive) way of action, and "give up," i.e. react auto aggressively [14].
The DSM-5 uses the following self-harm criteria:
A. During a year, a person intentionally inflicted injuries to a surface of the body for 5 or more days, followed by bleeding, bruising, or pain (hitting, self-cutting, cauterization, injections, etc.), expecting minor or moderate physical harm;
B. A person who self-injures expects one or more of the following consequences: 1) to reduce negative experiences or cognitive states; 2) eliminate intrapersonal difficulties; 3) get positive emotional changes;
C. Intentional self-injury is associated with at least one of the following: 1. Personal difficulties, negative feelings or thoughts (depression, anger, tension, anxiety, generalized distress, or self-criticism) immediately preceding the infliction of injury; 2. The frequency of thoughts about self-harm, even without committing it, increases; 3. Before damage occurs, a period of difficult-to-control anxiety occurs;
D. Behavior that goes beyond social approval (tattoos, piercings, religious or subcultural
ritual);
E. The outcome or consequences of the specified course of action result in clinically important distress or affect interpersonal, academic, or other important functioning;
F. The manifestation of the behavior does not consist solely of a psychotic state, delirium, intoxication, or withdrawal syndrome. In individuals with developmental disabilities, this behavior is not part of a pattern of repeated stereotypies. The behavior cannot be explained by another mental disorder or condition (psychosis, mental retardation, autism spectrum disorder, Lesch-Nychen syndrome, motor stereotypies with self-harm, trichotillomania, excoriation).
At the same time, we must not forget that some non-suicidal self-harm, especially in adolescence, can lead to death due to carelessness or incorrect "dose calculation". Also, suicide attempts and non-suicidal self-harm may overlap: people who consciously attempt suicide may engage in suicidal self-harm, and vice versa. Even a specialist with extensive practical experience often cannot correctly assess the presence of suicidal intentions, which is a serious barrier to the study of this problem.
A meta-analysis and systematic review of studies shows that non-suicidal self-injurious behavior arises from emotion dysregulation, regardless of age or gender [48].
Many authors consider the relationship between self-harm and eating disorders to be a serious problem in adolescents. There is an opinion about the comorbidity of these pathological phenomena, which often aggravate each other's manifestations [31]. They also promote the similarity of psychological functions motivating eating disorders and non-suicidal self-harm behavior, which explains the common mechanisms that reveal their frequent co-occurrence [37].
It is stated that even psychological assistance programs are often unable to overcome the tendency to self-harm and resistance to correction, which leads to manifestations outside the clinical environment where psychological interventions were implemented [47]. Also, experts note the contagiousness of self-harm, especially among adolescents. Observing another person's self-harm is a trigger for engaging in such behavior [20].
Many researchers consider rumination (repetitive thoughts) to be one of the significant factors predisposing to self-harm behavior. Rumination about negative events and experiences is defined by experts as a transdiagnostic process that underlies various forms of mental pathology [17]. Rumination and emotion-related impulsivity are significantly associated with suicidal ideation, suicide attempts, and non-suicidal self-harm [27, 29].
The greatest propensity for non-suicidal self-harm has been shown in adolescents with symptoms of depression, attention deficit hyperactivity disorder, and mood disorders [42]. It is noted that adolescents who seek help in a crisis are less prone to non-suicidal self-harm [21]. Peter Taylor showed that for 63-78% of people who committed non-suicidal self-harm, they acted as a short-term strategy for alleviating emotional distress, while this method of problem-solving provides short-term help, and in the long term only leads to a worsening of the situation [44].
Mood disorders and behavioral disorders aggravate the situation. Several researchers argue that depression in children and adolescents complicates the process of coping with difficult situations, having a significant impact on the ability to regulate emotions, which leads to the fact that children and adolescents focus exclusively on negative aspects of life. Researchers have found that depression, mood disorders, hyperkinetic disorder, and social behavior disorder are predictors of non-suicidal self-harm [15].
Self-harm behavior causes harm to the body and life of a teenager as a whole. This phenomenon may be a symptom of some mental illnesses, or it may be independent. In this regard, it is extremely important to understand and differentiate the conditions for the manifestation of self-harmful behavior. When diagnosing, it is necessary to differentiate non-suicidal self-harming
behavior and suicide attempts to avoid incorrect diagnosis and treatment tactics. In addition, one should take into account the various forms of manifestation of self-harm behavior and significant differences in the psychological characteristics of people with its manifestations.
