DSM-5 & Nonsuicidal Self-Injury Disorder, with Dr. Greg Lengel

In 2013, the 5th edition of the Diagnostic & Statistical Manual of Mental Disorders (DSM-5) was released, and for the first time it included Nonsuicidal Self-Injury Disorder as a Condition for Further Study. It is not an actual diagnosis at this time, but there are currently six criteria listed (see below, bottom of page). In this episode, Dr. Greg Lengel from Drake University in Iowa walks us through what research says about each of the six criteria, and he discusses the pros and cons of formalizing NSSI Disorder as a diagnosis.

Listen to his interview with Dr. Brooke Ammerman from Season 3 ("How Should Self-Harm Be Defined?") here. Learn more about Dr. Lengel at his faculty profile at Drake University here and follow him on Twitter/X at @DrGregLengel. Below are links to many of the papers discussed in this episode as well as other important papers on NSSI as a disorder in the DSM-5:

1. Shaffer, D., & Jacobson, C. (2009). Proposal to the DSM-V childhood disorder and mood disorder work groups to include non-suicidal self-injury (NSSI) as a DSM-V disorder. American Psychiatric Association, 1-21.
2. Lengel, G. J., Ammerman, B. A., & Washburn, J. J. (2023). NSSI in the DSM-5. In E. E. Lloyd-Richardson, I. Baetens, & J. Whitlock (Vol. Eds.), The Oxford Handbook of Nonsuicidal Self-Injury. New York: Oxford University Press .
3. Lengel, G. J., Ammerman, B. A., & Washburn, J. J. (2022). Clarifying the definition of nonsuicidal self-injury: Clinician and researcher perspectives. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 43, 119-126.
4. Lengel, G. J. & Mullins-Sweatt, S. N. (2013). Nonsuicidal self-injury disorder: Clinician and expert ratings. Psychiatry Research, 210, 940-944.
5. Ammerman, B. A., Jacobucci, R., Kleiman, E. M., Muehlenkamp, J. J., & McCloskey, M. S. (2017). Development and validation of empirically derived frequency criteria for NSSI disorder using exploratory data mining. Psychological Assessment, 29, 221-231.
6. Ammerman, B. A., Jacobucci, R., & McCloskey, M. S. (2019). Reconsidering important outcomes of the nonsuicidal self‐injury disorder diagnostic criterion A. Journal of Clinical Psychology, 75, 1084-1097.
7. Ammerman, B. A., Lengel, G. J, & Washburn J. J. (2021). Consideration of clinician and researcher opinions on the parameters of nonsuicidal self-injury disorder diagnostic criteria. Psychiatry Research, 296, 113642.
8. Ghinea, D., Edinger, A., Parzer, P., Koenig, J., Resch, F., & Kaess, M. (2020). Non-suicidal self-injury disorder as a stand-alone diagnosis in a consecutive help-seeking sample of adolescents. Journal of Affective Disorders, 274, 1122-1125.
9. Muehlenkamp, J. J. (2005). Self-injurious behavior as a separate clinical syndrome. American Journal of Orthopsychiatry, 75, 324–333.
10. Muehlenkamp, J. J., Brausch, A. M., & Washburn, J. J. (2017). How much is enough? Examining frequency criteria for NSSI disorder in adolescent inpatients. Journal of Consulting and Clinical Psychology, 85, 611619.
11. Washburn, J. J., Potthoff, L. M., Juzwin, K. R., & Styer, D. M. (2015). Assessing DSM-5 nonsuicidal self-injury disorder in a clinical sample. Psychological Assessment, 27, 31-41.
12. Zetterqvist, M. (2015). The DSM-5 diagnosis of nonsuicidal self-injury disorder: A review of the empirical literature. Child and Adolescent Psychiatry and Mental Health, 9, 31.

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NONSUICIDAL SELF-INJURY DISORDER (PROPOSED DIAGNOSIS):

A. In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual's repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death.

B. The individual engages in the self-injurious behavior with one or more of the following expectations:

1. To obtain relief from a negative feeling or cognitive state.
2. To resolve an interpersonal difficulty.
3. To induce a positive feeling state.

Note: The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.

C. The intentional self-injury is associated with at least one of the following:

1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act.
2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control.
3. Thinking about self-injury that occurs frequently, even when it is not acted upon.

D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting.

E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning.

F. The behavior does not occur exclusively during psychotic episodes, delirium, substance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder, intellectual disability, Lesch-Nyhan syndrome, stereotypic movement disorder with self-injury, trichotillomania [hair-pulling disorder], excoriation [skin-picking] disorder).