Etiology and risk factors for non-suicidal self-injurious behavior

Introduction

Non-suicidal self-injury (NSSI, suicidal gesture, parasuicide, deliberate self-harm, self-injury, self-poisoning, cutting) is one of the types of autoaggressive behavior. Nowadays, it is widely spread among adolescents and young adults. NSSI may be described as intentional, direct damage to the body without suicidal intentions, in order to reduce psychological discomfort. Most often, practitioners come across self-cuts, less often – intentionally inflicted burns, scratches, blows, etc. [1]. In recent years, researchers have noted an increase in the number of self-harm cases.

The purpose of the study is to explore, summarize, and present data on the causes and risk factors of non-suicidal self-harming behavior.

Materials and methods

This particular article presents a narrative review of the academic literature on the etiology and risk factors of NSSI. The authors selected and analyzed various articles in the databases such as MEDLINE/PubMed and Scopus in international medical journals. The articles were searched according to the keywords “self-injurious behavior”, “non-suicidal self-injury”, “deliberate self-harm”, “self-harm”, and “risk factors”. The inclusion criteria were as follows: the publication date ranging from 2017 to 2022, clinical trials, meta-analyses and systematic reviews, randomized controlled trials, and the availability of the full text or abstract in the public domain. The exclusion criteria were as follows: abstracts, monographs, textbooks, the publication date before 2017, and the inconsistency of the research topic. Therefore, a total of 94 publications were found. The review includes 61 publications dated from 2017 to 2022 that corresponded to the subject and purpose of the study, as well as 19 sources older than 2017 that are significant for the subject disclosure from references in the reference lists of the analyzed sources.

Results

A significant number of people, for different reasons (stressful situations, failures, low self-esteem, loneliness, interest, etc.), resort to NSSI at least once in their lives [2]. If at least for a short time the obtained result relieves emotional overstrain, the person may face a forming dependence on self-harm, which is manifested in various forms of self-inflicted serious injuries. According to a meta-analysis [3], the main goal of NSSI is the deregulation of emotions regardless of age or gender.

In addition to adolescents, young women, war veterans, residents of boarding schools, prisoners, representatives of sexual minorities, persons without a fixed place of residence, as well as persons who were subjected to abuse in childhood, are in the risk group.

Based on studies of different types of families, it became possible to identify the hereditary component of the NSSI tendency, partially independent of comorbid psychiatric diseases [4][5]. The psychological causes of self-harming behavior include low self-esteem, perfectionism, negative self-attitude and negative body perception, and feelings of failure [6]; the autoaggression may be associated with both emotional and sexual violence, trauma; cuts in or close to the genital area may be a way to combat unwanted sexual impulses or self-punishing for what seems to be wrong and unacceptable [7]. Recent studies reveal that adolescents with high neuroticism levels, as well as high levels of openness to new experiences and neuroticism, combined with a low level of personal organization, are more prone to self-harm practices [8].

Child abuse is also an identified risk factor for NSSI [9].

Some authors find addictive radicals in self-injurious behavior – that is why they consider it an addiction. In this variant, masochists are to be meant as they feel pleasure from harming themselves, while experiencing “love” for pain and suffering [10].

At a high level, the authors assess the relationship between self-injury and eating disorders. There is an opinion concerning the comorbidity of these pathological phenomena, which often aggravate each other's manifestations [11]. The leading authors assert the thesis about the similarity of psychological functions that motivate eating disorders and NSSI, thereby explaining the common mechanisms that reveal their frequent co-occurrence [12]. Therefore, the connection with the impaired regulation of emotions and interpersonal problems in eating disorders and NSSI is being discussed nowadays [13].

In the case of schizophrenia, self-injury may be caused by imperative hallucinations. In these cases, a person can hear orders to commit self-injury, which can hardly be resisted. It is worth noting that against the background of a psychotic disorder, self-harm should be considered exclusively as a symptom of the underlying disease; the DSM-5 criteria for NSSI-D are not applicable in this case.

