The NSSI criteria were finally placed in section 3 of DSM-5, Emerging Measures and Models as a condition that requires further study due to lack of reliability in the clinical trial. Two of the child adolescent sites had inadequate sample sizes which were insufficient to obtain accurate estimates of kappa. The third field trial was successful, but the test-retest reliability was unacceptable. American Psychiatric Association, Washington, D.C.

Criteria A through F.

Criteria A. Engagement in NSSI on five or more days in the past year.

Criteria B, the expectation that NSSI will solve an interpersonal problem, provide relief from unpleasant thoughts and or emotions, or induce a positive emotional state.

Criteria C, the experience of one or more of the following. ( a. )  interpersonal problems immediately prior to NSSI. ( b. ), preoccupation with NSSI that is difficult to manage or ( c. ) frequent thoughts about NSSI.

Criteria D, the NSSI is not socially sanctioned or restricted to minor self-interest behaviors.

Criteria E, the presence of NSSI related clinically significant distress or interference across different domains of functioning, ( e.g. work relationships. )

Criteria F. The NSSI does not occur only in the context of psychosis, delirium, or substance use, withdrawal, and is not better accounted for by another psychiatric disorder or medical condition

Divorce and loss within the family have been found to be antecedents of NSSI ( Nixon and Heath, 2009 ). Self-injury in youth. The essential guide to assessment and intervention ( Suyemoto, 1998 ). The Function of Self-Mutilation.

The potential etiologic factors of NSSI may be divided into two major categories. ( e.g. emotional dysregulation, psychiatric disorders ) , and environmental, ( e.g. childhood maltreatments, attachment disruption ). Most research focused on early childhood traumatic experiences found that childhood maltreatments emerged as a predictor of NSSI within adolescents and college students ( Paivio and McCulloch, 2004; Grantz, 2006;  Arens et al., 2012;  Auerbach et al., 2014; Wan et al., 2015 ).

Cipriano et al., ( 2017 ), referred to emotional dysregulation as another factor in NSSI behavior. Examining individual factors, results reported that NSSI frequently was strongly predicted by emotion dysregulation. ( Tao, Bi, and Deng, 2020 ), stated, “ when the individuals lack the ability to manage their negative emotions effectively, they try to relieve  the emotion through self-injury. “ ( Yurkowski et al., 2015  ) cites Linehan’s  widely accepted biosocial theory, ( 1993 ) for the development of NSSI, which proposes that invalidating relationships with parents, in which the individual’s emotions are negated or ignored, contribute to deficits in emotional regulating capacities — which in turn increase the likelihood of engaging in NSSI behaviour to cope with distress.

Many studies have found that “ adverse parent-child attachment will lead children into self-injuring behaviour. “ ( Gromatsky et al., 2017 ). The role of parental psychopathology and personality in adolescent non-suicidal self-injury ( Martin et al., 2016 ). Family-based risk factors for non-suicidal self-injury, considering influences of maltreatment, adverse family, life experience, and parent-child relationship, relational risk.

Emotion regulation ( ER ) deficits arise from biological anomalies combined with exposure to dysfunctional environments ( i.e., invalidating relationships with parents throughout development ). The invalidating environments component of Linehan’s Biosocial Theory is a particular focus for the current manuscript. Invalidating family environments are characterized by the parents’ unpredictable and insensitive responses to the offspring’s emotional expressions. Such environments may feature parent-child relationships in which there is limited trust within the parent-child dyad, where communication is disrupted and where the child ultimately becomes alienated from the parent ( C. Martin et al., 2011 ). Within such environments, individuals’ experiences of distressing emotions are overlooked by the parent and the individual’s understanding of his or her own behavior is disregarded. Family environments in which feelings are discredited, invalidated, or rejected fail to provide the child with the ability to appropriately manage their emotions, particularly negative emotions, using socially appropriate coping behavior. Consequently, as adolescents or young adults, these individuals may be at increased likelihood for engaging in NSSI in order to cope with their emotional limitations ( Bureau, JF, Cloutier, PF, LaFontaine, MF, 2011 ). A comparison of parent-child relational dimensions between university students engaging in self-injurious thoughts and actions and non-self-injuring university students,

