There is no universal definition for non-suicidal self-injury (NSSI). In 2013, the DSM-5, a publication used in classification and diagnostic of mental disorders, included non-suicidal self-injury for the first time, but only among the conditions for further study. As criteria to meet the diagnosis, it proposed that an individual must self-injure without suicide intent nor psychosis at least 5 days in a year, and would do so to gain relief from distress, or to induce a positive feeling1. However, while the DSM remains a reference for many psychiatrists, it is also heavily questioned and criticized for its subjectivity in classifying behaviors, some not being considered disorders by other professionals.
It is regrettable the DSM-5 took so long to consider NSSI. Fortunately, research about the behavior did not wait for the DSM to classify it, and many health professionals and academics defined it in very pertinent ways. A definition I personally appreciate is that of Trybou, Brossard and Kédia, who define non-suicidal self-injury as “a self-aggressive, intentional and repetitive activity, performed without deliberate suicidal, aesthetic or sexual wish, and that is in no way socially accepted”2.
Categorizing self-harm
Self-harm is a broad term that encompasses both suicide and self-injury or self-poisoning. But types of self-harm vary depending on the population and setting. Self-harm observed at hospital is predominantly self-poisoning, whereas in community setting cutting is the most common form3. This calls for a need to categorize types of self-harm, which can be done according to several criteria. The presence or absence of suicide intent, for instance can lead to distinction between suicidal behaviors and non-suicidal self-injury4. Studies from the United Kingdom tend to avoid determining the intent behind an act of self-harm3 whereas in the United States, there is a clear distinction between non-suicidal self-injury and suicide attempt5.
Self-harm has also been classified depending on the severity or frequency of injury4 and I feel the frequency of injury is too often neglected. Many studies include in their sample individuals who self-injured only once or twice in their life, and while their experience should not be minimized, we may question whether they fit the category of NSSI. As flawed as the DSM-5 is, it suggests repetition is a key criterion in NSSI, which several health professionals and academics agree on.
Naming
A great diversity of terms have been used across time and place to refer to self-harm and its different categories. Naming of forms of self-harm changed over time to fit the evolution of our understanding of the behavior. Some terms became archaic and are no longer used, such as self-mutilation or delicate self-cutting. Please refer to the table below for more information.
| Cutting | Specific method of NSSI, although sometimes used informally to refer to any form of NSSI |
| Deliberate self-harm | Similar to the UK meaning of self-harm, although tend not to be used anymore due to the potentially stigmatizing and blaming connotation of the term “deliberate”5 |
| Delicate self-cutting | Archaic term used in the 1960s to refer to female NSSI. Note the stigmatizing use of the term “delicate” which renders the behavior less violent and aggressive, and therefore perpetuates gender stereotypes3 |
| Focal-suicide | An archaic term which psychiatric Karl Menninger defined in 1938 as “localized self-destruction”, a form of suicide committed on a part of the body in order not to commit total suicide. It includes self-mutilation, malingering, addiction to surgical operations, some unconsciously purposive accidents and sexual impotence6 |
| Non-suicidal self-injury (NSSI) | One of the current terms to refer to the repetitive self-infliction of injury, in order to induce a positive state or reduce negative feelings, in a way that is neither socially sanctioned nor motivated by sexual nor aesthetic reasons1, 2 |
| Parasuicide | A form of self-harm that appears to be a suicide attempt but which was actually committed without the intent to commit suicide7 |
| Self-harm | UK meaning: Self-poisoning or self-injury irrespective of the motive, which therefore includes both NSSI and suicidal behaviors US meaning: commonly used to refer to NSSI5 |
| Self-mutilation | Archaic term to refer to self-injury |
The problem with poor classification and naming
Many studies do not define self-harm, and do not explicitly state which form they study3. Unfortunately, as we have seen, the meaning of self-harm varies, and can refer to NSSI, self-poisoning and / or suicidal behaviors. Without these key elements, it is not possible to understand to which behavior findings apply.
Gathering all forms of self-harm under one category can be useful when a patient’s intentions cannot be easily determined, as when dealing with statistics only. But dividing NSSI from suicidal self-harm allows for better research and understanding of each behavior. Each classification has advantages and disadvantages, but no matter the researcher’s choice, it should be clear which type of self-harm is written about.
Conclusion
As we have seen, self-harm is an umbrella term which can refer to a diversity of behaviors. Moreover, its meaning differs in the US and UK. Terminology to discuss self-harm has also changed over time, as our understanding evolved. Nowadays, mental health advocates call for a discussion about our use of language in order to avoid perpetuating stigma and stereotypes and adopt a more compassionate perspective.
Edit: For a more in-depth discussion about how self-harm should be defined, I recommend this episode from the podcast “The Psychology of Self-Injury”.
References
[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association.
[2] Trybou, V., Brossard, B., & Kédia, M. (2018). Automutilations: comprendre et soigner. Odile Jacob.
[3] Chandler, A., & Simopoulou, Z. (2021). The Violence of the Cut: Gendering Self-Harm. International Journal of Environmental Research and Public Health, 18(9). https://doi.org/10.3390%2Fijerph18094650
[4] Angelotta, C. (2015). Defining and refining self-harm: a historical perspective on nonsuicidal self-injury. The Journal of Nervous and Mental Disease, 203(2), 75-80. https://doi.org/10.1097/nmd.0000000000000243
[5] Wilson, E., & Ougrin, D. (2021). Commentary: Defining self-harm: how inconsistencies in language persist – a commentary/reflection on Ward and Curran (2021). Child and Adolescent Mental Health, 26(4), 372-374. https://doi.org/10.1111/camh.12502
[6] Menninger, K. (1938). Man Against Himself. Harvest Book.
[7] Parasuicide (Concept Id: C0595861). (n.d.). NCBI. Retrieved December 26, 2023, from https://www.ncbi.nlm.nih.gov/medgen/108886
Exploring self-harm 