A prospective study that lasted 2.5 years showed that dysfunctional relationships are significant risk factors for self-aggressive behavior [28]. The development of self-harm behavior is also influenced by communication with peers and friendships between teenagers, both positively and negatively. Emotionally unstable teenagers most often fall under the influence of friends. Emotionally unstable teenagers face peer pressure, loneliness, and conflicts with loved ones or significant others. According to the research results, it can be seen that the connection between problems with peers (quarrels, loneliness, etc.) and self-harm behavior is due to common underlying factors. At the same time, there is evidence that self-harm behavior may increase the risk of adolescents having difficulties in relationships with peers, in part due to increased symptoms of depression [25].
At the same time, social relationships with parents and peers are also important when assessing self-harm behavior, which is associated with problems in relationships with family members and peers [45]. Strict parental control, punishment, parental indifference, and weak attachment to them contribute to an increase in the likelihood of subsequent development of self-harm behavior in adolescence.
Experience of adverse events in childhood, such as parental neglect, abuse, or significant restrictions in childhood, increases the risk of auto-aggression. This finding is consistent with a meta-analysis showing that the experience of sexual abuse is not significantly associated with the development of non-suicidal self-injurious behavior [32]. Families of adolescents with self-harm behavior show high levels of hostility and criticism, indicating problems in receiving weak speech signals. If parents respond only to some stimuli and ignore others, a kind of selective reality is formed in the child's perception.
Parents may ignore affective and kinesthetic signals, reacting only to the child's experience of pain [8, 33]. Other work has shown that indirect childhood abuse is more associated with non-suicidal self-aggressive behavior than direct forms of abuse (physical or sexual abuse). Emotional abuse was not considered in this study. In addition, a strong connection with increased parental criticism or, conversely, indifference has been repeatedly shown [30].
Risk factors for self-harm behavior also include early and massive mastery of a high-tech arsenal of new cultural means and tools - increasingly personalized and mobile modern electronic devices, which determines the privacy and uncontrollability of their use. Content risks are various types of negative information that you can encounter on the Internet. This type of risk is quite widespread: more than half of teenagers encounter disturbing content online. You can encounter content risks almost everywhere: on social networks, blogs, torrent sites, personal sites, and video hosting sites [18].
From the first episode of self-harm, there is an increased risk of reoccurring self-harm behavior. Some factors increase the risk of non-suicidal auto-aggressive behavior at this age, including puberty, depression, and addictive disorders [39].
To summarize, we can say that every case of self-harm behavior is the result of the interaction of social, personal, and psychopathological factors. The study of various aspects of this phenomenon reveals a wide range of issues that require solutions with a reasonable analysis of its psychopathology. Non-suicidal self-injurious behavior may represent a relatively distinct
behavioral pattern that exists outside the suicidal context, warranting further exploration of the
relationship between suicidal and parasuicidal behavior.
REFERENCES
1. Babarahimova S.B., Abdullaeva V.K. Faktory riska razvitiya suicidal'nyh tendencij u detej i podrostkov. Biopsihosocial'naya psihiatriya: novye podhody i perspektivy razvitiya, 2023,
I (1), 19-23. (In Russ.).
2. Borohov A.D. Znachenie tatuirovok v diagnostike psihicheskih i povedencheskih rasstrojstv. Med.sestra. 2011; 7: 24-32. (In Russ.).
3. Bohan N.A., Evseev V.D., Mandel' A.I., Peshkovskaya A.G. Obzor issledovanij nesuicidal'nyh form samopovrezhdenij po shkalam i oprosnikam nSSI. Suicidologiya. 2020;
II (1): 70-83. (In Russ.).
4. Zmanovskaya, E.V. Deviantologiya: Psihologiya otklonyayushchegosya povedeniya. 3-e izd., ispr. i dop. / E.V. Zmanovskaya. - M.: NORMA-INFRA, 2015. - 402 s. (In Russ.).
5. Igumnov S.A., Gelda A.P., Gutkevich E.V., Schastnyj E.D. Mediko-social'nye aspekty suicidal'nogo povedeniya podrostkov i molodezhi / Pod nauchnoj red. N.A.Bohana. M., Minsk, Tomsk: Otdel poligrafii Tomskogo Centra nauchno-tekhnicheskoj informacii, 2020: 178. (In Russ.).
6. Investiruya v budushchee detej: Evropejskaya strategiya ohrany zdorov'ya detej i podrostkov, 2015-2020 gg. Kopengagen: Evropejskoe regional'noe byuro VOZ, 2014
http://www.euro.who.int/ data/assets/pdf file/0003/253776/64wd_12 Rus
InvestCAHstrategy 140440.pdf (In Russ.).
7. Krylova E.S., Beburishvili A.A., Kaleda V.G. nesuicidal'nye samopovrezhdeniya pri rasstrojstve lichnosti v yunosheskom vozraste i ocenka ih vzaimosvyazi s suicidal'nym povedeniem. Suicidologiya. 2019; 1 (34): 48-57. (In Russ.).