The researchers note that, despite the existence of developed psychological assistance programs, the tendency to self-harm is consolidating and resisting correction, manifesting itself again outside the clinical environment where psychological interventions were implemented [14]. In addition, specialists point to the contagiousness of self-injury, which is especially important in the adolescent environment. The experience of a “witness” while observing the self-harm process of another person is a trigger for turning to such behavior [15].

That is why one of the prospects for further scientific research could be the development of self-help and mutual assistance programs; now there are many stories of young people who practiced self-injury and managed to achieve the condition compensation. Self-help strategies, such as changing the environment, distraction, and a pre-prepared arsenal of auxiliary tools, as well as building a social support network consisting of trusted persons, proved to be effective [16].

Also, self-injury may be associated with a number of mental disorders, for example, depression, mood and eating disorders, sexual and other personality disorders, and suicidal ideation [17].

Proposed models

Nowadays, several models used in order to describe self-harm within the framework of NSSI have been proposed. One of the presented models is called the emotional cascade model [18]. The emotional cascade model postulates that NSSI serves to distract attention from cascades of intense negative emotions and reflections.

The theory of the family cascade (“The NSSI Family Distress Cascade Theory”) is proposed as well [19]. The author suggests a promising direction for NSSI research. According to the prevailing perceptions, NSSI is a complex behavior, which most often occurs in the period of adolescence. This period is characterized by the desire to establish a balance between personal autonomy and communication with the main guardians. When a teenager injures him/herself, parents (guardians) often do not understand how to react. Reports of guilt, fear, and shame are common after they learn about a child's self-harm. This cascade of negative feelings and self-esteem can lead to excessive vigilance and increased control over the child's behavior. A teenager may perceive this as an intrusion, which as a result will lead to further deterioration of the functioning of the family and an increased NSSI risk. This cascade is not well known in modern academic literature, which opens up prospects for further research.

There are publications with attempts to apply a new cognitive-emotional model to NSSI cases. The recently proposed cognitive-emotional model of NSSI is based on models of emotion regulation and social cognitive theory [20]. The authors tested the prediction of the model that the relationship between emotional reactivity and NSSI is regulated by specific notions of self-harm (i.e. self-efficacy for NSSI resistance, expectations of the NSSI outcome), emotion regulation and reflection. Researchers have found that emotional reactivity is significantly associated with NSSI, especially in people with weak self-organization to resist. However, an inverse relationship of emotional reactivity with NSSI was found in people who used suppression to regulate emotions rather more often.

In the course of NSSI research, the team of authors [21] presented a new model — the model of NSSI advantages and barriers. This model is based on the supported elements of the previous ones, combines information from recent experimental and longitudinal NSSI studies, and is closely related to advances in fundamental psychology. The basic principles of this model are that (a) NSSI has many powerful benefits available to most people, but (b) most people do not have access to these benefits because there are several natural or instinctive barriers that encourage them to avoid self-harm. Preliminary work based on this model has identified new risk factors for NSSI, and its materials have formed an effective approach to NSSI treatment that is now being developed.

Psychological factors

Many authors consider rumination to be one of the significant factors predisposing to NSSI. Repetitive thoughts (rumination) about negative events and experiences are increasingly viewed as a transdiagnostic process underlying various forms of mental pathology [22]. Rumination and emotion-related impulsivity are significantly associated with suicidal thoughts, suicidal attempts, and NSSI [23].

In addition, modern research draws attention to self-compassion [24]. Self-compassion is a manifestation of compassion for oneself in cases of perceived inadequacy, failures, or general suffering. Kristin Neff has determined that self-compassion consists of three main elements: self-kindness, humanity, and mindfulness.

In the study [25], the researchers discuss whether reflections and self-compassion soften or aggravate the manifestations of both NSSI and suicidal thoughts, and also answer the question of how rumination and self-compassion are interrelated with affective manifestations and a lifetime history of NSSI and suicidal thoughts.