Research also has indicated that overall poor quality of parent-child relationships, especially parental relationships characterized by lack of trust, poor communication, and feeling alienated from parents are linked with NSSI behaviors during adolescence. ( Hilt et al. 2010 ). Of note, a feeling of alienation was the sole significant predictor of NSSI action after accounting for shared variants of other parent-child relationship variables, ( Bureau et al. 2010 ), and was related to higher frequency of NSSI actions in a male subset of self-injurers ( Yates et al. 2008 ). Thus, alienation is perhaps a better indicator of invalidating family environments than either lack of trust or poor communications ( Bureau J.F., Martin, J., Freynet., N. Poirier, A.A., LaFontaine, M.F., and Cloutier, P. 2010 ). Perceived dimensions of parenting and non-suicidal self-injury in young adults.

Careless, non-protective and invalidating caregiving relationships have been shown to be associated with the occurance, frequency and severity of NSSI among adolescents ( Baetens et al., 2014 ) Is non-suicidal self-injury associated with parents and family factors.

Recent studies have demonstrated that poor quality parent-child attachment can increase the incidence of self-injury behavior ( Honglei et al., 2018 ). Interpersonal or systematic models have also pointed out that self-injury is the result of family dysfunction and that family environment of certain individuals will unconsciously support or strengthen their self-injury behavior ( Crouch & Wright, 2004 ).

Recent studies suggest that the quantity of negative life events events is significantly related to NSSI ( Baetens, I, et al., 2011 ). Non-suicidal and suicidal self-interest behaviour among Flemish adolescents, a web survey ( Horesh, et al., 2009 ), A comparison of life events in suicidal and non-suicidal adolescents and young adults with  major depression and BPD.

Two main theories used to explain self-injury behavior are the interpersonal or systematic models as well as the emotion regulation model ( Yulong et al.,  2016 ). Interpersonal or systemic models emphasize the impact of the family environment on self-injury behaviour, demonstrating the influence of the family system on adolescent problematic behavior, especially from the perspective of parent-child relationships ( Crouch and Wright, 2004 ). By contrast, the emotion regulation model shows that individual self-injury behavior is a behavioral strategy to deal with negative emotions or reduce pain self-injury behavior is a behavioral strategy to deal with negative emotions or reduce pain from the angle of emotional management ( Messer and Fremouw, 2008 ). However, these two models do not explore the negative emotions caused by parent-child relationship in the family system, so they fail to fully reveal the effect of parent-child attachment on negative emotions, emotional coping style, and self-injury behaviour.

Parental alienation, ( defined as perceived parental criticism ), was found to be associated with an increased probability of engaging in NSSI ( Weihau W. 2016 ).

The relationship between Parent child attachment and self-injuring behavior of stay-

at-home children: The role of social self-efficacy and emotional regulation.

Most of the scientific literature analyzing the problem of self-harm identifies self-injury with physical wounds and body tissue damage. Cutting, burning, hitting, tearing out hair or other ways of causing physical pain to oneself are the most frequent and most visible examples of auto-mutilation and represent the paradigm of self-harm. However, all these forms of somatic self-harm have their own mental causes.

Although a serious discussion exists in the specialist literature concerning the very existence and nature of mental pain ( e.g. Biro, 2010 ), As shown in a study, ( Coghill, McHaffie, Yen, 2003 ), highly sensitive individuals exhibited more frequent and more robust pain-induced activation of the primary somatosensory cortex, the anterior cingulate cortex, and prefrontal cortex than insensitive individuals.

Indirect forms of self-injury refer to behaviors in which people harm themselves in an indirect way, ( e.g. substance use ). Existing literature suggests that a negative parent-child relationship may increase vulnerability to NSSI and indirect forms of self-injury. NSSI behaviours commonly confirmed by research include: cutting, burning, scratching and self-hitting ( Briere and Gill, 1998; Laye and Gindhu; Schoenert, Reichel, 2005; Whitlock et al., 2006, Klonsky and Muehlenkamp, 2007 ).and most self-injurers report using multiple methods ( Farazza and Contario; 1988, Favazza, 1992 ).

