Academic journal article Journal of Cognitive Psychotherapy

Co-Occurring Disorders in the Treatment of Nonsuicidal Self-Injury: An Evidence-Informed Approach

Academic journal article Journal of Cognitive Psychotherapy

Co-Occurring Disorders in the Treatment of Nonsuicidal Self-Injury: An Evidence-Informed Approach

Article excerpt

Co-occurring disorders are common among patients who present for treatment with nonsuicidal self-injury (NSSI). Evidence-based approaches specifically designed for the treatment of NSSI are limited, although interest in this area of research is growing. An evidence-informed model for the treatment of NSSI and co-occurring disorders is presented here to stimulate interest in addressing co-occurring disorders in the treatment of NSSI. Case examples are presented to highlight the complexity of treating NSSI and co-occurring disorders and to illustrate a model of treatment at the acute level of care. The case examples also underscore the need for clinical researchers to address co-occurring disorders when developing treatments specifically for NSSI.

Keywords: nonsuicidal self-injury; co-occurring disorders; treatment; self-regulation

Nonsuicidal self-injury (NSSI) is the deliberate, self-inflicted damage of body tissue that induces bleeding, bruising, or pain but is absent of evidence for suicidal intent (Nock & Favazza, 2009). NSSI does not include activities engaged in solely for socially sanctioned purposes (e.g., body art) or common or trivial behaviors (e.g., nail-biting). Although estimates of the lifetime prevalence of NSSI vary by study, most studies report a rate of 13% to 23% for adolescents and young adults in the community and between 2% and 8% for adults and older adults (Jacobson & Gould, 2007; Rodham & Hawton, 2009). The prevalence rate of NSSI among clinical populations is even more varied, with rates reported between 12% and 82% (Heath, Schuab, & Nixon, 2009; Klonsky & Muehlenkamp, 2007).

NSSI aNd Co-°CCurrINg dISorderS

An individual with NSSI who presents for treatment is likely to also present with additional mental and substance use disorders (Lofthouse, Muehlenkamp, & Adler, 2009). Although the number of studies that have examined the prevalence rates of co-occurring mental and substance use disorders among those with NSSI is limited, some tentative conclusions can be reached. Available evidence indicates that NSSI most commonly co-occurs with depressive disorders, suicidality, and borderline personality disorder (BPD; Andover, Pepper, Ryabchenko, Orrico, & Gibb, 2005; Hawton, Rodham, Evans, & Weatherall, 2002; Jacobson & Gould, 2007; Klonsky, Oltmanns, & Turkheimer, 2003; Lofthouse et al., 2009; Rodham & Hawton, 2009). For example, one study of adolescent inpatients with NSSI found that 41.6% had a major depressive disorder, 51.7% of the females had BPD, and 70.0% of the overall sample engaged in at least one suicide attempt (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). A study of adolescent outpatients with NSSI found that 46% had major depressive disorder, 28% had dysthymia, and 27% had "features" of BPD, although rates of major depressive disorder (77%) and features of BPD (44%) were higher among those with NSSI who had also made a suicide attempt (Jacobson, Muehlenkamp, Miller, & Turner, 2008).

The co-occurrence of NSSI with disorders that cause significant emotional stress is not surprising. For many patients, NSSI is a purposeful attempt to regulate depression or suicidal thoughts and behaviors or the affective dysregulation and distress associated with BPD (Nixon, Cloutier, & Aggarwal, 2002). Indeed, affective regulation is the most commonly endorsed reason for engaging in NSSI; for some patients, NSSI is a way to avoid suicidal behavior (Klonsky, 2007).

The co-occurrence of NSSI is not limited to those who present with depression, suicidality, or BPD. NSSI has also been found to co-occur with other mental and substance use disorders, most commonly with anxiety disorders, eating disorders [EDs], and substance use disorders (Claes, Klonsky, Muehlenkamp, Kuppens, & Vandereycken, 2010; Jacobson & Gould, 2007; Lofthouse et al., 2009; Sansone & Levitt, 2002). Among anxiety disorders, generalized anxiety disorder and posttraumatic stress disorder (PTSD) most frequently co-occur with NSSI (Crowell et al. …

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