Buelens et al. [26] reach similar conclusions. They write that NSSI may play a significant role in increasing distress and rumination.

The factor of alexithymia remains important [27]. The role of difficulties in identifying and describing feelings in NSSI is also described by Cerutti et al. [28].

In the publication by Miller et al. [29], the authors appeal to the sample of adolescent girls in order to prove that self-mutilation may be considered to be a compulsive, rather than an impulsive disorder, which represents a new view of behavior. The authors identified the main factors, such as emotion regulation, compulsive attraction, and interpersonal triggers. The conclusion highlights the importance of interpersonal relationships as a factor in reducing NSSI and suicidal risk.

The interrelation of manifestations of anxiety, hostility, depression, impulsivity, shyness, and vulnerability with NSSI manifestations is indicated as well [30]. Adolescents suffering from depression are also more likely to commit NSSI and have similar psychological characteristics [31]. In a group of adolescents with depressive disorder combined with NSSI, suicidal thoughts and emotional dysregulation were much more frequent; symptoms of depression and symptoms of anxiety were more pronounced as well. The NSSI seems to characterize more severe phenotypes of adolescent depression, claiming a potential role as a “specifier” of depressive disorder.

Important psychological features are also models of risk avoidance and acceptance, especially relevant in adolescence. According to new data, self-harm in adolescence is associated with greater avoidance of behavioral risk, rather than risk-taking [32].

According to many authors, neuroticism, depression [33], impulsivity, alexithymia, virtual social support, dissatisfaction with school performance, as well as a decrease in subjective well-being, a decrease in self-esteem, a decrease in actual and perceived social support [34], and family dysfunction are relevant psychological NSSI factors for adolescents.

Social support remains an important antisuicidal factor, but also has an impact as a protective factor against various forms of autoagression [35].

In particular, shame and guilt may be important emotions in self-injury. A meta-analysis [36] confirms the link between shame and self-harm, especially NSSI. The specifics of the revealed relationship are to be established, but the role of shame among people suffering from NSSI should be taken into account clinically.

The issue of the stigmatization of NSSI patients is relevant, which can increase clinical manifestations and distress and aggravate the condition [37].

According to a large-scale metasynthesis of 20 studies of adolescents [38], four “meta-subjects” were named as the main psychological factors of self-harming behavior, which were associated with the subjective experience of participants in relation to self-harm: (1) receiving liberation, (2) control of harsh feelings, (3) visualization of unacceptable feelings, and (4) establishing a connection with others. Meta-subjects support self-harm as a function of affect regulation, but self-harm may also contain important emotional and relationship-related content, an intention or desire to establish a connection and communicate with others. The results of this study emphasize the importance of linking self-harm with psychological needs and developmental problems in adolescence, such as separation, autonomy, and personality formation. Self-harm in adolescence may be the result of a conflict between the need to express affective experiences and the need for caring in a relationship.

Metasynthesis [39] presented the results of the search and processing of all the articles in electronic databases from the date of creation to November 2020. In total, 30 articles were included in the final review. Two overarching topics were discovered therefore. Being a part of the “Powerful Relationship Dynamics”, NSSI has been called a response to participants getting stuck in hostile or disempowering relationships with others. At the same time, being a part of the “Take Matters into Your own hands” sub-subject, NSSI was described as a way to meet the interpersonal and emotional needs of participants.

These large studies are confirmed by meta-analysis, which describes the distribution of functions of non-suicidal self-harm. Most often, NSSI practitioners report intrapersonal functions (66–81%), and especially those related to the regulation of emotions (63–78%). Interpersonal functions (for example, expression of distress) are less common (33–56%) [40].

Social factors

In a prospective study, which took 2.5 years [41], it was shown that dysfunctional relationships were significant risk factors for NSSI. In the same connection, it has been repeatedly shown that bullying is a risk factor for the development of NSSI. It was revealed [42] that peer bullying in childhood and early adolescence posed a greater risk of self-harm in adulthood than parental abuse in two large longitudinal samples (the Longitudinal Study of Parents and Children in the UK (ALSPAC) and the Great Smoky Mountains Study in the USA (GSMS)).