8. Lyubov E.B., Zotov P.B. Nesuicidal'nye samopovrezhdeniya podrostkov: obshchee i osobennoe. Chast' I. Suicidologiya. 2020; 11 (3): 44-71. doi.org/10.32878/suiciderus.20-11-03(40)- 44-71. (In Russ.).
9. Makarova O.S., Pyrkova K.V., Krasil'nikov A.M., Nasibullina R.R. obraz tela i osobennosti sovladayushchego povedeniya u podrostkov s samopovrezhdayushchim povedeniem (klinicheskie sluchai). Nevrologich. vestn. 2020; 1: 92-96. (In Russ.).
10. Mendelevich, V.D. Psihologiya deviantnogo povedeniya: Uchebnoe posobie. / V.D. Mendelevich. - M.: YuNITI-DANA, 2015. - 445 s. (In Russ.).
11. Mendelevich V.D., Medvedeva T.I., Bojko O.M., Voroncova O.Yu. i dr. Smysly samopovrezhdayushchego povedeniya: rezul'taty internet-issledovaniya. Nevrologich. vestn. 2020; 1: 19-21. (In Russ.).
12. Muhtorov B.O., Babarahimova S.B., Abdullaeva V.K., Sulejmanov Sh.R., Sharipova F.K. Vliyanie stilej roditel'skogo vospitaniya na formirovanie nesuicidal'nogo samopovrezhdayushchego povedeniya u podrostkov. Zhurnal Voprosy psihicheskogo zdorov'ya detej i podrostkov, 2023 (23). № 1, s. 80-85. (In Russ.).
13. Nesuicidal'noe samopovrezhdayushchee povedenie v obshchemedicinskoj praktike. metodicheskie rekomendacii. Pod red. A.S.Avedisovoj. M.: GBUz PNC im. Solov'yova dzm. 2019; 24 s. (In Russ.).
14. Pishchulin N.P., Ogorodnikov Yu.A.. Filosofiya obrazovaniya. A.O.»Moskovskie uchebniki». M.2003. (In Russ.).
15. Pol'skaya N.A. Psihologiya samopovrezhdayushchego povedeniya. - M.: Lenand; 2017 (In Russ.).
16. Rajnfrid, H-V. Klinicheskaya psihologiya / H-V. Rajnfrid. (In Russ.).
17. Sirota N.A., Moskovchenko D.V., Yaltonskij V.M., Makarova I.A., Yaltonskaya A.V. Kognitivnaya terapiya depressivnyh ruminacij. Zhurnal nevrologii i psihiatrii im. S.S.Korsakova. Specvypuski. 2019;119(1-2):62-68. (In Russ.).
18. Soldatova G. U., Chigar'kova S. V., Drenyova A. A., Ilyuhina S. N. My v otvete za cifrovoj mir: Profilaktika destruktivnogo povedeniya podrostkov i molodezhi v Internete: Uchebno-metodicheskoe posobie. - M.: Kogito-Centr, 2019. - 176 s. (In Russ.).
19. Fadeeva T.E. Telesnost' v paradigme transgumanizma i postfordizma. Artikul't. 2019; 2 (34): 6-17. (In Russ.).
20. Arendt F., Scherr S., Romer D. Effects of exposure to selfharm on social media: Evidence from a two-wave panel study among young adults. New Media & Society. 2019;21(1112):2422-2442.
21. Baiden P., Stewart S.L., Fallon B. The role of adverse childhood experiences as determinants of non-suicidal self-injury among children and adolescents referred to community and inpatient mental health settings // Child Abuse & Neglect. -2017. - V.69. - P.163-176.
22. Bui T., Rodgers R., Cailhol L. et al. Body piercing and psychopathology: A review of the literature. Psychother. Psychosom. 2010; 79: 125-129. doI: 10.1159/000276376.
23. Colle L., Hilviu D., Rossi R. et al. Self-harming and sense of agency in patients with borderline personality disorder. Front. Psychiatry. 2020; 11: 449. doI: 10.3389/fpsyt.2020.00449.
24. Dar'in E.V. Non-suicidal self-injurious behavior in adolescents // Medicinskij vestnik Yuga Rossii. 2019; 10 (4): 6-14.
25. De Luca L., Giletta M., Menesini E., Prinstein M.J. Reciprocal associations between peer problems and non-suicidal selfinjury throughout adolescence. J Child Psychol Psychiatry. 2022;63(12):1486-1495.
