Addictiveness of Self-Harm [2020]

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March 26, 2020

THE ADDICTIVENESS OF SELF-HARM

Non-suicidal self-injury (NSSI) has no well-established diagnosis yet. While episodes

of self-inflicted injury that occurred only once or a twice are considered NSSI by some
researchers and health-care providers, another definition argues that NSSI is a repetitive
behavior (Sandman & Hetrick, 1995). NSSI has no diagnosis in the DSM-5 yet, but it is
included as a condition for further study and the proposed diagnosis states that NSSI is a
repetitive behavior that has occurred “on 5 or more days” in the last year (American Psychiatric
Association, 2013).

Most individuals who self-injure quit this behavior after a few years but for
approximately 20% of them, the behavior persists for more than five years (Liu, 2017). The
behavior can become habitual and persists into adulthood (Stanley, et al., 2010) and is often
perceived as addictive by people who self-injure (Buser & Buser, 2013). We may therefore
wonder what factors lead to the repetition of NSSI and whether repeated self-harm can be
considered an addiction. A good understanding of this behavior and its nature might help
finding more appropriate treatment options.

THE ADDICTIVE FEATURES OF SELF-HARM

Individuals who self-harm often report addictive qualities to this behavior and several
studies show results that seem to validate this hypothesis (Nixon & Cloutier, 2002; Martin, et
al., 2013; Buser & Buser, 2013). The DSM-5 (American Psychiatric Association, 2013)
suggests individuals may experience a “dependence on repeatedly engaging it” and similarities
with substance use disorder (SUD) and behavioral addiction have been pointed out, such as loss
of control, tolerance, withdrawal, relapse and continued use despite negative consequences
(Buser & Buser, 2013; Blasco-Fontecilla, et al., 2016; Guérin-Marion, Martin, Deneault,
Lafontaine, & Bureau, 2018).

People with NSSI often have difficulties to stop the behavior. Similarly to people with
substance use disorder and other addictions, they frequently experience ambivalence, that is to
say they know their behavior is a problem, they want to stop but still engage in self-harm (Buser
& Buser, 2013; Yale University, Ellen Edens, 2020). The DSM-5 also notes that the behavior

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can “cause clinically significant distress or interference in interpersonal, academic, or other

important areas of functioning” (American Psychiatric Association, 2013). These aspects have
similarities to the loss of control and consequences caused by SUD and addictions in general.

Moreover, people with NSSI often report feeling “urges” to self-harm, having
difficulties to resist these urges and suffering from post-cessation dysphoria (Nixon & Cloutier,
2002; Roberts, 2003; Buser & Buser, 2013). The DSM-5 proposed criteria state that people may
experience cravings, “a period of preoccupation with the intended behavior that is difficult to
control” “prior to engaging in the act” and frequently think about the behavior. Furthermore,
tolerance can be experienced by people who self-harm. They often report an escalation of the
frequency and severity of NSSI in order to achieve the same effect. They may gradually need
more injuries per session, injure themselves more often or cut deeper in order to experience a
feeling of relief (Nixon & Cloutier, 2002; Roberts, 2003; Buser & Buser, 2013; American
Psychiatric Association, 2013). The switch from needles to razor blades for example, or the use
of more methods of self-harm might be a consequence of tolerance. Previous NSSI gets
individuals used to pain and fear. As they learn that the behavior will be followed by a reward,
become less afraid of injuring themselves and deterrents gradually disappear, the habit requires
less effort, becomes more automatic, habitual and repetitive (Gordon, et al., 2010; Blasco-
Fontecilla, et al., 2016; Liu, 2017). Individuals who self-harm may exhibit higher pain tolerance
(Gordon, et al., 2010; Liu, 2017), however it is unclear whether this high pain tolerance is a
cause or a consequence of NSSI (Liu, 2017).

Therefore, non-suicidal self-injury’s addictive features have some similarities to the

three C’s of substance use disorder: namely loss of control, consequences and cravings. As the
DSM-5 notes, NSSI may resemble an addiction. Yet, while NSSI similarities to addiction is
undeniable, its status as an addiction is debatable.

