Epidemiologic study results published in the Journal of Affective Disorders found that there may be critical issues with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for the diagnosis of non-suicidal self-injury disorder (NSSI-D), which is common among adolescents.  

Evidence suggests that 17% of adolescents engage in NSSI at least once. NSSI is associated with internal distress, rejection by peers, academic difficulties, and an increased risk of developing mental disorders and attempting suicide. Controversy remains regarding several of the criteria for NSSI-D in the DSM-5. A clear and consistent definition of the disorder is essential to distinguish individuals with NSSI-D from individuals who have engaged in NSSI but do not have NSSI-D.

By analyzing a large community sample of adolescents, Tinne Buelens, MSc, of the faculty of psychology and educational sciences at the Katholieke Universiteit Leuven in Belgium, and colleagues investigated prevalence rates of NSSI-D. In addition, they examined the 4 most controversial criteria established by the DSM-5:

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  • NSSI must occur at least 5 days in the past year (A)
  • Various expectations or reasons for engaging in behavior (B)
  • Preceding factors for NSSI (C)
  • Clinical interference or distress (E)

The researchers argued that criterion A was set too low, stating that a cutoff based on 5 days of NSSI behavior in the past year should be raised to ≥10 days in the past year. When the alternative ≥10 days cutoff was applied, the overall prevalence dropped from 7.6% to 5.5%, suggesting that the criterion A cutoff may be too low to be clinically relevant. Criteria B and C were met by 89% and 99% of the community sample, respectively, with considerable overlap, making it unlikely that any specificity or sensitivity would be added by these criteria.

For criterion E, relatively few adolescents reported interference in daily life due to NSSI, although the criterion significantly distinguished between adolescents with and without NSSI-D. The investigators concluded that the clinical utility of this criterion demands greater scrutiny.

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The study is limited by the self-reported nature of the data and may not be generalizable to clinical populations.

The researchers also noted a disturbing trend: many adolescents who engage in NSSI seek information online and communicate with others on social media platforms about NSSI. These sites contain graphic content, which may serve as positive reinforcement. The investigators wrote, “The present study encourages mental health professionals to assess the influences of social media, especially when working with adolescents who engage in more severe self-injury, such as those meeting NSSI-D criteria.”


Buelens T, Luyckx K, Kiekens G, Gandhi A, Muehlenkamp JJ, Claes L. Investigating the DSM-5 criteria for non-suicidal self-injury disorder in a community sample of adolescents. J Affect Disord. 2019. doi:org/10.1016/j.jad.2019.09.009