26. Ekinci O., Topcuoglu V., Sabuncuoglu O. et al. The association of tattooing/body piercing and psychopathology in adolescents: A community based study from Istanbul. Community Mental Health J. 2012; 48 (6): 798-803.
27. Frey L.M., Higgins G.E., Fulginiti A. Testing the psychometric properties of the self-harm and suicide disclosure scale. Psychiatry Res. 2018; 270:134-142.
28. Hankin B.L., Abela J.R. Nonsuicidal self-injury in adolescence: prospective rates and risk factors in a 2/ year longitudinal study. Psychiatry Res. 2011;186(1):65-70.
29. Johnson S.L., Robison M., Anvar S., Swerdlow B.A., Timpano K.R. Emotion-related impulsivity and rumination: Unique and conjoint effects on suicidal ideation, suicide attempts, and nonsuicidal self-injury across two samples. Suicide Life Threat Behav. 2022;52(4):642-654.
30. Kaess M, Parzer P, Mattern M, Plener PL, Bifulco A, et al. Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth. Psychiatry Res. 2013;206 (2-3):265-72.
31. Kiekens G, Claes L. Non-Suicidal Self-Injury and Eating Disordered Behaviors: An Update on What We Do and Do Not Know. Curr Psychiatry Rep. 2020;22(12):68.
32. Klonsky E.D., Moyer A. Childhood sexual abuse and non-suicidal self-injury: metaanalysis. Br J Psychiatry. 2008;192(3):166-70.
33. Krueger D.W. Integrating body self and psychological self: Creating a New Story in Psychoanalysis and Psychotherapy. NY: Psychology Press, 2002.
34. McKay D., Andover M. Should non-suicidal selfinjury be a putative obsessive-compulsive related condition? A critical appraisal. Behav. Modif. 2012; 36 (1): 3-17.
35. Mork R., Mehlum L., Barrett T.A. et al. Self-harm in patients with schizophrenia spectrum disorders. Arch. Suicide Res. 2012; 16 (2): 111-123.
36. Moseley R.L., Gregory N.J., Smith P. Links between selfinjury and suicidality in autism. Mol. Autism. 2020; 11: 1-14. dol: 10.1186/s13229-020-0319-8.
37. Muehlenkamp J.J., Takakuni S., Brausch A.M, Peyerl N. Behavioral functions underlying NSSI and eating disorder behaviors. J Clin Psychol. 2019;75(7):1219-1232.
38. Nock M.K. Self-Injury. Annu Rev Clin Psychol. 2010; 6: 339-363.
39. Patton G.C., Hemphill S.A., Beyers J.M., Bond L., Toumbourou J.W., et al. Pubertal stage and deliberate self-harm in adolescents. // Journal of the American Academy of Child and Adolescent Psychiatry. - 2007. - V.46(4). - P.508-514.
40. Perrin A.J. Body modification and personality: Intimately intertwined? Am. J. Psychiatry Residents' J. 2017; 8: 6-8.
41. Reichl C., Kaess M. Self-harm in the context of borderline personality disorder. Curr. Opinion in Psychology. 2021; 37: 139-144.
42. Serra M., Presicci A., Quaranta L., Caputo E., Achille M. et al. Assessing Clinical Features of Adolescents Suffering from Depression Who Engage in Non-Suicidal Self-Injury. Children (Basel). 2022;9 (2):201
43. Simioni A.R., Pan P.M., Gadelha A., Manfro G.A., Mari J.J., Miguel E.C., Rohde L.A., Salum G.A. Prevalence, clinical correlates and maternal psychopathology of deliberate self-harm in children and early adolescents: results from a large community study. Brazilian Journal of Psychiatry. 2018; 40 (1): 48-55.
44. Taylor P.J., Jomar K., Dhingra K., Forrester R., Shahmalak U., Dickson J.M. A metaanalysis of the prevalence of different functions of non-suicidal self-injury. // Journal of Affective Disorders. - 2018. - V.227. - P.759-769.
45. Victor S.E., Hipwell A.E., Stepp S.D., Scott L.N. Parent and peer relationships as longitudinal predictors of adolescent nonsuicidal self-injury onset. Child Adolesc Psychiatry Ment Health. 2019;13:1.
46. Walsh B. Treating self-injury. 2ns ed. New York: Guilford Press; 2012.
47. Witt K.G, Hetrick S.E., Rajaram G., Hazell P., Taylor Salisbury T.L., et al. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev. 2021;4(4):CD013668
48. Wolff J.C, Thompson E., Thomas S.A., Nesi J., Bettis AH, et al. Emotion dysregulation and non-suicidal self-injury: A systematic review and meta-analysis. Eur Psychiatry. 2019;59:25-36.