IS SELF-HARM AN ADDICTION?

Findings about the addictiveness of non-suicidal self-injury are inconsistent. Some

research suggest that individuals may experience physical dependency to opiates released
during an episode of self-harm as they have addictive properties (Sandman & Hetrick, 1995;
Groschwitz & Plener, 2012). This theory, known as the endorphin theory, is sometimes
mentioned by people who self-harm. However, it is often contested. Nixon (2002) notes that
“symptoms of endogenous opiate withdrawal (e.g., anxiety, irritability, emotional lability) from

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self-injury may be difficult to distinguish from the dysphoric states that this population already
experiences”. Moreover, Pembroke, Shaw & Thomas (2007) points out the fact that if people
who self-harm were addicted to endorphins only, they could not stop for long period as it is
sometimes the case. Other research suggest that NSSI might be a behavioral addiction (Buser
& Buser, 2013; Blasco-Fontecilla, et al., 2016), but Buser & Buser point out that addictive
features are not experienced by every individuals who self-harm, suggesting that NSSI may not
always be an addiction, but may become one only for some people. As Blasco-Fontecilla, et al.
explain, (2016) some authors “were of the opinion that the repetition of NSSI was better
explained by emotional processes than by addiction mechanisms”.

Self-harm has several functions and is often said to be used to regulate negative
emotions and to release tension. Unlike substance use disorder, self-harm may be mainly
negatively reinforced, that is to say be used as a way to avoid or reduce negative feelings, and
not as a way to feel positive feelings. Therefore, NSSI might be limited to a specific context
only, when the individual experiences negative feelings, and be craved only in those situations.
A study found that cravings in NSSI was significantly lower than in SUD since it was mainly
experienced in case of negative emotions (Nixon & Cloutier, 2002; Gordon, et al., 2010; Victor,
Glenn, & Klonsky, 2012; Liu, 2017; Guérin-Marion, Martin, Deneault, Lafontaine, & Bureau,
2018). We might surmise that the withdrawal feelings that is reported by some individuals is
more due to the lack of coping mechanism in a negative situation than to the addictive properties
of self-harm. It might explain why, as mentioned above, some people can stop for a long period
of time, possibly because they feel better and have less need to self-harm. While emotion
regulation remains the function that is the most linked to frequent NSSI, some studies find that
the sensation-seeking function is greatly linked to the maintenance of self-harm as well, which
suggests that NSSI can also be positively reinforced, although probably to a lesser extent
(Stanley, et al., 2010; Martin, et al., 2013; Guérin-Marion, Martin, Deneault, Lafontaine, &
Bureau, 2018). It might be why some individuals report feeling a “buzz” when they self-harm.
This theory is supported by the DSM-5 proposed criteria as well. Gordon, et al. (2010) suggest
NSSI may be “more likely to become habitual through positive reinforcement”.

CONCLUSION

To conclude, while self-harm can have addictive features, it is not necessarily an

addiction. Treating it as an addiction only might be ineffective since it is often primarily an
emotion-regulation behavior. Yet, NSSI is complex and according to Guérin-Marion et al.

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(2018), “greater endorsement of addictive features is associated with more frequent NSSI, a
longer duration of NSSI, unintentionally severe injury and comorbid suicidal ideation”. It may
therefore be important to learn to recognize these addictive features in order to help those at
greater risk, to know whether or not an individual is addicted to self-harm and find appropriate,
effective treatments to each situation. Counselling models used to treat substance use disorder
and process addictions such as motivation interviewing (MI) might be used to help some people
with NSSI. MI is a non-judgmental empathetic approach of interaction that uses a patient’s
ambivalence, acknowledges the positive functions of an unhealthy behavior while also
highlighting its negative consequences and aims at enhancing the patient’s motivation to change
(Buser & Buser, 2013; Yale University, Ellen Edens, 2020). It may be disappointing to some
that this article does not inform whether or not NSSI is an addiction. As we have seen studies
are inconsistent but it is a reminder that each individual who self-harms is different and does so
for different reasons, and we should therefore avoid generalization.

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