The common ways of NSSI include self-cutting or slashing, self-burning, self-battery, scratching, biting, wound interference, and head banging ( Swammell et al., 2014 ). In a multinational study, the lifetime NSSI rate was 18 percent ( Zetterqvist et al., 2020 ). NSSI is commonly seen in adolescents. In community samples of adolescents, the lifetime self-injury rate is 13 – 45 percent ( Brunner, et al., 2014; Jacobson and Gould, 2007; Nock, 2010 ). While in psychiatric samples of child and adolescents, the rate is as high as 50 percent ( Plenner, et al., 2015 ). In China, two newly published studies reported that 33.7 – 51% of the community adolescents had NSSI. ( Hu et al., 2020a, 2020b. )

There is also evidence that the rate of NSSI in adolescents is still rising ( Muchlenkamp et al. 2012 ). Many studies have shown that NSSI is a strong predictor of later completed suicide ( Asarnow et al. 2011; Bryan et al. 2014; Cox et al. 2012; Goldstein et al. 2012; Whitlock et al. 2013 ).

Additional research has identified more symptoms of NSSI that include biting, wound interference, and head banging ( Swannell et al., 2014 ).

Recent studies have shown mother’s overprotection is related to children’s unhealthy self-conscious emotions, which has been associated with the presence of NSSI and frequent NSSI ( Spitzen et al., 2020; Liu Y. et al., 2020 ). Association between parenting and non-suicidal self-injury among adolescents in Yunnan, China, a cross-sectional survey.

Exploring the association between NSSI and psychiatric diagnoses, several researchers have reported self-injuring behavior in a wide range of other disorders such as PTSD, dissociative disorder,, OCD, intermittent explosive disorder, anxiety and mood disorder and dissociative identity disorder ( Briere and Gill, 1998; Nock, et al 2006; Claes et al, 2007; Selby-et al., 2012; Glenn and Klonsky, 2013; In-Albon et al 2013;  Gratz et al., 2015, Jenkins et al. 2015; and Turner et al. 2015 ).

Researchers found that an NSSID diagnosis was associated with higher levels of emotion dysregulation, identity disturbance, genetic severity of depression, anxiety and stress symptoms, and higher rates of PTSD ( Turner, B.J., Layden, B.K., Butler, S.M., and Chapman, A.I., 2013 ). How often or how many ways: clarifying the relationship between non-suicidal self-injury and suicidality.

Researchers found that an NSSID diagnosis was associated with higher levels of emotion dysregulation, identity disturbance, genetic severity of depression, anxiety and stress symptoms, and higher rates of PTSD ( Turner, B.J., Layden, B.K., Butler, S.M., and Chapman, A.I., 2013 ). How often or how many ways: clarifying the relationship between non-suicidal self-injury and suicidality.

Several studies have assessed NSSI-D criteria indirectly with instruments not originally developed for this purpose. The CANDI, and the self-report measure The AlexIan Brothers Assessment of Self-Injury, ABASI, were designed to assess and identify NSSID. The candy showed good inter-rater reliability. The overall diagnostic agreement was 92%. There was a 100% agreement for criteria A, B, C, D, and F and 92% for criterion E. Furthermore, internal consistency was adequate and there was support for construct validity ( Gratz KL, Dixon-Gordon, K.L. Chapman, A.L. Tull, M.T. 2015 ). Diagnosis and characterization of DSM-5 non-suicidal self-injury disorder using the clinician-administered administered non-suicidal self-injury disorder index assessment. administered non-suicidal self-injury disorder index assessment.

Results of the present study provide support for the reliability, validity, and feasibility of the CANDI as a structured diagnostic interview for NSSID. Despite receiving limited training, paraprofessionals were able to reliably administer the CANDI with excellent diagnostic agreement across independent raters. Given that the poor reliability of NSSID in the DSM-5 field trials was one of the primary reasons NSSID was relegated to Section 3 of the DSM-5, ( Rieger et al. 2013) , findings that the CANDI has such high interrater reliability are particularly promising and provide further support for the utility of this diagnostic interview. Likewise, evidence that the CANDI can be reliably administered in approximately 15 to 20 minutes suggests that this measure may be feasible to administer in a variety of clinical and research settings Although the use of valid and reliable structured diagnostic interviews in clinical practice is imperative for both assessment and treatment planning, these benefits must be balanced with the costs of administering such measures. Given the heavy caseloads and limited time and resources of community clinicians, structured diagnostic interviews are unlikely to be used unless they are relatively brief and can be easily incorporated into an initial intake assessment. Results of this study suggest that the CANDI may be one such measure.