Bullying and emotional abuse are largely associated with self-harming behavior and influence aggressive behavior and suicidal thoughts of adolescents [43].

A systematic review and meta-analysis [44] also confirm that childhood abuse and its subspecies are associated with non-suicidal self-harm. Screening for a history of childhood abuse when assessing the risk of non-suicidal self-harm may be of particular importance in a community setting.

Communication with peers, close and friendly relationships of adolescents can influence the development and course of NSSI both positively and negatively. Emotionally unstable teenagers are more likely to fall under the influence of friends. NSSI frequency in friends is an important and unique predictor of the increase in intrinsic NSSI frequency in adolescents over time.

The results [45] show that the relationship between peer problems (e.g., friendship stress, loneliness) and NSSI can be largely explained by common underlying factors; however, some evidence also suggests that participation in NSSI may increase the risk of adolescents having difficulties in relationships with peers in part due to increased symptoms of depression.

However, one cannot deny the importance of social relations with parents and peers as a factor in assessing the NSSI. NSSI is associated with problems in relationships with family members and peers [46]. Harsh parental punishments, weak parental control, and low attachment to the parent predicted an increased likelihood of subsequent development of NSSI in adolescence. Young people who reported more frequent peer victimization, lower social self-esteem and self-competence, as well as negative peer perceptions, were also at increased risk of NSSI.

The risk of autoaggression increases due to the experience of adverse events in childhood, such as parental neglect, abuse, or significant restrictions in childhood.

This is consistent with the data of meta-analysis, which demonstrates that the experience of sexual abuse is slightly associated with the development of non-suicidal autoaggressive behavior [47]. In another study, only indirect childhood abuse (domestic violence) was significantly associated with non-suicidal autoaggressive behavior, and direct forms of abuse (physical or sexual violence) were not. Emotional abuse was not considered in this study. In addition, a strong association with increased parental criticism or parental apathy has been repeatedly shown [48]

According to another study [49], adolescents who had a family experience of suicidal behavior of one of the parents increased the risks of all types of autoaggressive behavior. There was a concordant pattern of higher rates of the same type of suicidal behavior as in one of the parents, including the type of suicidal method.

According to the work by Mendez et al. [50], social factors play a role in the emergence and maintenance of NSSI in adolescents. Low perceived social support is significantly associated with involvement in NSSI. The interrelation of borderline personality traits and NSSI in multivariate analysis is also noted. Borderline personality traits are characteristic and interrelated with low perceived social support and NSSI.

A number of studies have shown that non-heterosexual orientation is closely associated with the risk of NSSI. This statement is expanded by studies of diverse minority groups. The data show that belonging to minorities increases the risks of all variants of autoaggressive behavior [51].

A systematic review and meta-analysis [52] present the prevalence and correlates of non-suicidal self-harm among lesbian, gay, bisexual, and transgender people. According to the results, the prevalence rates of NSSI were quite high among representatives of sexual (29.68% during life) and gender (46.65% during life) minorities compared with heterosexual and/or cisgender peers (14.57% during life), among transgender (46.65% during life) and bisexual (41.47% during life) ones. Young people from sexual minorities turned out to be a particularly vulnerable group of the population.

Nowadays, the number of studies in this field is growing worldwide [52–54].

Neurobiological factors

Various studies of neurobiological factors related to the development and continuation of autoaggressive behavior were mainly conducted in adults with borderline personality disorder [55]. The presented studies are limited to small sample sizes and focused on pain sensitivity studies. However, some studies have focused on neurobiological changes in adolescents with episodes of autoaggressive behavior.

Since self-injury is often associated with stressful events or situations, and the hypothalamic-pituitary-adrenocortical system participates in overcoming stressful situations. Studies have been conducted on the relationship between manifestations of non-suicidal autoaggressive behavior and indicators of the hypothalamic-pituitary-adrenocortical system. In each of the studies, a violation in the functioning of the regulation of the hypothalamic-pituitary-adrenocortical system was revealed [56–58].

The study [59] proved a decrease in cortisol levels in adolescents with non-suicidal autoaggressive behavior in response to the Trier social stress test, which may indicate hyperreactivity of the hypothalamic-pituitary-adrenocortical system in adolescents with non-suicidal autoaggressive behavior in stressful situations. A limitation of this study may also be called a small sample set of 14 patients and 14 patients of the control group.

In another study devoted to socially stressful situations, differences in the neural processing of the situation of social isolation using functional magnetic resonance imaging (fMRI) were studied. In this one, Groschwitz et al. found differences in the treatment of social isolation in adolescents suffering from depression with non-suicidal autoaggressive behavior compared with adolescents with simple depression and a healthy control group [60]. These differences mainly prevailed in the medial prefrontal cortex and ventrolateral prefrontal cortex, which may indicate that adolescents with non-suicidal autoaggressive behavior are more prone to social alienation. The participants were 28 adolescents with depression (14 with concomitant NSSI, 79% girls) and 15 healthy people from the control group, whose average age was 15.2 years. The study demonstrated that adolescents with NSSI differed significantly from adolescents with depression, as well as adolescents with NSSI differed significantly from healthy controls.

The peculiarities of excitation of some areas of the cerebral cortex are demonstrated in the work by Plener et al. [61] that used an fMRI examination. This pilot study assessed differences in emotion processing between 18 adolescent girls with and without NSSI using verbal responses and fMRI. Reactions to images from the International System of Affective Images and slides linked to NSSI were recorded both by the verbal assessment of valence and arousal and by fMRI. The NSSI group rated self-harm images as significantly more arousing than the control group. For emotional images, the NSSI group showed significantly stronger brain responses in the amygdala, hippocampus, and anterior brain regions. The cingulate cortex fixed the reaction on both sides. Depression explained the differences between the groups in the limbic region. In addition, the NSSI group also showed increased activity in the middle orbitofrontal cortex, as well as in the lower and middle frontal cortex when viewing the NSSI graphic material. The participants with NSSI showed a decrease in activity depending on arousal in the occipital cortex and valence in the lower frontal cortex when viewing emotional images. Therefore, fMRI data supports the view that people with NSSI exhibit an altered neural pattern for emotional and NSSI images. Behavioral data indicate a tendency to worry about NSSI topics. This fMRI study provides evidence of emotion regulation deficits in the developing brains of adolescents with NSSI, it has also been considered in a few studies to search for genetic factors in the development of autoaggressive behavior [62].

As for the perception and processing of physical pain, the data obtained from adolescent samples show rather contradictory results. One study of adolescents with borderline personality disorder showed an increased pain threshold [63]. The authors fixed the differences during the sensation of pain (the feeling of relief is stronger), as well as according to neuroimaging data (in areas related to reward) [64]. The main functions of non-suicidal autoaggressive behavior are intrapersonal functions (66–81%), especially those related to the regulation of emotions and interpersonal functions (for example, the expression of distress), which were less frequent (33–56%) [65].

In their study, Hetrick et al. [66] consider the biological factors of the role of inflammation (immunological response) in suicidal behavior in adolescents who have been subjected to abuse. It was found that systemic inflammation was positively associated with suicidal thoughts, which confirms the unique role of systemic inflammation in the pathogenesis of suicidal thoughts, although the hypothesis of a relationship with childhood abuse has not been confirmed. This study provides new insight into a potential immunobiological model for the development of suicidal thoughts in young people.

The object of the next study [67] was a group of adolescents suffering from bipolar disorder. Resting fMRI data were analyzed for 141 adolescents aged 13–20 years, including 38 with bipolar disorder and self-injury during their lifetime. This study provides preliminary evidence for changes in reward-related resting functional connections (rsFC) in relation to self-harm in adolescents with bipolar disorder. Additional ones are needed to evaluate changes in rsFC in response to treatment and related changes in self-harm.

A team of authors [68] attempted to generalize and systematize the available publications, as a result of which a review was presented. The publication focuses on MRI studies reporting structural and functional neural correlates of suicidal thoughts and behavior (STB) and NSSI in adolescents. As a result, 47 articles were analyzed (STB=27; NSS=20), with 63% of STB articles and 45% of NSSI articles published during the previous 3 years. A structural MRI study demonstrates a decrease in the volume of the ventral prefrontal and orbitofrontal cortex in young people reporting STB. There is a reduced volume of the anterior cingulate cortex, manifested in both STB and NSSI. As for functional changes, blunted activation of the striatum can characterize young people with STB and NSSI, and in persons initiating and attempting to commit suicide, frontal-limbic interaction is reduced. The results of functional communication show that people who self-injure have frontal-limbic changes. Together, suicidal and non-suicidal behavior is associated with descending and ascending neural changes that can jeopardize the systems of approach, avoidance, and regulation.

At the moment, it can be concluded that there is not any specific neural marker of STB or NSSI, there are only isolated studies made by MRI and fMRI, and their data remain contradictory. Compared to adults, research among young people is even more limited. In the future, new longitudinal studies of neurobiological features are needed, with larger and well-characterized samples, especially those that include the assessment of outpatient patients.

Media influence

Speaking about the NSSI spread around the world, it is important to note that the use of the Internet and especially social networks provokes the increasing interest of researchers trying to understand the distribution of NSSI content.

It is worth repeating that, according to reports, the experience of a “witness” in observing the self-harm of another person may be a trigger for turning to such behavior [15], initial participation in NSSI can greatly affect social contagion (i.e. friends or acquaintances participating in NSSI, or exposed to NSSI in the media, especially on the Internet), while the continuation of NSSI is most likely related to intrapersonal functions [69].

Social networks are an important means of social interaction, especially among teenagers. Instagram is the most popular platform in this age group in the world (at the moment, the activities of the American multinational holding company Meta Platforms Inc. on the sale of products – social networks Facebook and Instagram are prohibited on the territory of the Russian Federation on the grounds of extremist activity). Photos and messages about self-mutilation can often be seen in the publications of teenagers on the social network [70]. Most often, the photographs depicted wounds received as a result of cuts on the arms or legs, and they were assessed as injuries of mild or moderate severity. Images with an increasing degree of injury and images of several NSSI methods caused an increased number of comments. Most of the comments were neutral or sympathetic, some offered help, and only a few comments were hostile. The pictures were mostly published in the evening hours, with a slight peak in the early morning. Despite the fact that there was a small peak in the publication of photos on Sundays, the publications were fairly evenly distributed throughout the week.

Based on the available data, the researchers hypothesized that viewing this content may cause a risk of self-harm and suicide for vulnerable groups of the population. A team of authors [15] tested this hypothesis using a two-stage panel survey of young people in the United States. The analysis showed that viewing posts with self-harm on Instagram (a project of Meta Platforms Inc., whose activities are prohibited in Russia) was associated with suicidal thoughts, self-harm, and emotional disorders, even taking into account the impact of other sources of information with similar content. As expected, the impact of self-harm on Instagram during the first wave of the study prospectively predicted the results associated with self-harm and suicide in the second wave after 1 month. These results indicate that such an impact can lead to infection of vulnerable users and are confirmed by publications of other researchers [71][72].

In the analysis of the Yahoo! database, it was shown that the majority of self-harm-related questions (30.6%) were published with the intention of getting help, which hypothetically explains the reasons for posting such content. This hypothesis is supported by a recent study, which claims that a third of young people (14 to 25 years old) with episodes of autoaggressive behavior reported seeking help online [69][73].

The romanticization of autoagression, suicides, and other mental disorders in literature and art is of concern, which can negatively affect the development and condition of young people [74].

The possibilities and problems of regulating the Internet to prevent self-harm and suicide in their work are highlighted by Morrissey et al. [75] in the context of the discussion of the new law on the regulation of the Internet information space. Regulatory issues are becoming increasingly relevant, including against the background of reports of widespread online communities promoting suicide [76], as well as individual reports of targeted malicious actions of unidentified persons on the Internet aimed at inciting aggression towards others or autoaggression [77].

Thus, online activity regarding non-suicidal autoaggressive behavior may be regarded with reservations as useful (for example, reducing social isolation, receiving support for recovery, reducing self-harm urges), but it is impossible to deny the factors contributing to the spread of NSSI (for example, triggering self-harm urges, social reinforcement) [71][78][79].

Conclusion

In conclusion, it is important to note that autoaggressive behavior, self-harming behavior, and NSSI are currently phenomena that are widespread among young people and adolescents and are closely related to true suicide attempts [80]. The studies have fixed an increase in the number of self-harm cases in recent years, which often causes irreversible consequences negatively affecting psychological well-being and physical health. It should be mentioned that unfortunately, in Russia there is an obvious lack of large-scale studies concerning the self-harm problem.

According to the available ideas, the basis for the development of non-suicidal self-harming behavior is emotional dysregulation. However, an analysis of the academic literature shows that self-harm is also characterized by varying degrees of severity and a variety of psychopathological symptoms, disorders that do not exclude each other, as well as comorbid conditions that can exist simultaneously. Also, over time self-aggression functions may evolve.

It is logically advisable to divide the risk factors of adolescent NSSI into external (environmental factors, psychosocial factors) and internal (demographic, personal, neurobiological) ones.

Internal significant NSSI risk factors

• Demographic risk factors:
  • female sex;
  • adolescence;
• Mental disorders/symptoms/personality factors:
  • anxiety disorders;
  • depression and depressive symptoms;
  • hopelessness;
  • aggression, externalization of behavioral deviations;
  • personality disorder;
  • eating disorders;
  • internalization of behavioral anomalies;
  • problems of emotional regulation;
  • alexithymia;
  • substance abuse;
  • sexual orientation.

External significant NSSI risk factors

• Family risk factors:
  • mental stress affecting one or both parents;
  • conflict between parents;
  • conflict in child-parent relations.
• Violence and physical abuse in childhood:
  • physical neglect and abuse;
  • emotional neglect and abuse;
  • sexual violence;
  • post-traumatic stress disorder.
• Social contagion:
  • NSSI experience in an environment;
  • social networks and their influence.

Nowadays, there is difficulty in assessing the contribution of risk factors and their hierarchy in NSSI development. It is unclear whether the observed risk estimates accurately reflect the strength of the risk factor in these different categories. Additional studies of NSSI risk factors are needed to better assess the magnitude of risk factors and their prognostic significance. The most reliable risk factor with the maximum contribution is indicated by the existing NSSI experience and the presence of suicidal thoughts and attempts in the anamnesis.

Adolescence, female gender, social or medical contact with NSSI, alexithymia, depressive disorders, nonspecific behavioral and emotional disorders, bullying, and adverse childhood experiences such as emotional abuse or neglect – all the parameters mentioned seem to be the main risk factors for NSSI development.

At the same time, there is a correlation between the manifestations of personality disorders and eating disorders and self-harm. Apparently, there are common mechanisms for the development of these pathological manifestations.

The results of neurobiological studies indicate anomalies in the hypothalamic-pituitary-adrenal axis, the endogenous opioid system, as well as the neural processing of emotionally, socially, or physically unfavorable stimuli. The neurobiological NSSI research mainly turns to literature on adult patients. Many adult patients experience hypoalgesia or analgesia during NSSI and suppression of limbic areas after pain stimuli. However, the results obtained for adolescents have been contradictory so far and there is a lack of data.

The number of academic publications describing the impact of social networks and mass media on the mental health of adolescents is growing. The prevalence of autoaggression and self-harming behavior among young people is increasing due to the involvement of adolescents in the exchange of NSSI experience through social networks.