Findings also provide support for the construct validity of the CANDI as a diagnosis of NSSID on this interview was associated with greater clinical and diagnostic severity on a number of relevant measures as well as greater NSSI versatility considered a marker of more severe NSSI ( Turner et al., 2013 ). The results of this study also provide further information on and support for the NSSID diagnosis. Even with a rigorous comparison group of recent recurrent self-injurers, the presence of an NSSID diagnosis was associated with higher levels of emotion dysregulation and borderline personality disorder pathology, overall and across the specific domains of affective instability, identity disturbance and self-harm, greater severity of depression, anxiety and stress symptoms and higher rates of borderline personality disorder, bipolar disorder, post-traumatic  stress disorder, social anxiety disorder and alcohol dependence ( Rieger.

DA, Narrow WF, Clark DE, Kraemer HC, Kuramoto SJ, Kull EH, Kupfer DJ. ) DSM-5 field trials in the United States and Canada, Part 2, Test-Retest Reliability of Selected Category reliability of selected category diagnosis. American Journal of Psychiatry.

International research has reported an average age of onset of NSSI between 12 and 14 years, ( Heath, Toaste, Nedecheva and Charliebois, 2008 ), with a peak in prevalence from age 15 onwards ( Martin, Swanell, Hazel, Harrison and Taylor, 2010 ).

Research continues to show the age of onset for NSSI is between 12 and 14 years. ( Nock, et al., 2006 ). Non-suicidal self-injury among adolescents. Diagnostic correlates in relation to suicide attempt ( Mullenkamp and Gutierrez, 2007 ). Risks of suicide attempts among adolescents who engage in non-suicidal self-injury — but findings have also reported NSSI behavior in children under the age of 12. Rates of non-suicidal self-injury in youth, age, sex, and behavioral methods in a community sample.

Research has found empirical evidence that parent-child relationships can induce negative emotion, which will further trigger the occurrence of self-injury, both being consistent with the previous studies ( Klonsky et al. 2003; Feng, Y. 2008 ). When the individuals lack the ability to manage their negative emotion effectively, they try to relieve the emotion through self-injury

One study showed that pre-adolescents who report NSSI perceive their parents behaviour as more psychologically and behaviourally controlling. These results are consistent with previous research ( Bureau e al 2010 ). Perceived dimensions of

parenting and NSSI in young adults.

NSSID research has found tissue damage is a visual demonstration of extreme emotional distress and the physical act of mutilation seems to reconcile this emotion. A release of endorphins after the physical damage contributes to a feeling as relief and an addictive maladaptive coping cycle of pain, relief, shame and self-hate. ( Hicks, Hinck, 2008 ). Concept Analysis of Self-Mutilation.

Research has found that social distress, in particular the feeling of isolation or the feeling of being victimized, is also a common reason for NSSI. ( Hilt et al., 2008 ).When an adolescent is experiencing emotional distress, the affective processing of physical pain may be inadvertently activated in order to motivate the individual to seek social support and attachment.

Insecure paternal attachment and both maternal and paternal emotional neglect were significant predictors of NSSI with women. NSSI in men was primarily predicted by childhood separation, usually from father ( Gratz et al., 2002 ), Risk factors for deliberate self-harm among college students. Research in self-control has found poverty to be a factor in self-control failure. Overlapping research has also found a correlation between poverty and NSSI behavior. ( Bureau et al. 2010 ). Perceived dimensions of parenting and non-suicidal self-injuring and pain processing mechanisms.

What is the reason that we can transfer the emotional pain to physical pain? Many different neuroscientific studies show that when it comes to sensing physical and emotional pain, our brains use the same two areas, the anterior insula, a small patch of neural real estate that’s part of the cerebral cortex behind each ear, and the anterior cingulate cortex, a hook-shaped piece of brain tissue towards the front of the brain. These are the areas in the brain that process pain, regardless of whether we’ve felt the sting of rejection or the sting of a bee (  Arno, 2014 ). How self-harm provokes the brain into feeling better.

From a neurophysiological point of view, it is not entirely possible that the same nocistructures can be used simultaneously for the transmission of two wholly different types of signals and thus cause two completely different types of pain to be experienced at the same time. Therefore, the more intense feeling of somatic pain usually has priority and suppresses the longer term feelings of mental suffering. The reason is that they use the same cells, neurotransmitters and areas. If the neuronal area is excited by one stimulus, it is impossible to stimulate it at the same time by another stimulus.

Brain imaging studies have shown which brain areas within pain processing pathways may be altered in NSSI. An imaging study with borderline personality disorder patients showed that the decreased sensation of pain is associated with changes in the system modulating the affective responses to pain, most specifically the anterior cingulate cortex, ACC, and the amygdala ( Schmahl et al. 2006 ).

Pain researchers and clinicians define physical pain as the unpleasant sensory and emotional experience associated with actual or potential tissue damage. International Association for the Study of Pain Task Force on Taxonomy, (1994 ). Even within this definition, it is understood that physical pain has both somatosensory and affective emotional components. The pain system is unique because of the implications of sensory components in the anterior parietal lobe as well as areas involved in emotion in the limbic system, hippocampus, amygdala, anterior thalmic nuclei and limbic cortex, which mediate mood, sleep, appetite and endocrine and cardiovascular function.

Painful stimuli are thought to activate multiple brain regions through several ascending pathways from the spinal dorsal horn. These pathways, which activate in parallel as well as serially, include the spinohippothalamic, spinoamigdaloid, and spinothalamic pathways. These and other pathways have projections to specific thalmic nuclei that connect to the anterior cingulate cortex, ACC, and insular cortex, IC, of the limbic system, and also through corticolimbic pathways from the sensory cortex to brain structures involved in other sensory modalities, hearing, smell, and vision, and memory ( Price, 2000; Klossika et al., 2006 ). Spinalamygdaloid projections seem to influence fear and avoidance;  spinalthalmic projections to the parietal lobe identify the location of a pain stimulus, while projections to the insular cortex provide information about pain intensity. The processing of pain affect is encoded in the ACC rather than the somatosensory cortex ( Rainville, et al. 1997 ). Projections to the ACC give information about the emotional valence or unpleasantness associated with pain. Thus, the somatosensory and affective components of pain perception are processed through several parallel pathways. ( Eisenberger 2008; Lieberman and Eisenberger 2009; O’Connor et al. 2008 ). Specifically, Eisenberger and colleagues suggest that the unpleasantness of physical pain is processed in the same area of the brain as social pain or distress related to loss, rejection or isolation.

Some research has shown that adolescent inpatients who engaged in NSSI reported little to no pain at the time of self-injury ( Nock and Prinstein, 2005 ). Contextual features and behavioral functions of self-mutilation among adolescents.

The ACC, along with the periaqueductal grey, PAG, amygdala, and anterior insula, plays a key role in how mood and pain modulate one another (Leitch and Tracy, 2009 ). These areas of the brain are implicated in affective pain processing as separate and distinct from somatosensory pain processing pathways. Understanding distinctions between the somatosensory and affective pain pathways can help explain the physiological mechanisms involved in NSSI, particularly when pain is used to regulate psychological distress.

Scientific research has found that pain can become associated with a stimulus that becomes associated with pain relief. People who self-injure may unwittingly tap into this mechanism. The repetition of self-injuring turns pain into a satisfying feeling.

NSSI presents researchers and clinicians with a unique opportunity to look at the interaction between distress, emotional dysregulation, and physical pain.

The self-harming individual can often convincingly justify the origins and existence of such injury through a very persuasive, non-self-harming explanation so the observer may not realize that they are looking at self-harm but assumes to be the consequences of a different type of behavior, e.g. a fall, scratches incurred when climbing a tree, etc.( Hicks K.M., Hinck S.M., 2008 ). Concept Analysis of Self-Mutilation

Several research teams have identified a distinct category for indirect forms of self-injuring behaviors such as dysfunctional eating behaviors, e.g. starvation, vomiting, purging, engaging in reckless behaviors, e.g. risky sexual practices in which people harm themselves in an indirect way, e.g. alcohol abuse can cause liver cirrhosis, ( Claes et al., 2003 ). Eating disordered patients with and without self-injuring behavior, a comparison of psychopathological features ( M St. Germain & Hooley, J.M., 2012 ).

Evidence for a distinction. Existing literature suggests that a negative parent-child relationship may increase vulnerability to NSSI and indirect forms of self-injury should focus on improving family relationships ( Glenn et al. 2015 ). Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth.