Background: Nonsuicidal self-injury (NSSI) is widely thought to serve an emotion-regulatory function. Method: The focus of the present paper is to provide a conceptual framework for understanding how NSSI might modify a person's emotions. Results: Drawing upon the process model of emotion regulation, we argue that 5 families of emotion regulation strategies may be engaged by NSSI. Individuals may engage in NSSI as an alternative to more distressing situations. They also may use NSSI to modify their social environment. Individuals may shift their attention away from unpleasant emotions or thoughts via NSSI. NSSI may change cognitions about the self via self-punishment or transformation of the self from higher-order to lower-order awareness. NSSI may also bring about various physiological effects, such as changes in endogenous opioids or parasympathetic nervous system activation, as a way of modulating emotional responses. Conclusion: Simply labeling NSSI as ‘emotion regulatory' does not tell us precisely what is going on. This is because at any given moment, NSSI can serve to regulate emotions in many different ways. One key challenge is to clarify the precise functions NSSI may be serving for a given individual in a particular context.

Keywords:
Nonsuicidal self-injury, Self-harm, Emotion regulation, Critical review
1.
Clarke L, Whittaker M: Self-mutilation: culture, contexts and nursing responses. J Clin Nurs 1998;7:129-137.
2.
Favazza AR: The coming of age of self-mutilation. J Nerv Ment Dis 1998;186:259-268.
3.
Rosenthal RJ, Rinzler C, Wallsh R, Klausner E: Wrist-cutting syndrome: the meaning of a gesture. Am J Psychiatry 1972;128:1363-1368.
4.
Adler PA, Adler P: The demedicalization of self-injury: from psychopathology to sociological deviance. J Contemp Ethnogr 2007;36:537-570.
5.
Finn N: Demi Lovato gets brutally honest, talks rehab, cutting and rebuilding with ‘Skyscraper'. E! Online, Jul 13, 2011. http://uk.eonline.com/news/251954/demi-lovato-gets-brutally-honest-talks-rehab-cutting-and-rebuilding-with-skyscraper.
6.
Haygood J: I self-injure (television series episode); in True Life. New York, MTV, March 22, 2007.
7.
Hutchinson C: Self-harm videos on YouTube: dangerous or therapeutic? ABC News, Feb 21, 2011. http://abcnews.go.com/Health/WomensHealth/harm-vids-youtube-dangerous-therapeutic/story?id=12950980.
8.
Lewis SP, Heath NL, St Denis JM, Noble R: The scope of nonsuicidal self-injury on YouTube. Pediatrics 2011;127:e552-e557.
9.
MTV: True Life ‘I self-injure' episode summary, n.d.
10.
Gross JJ: Handbook of Emotion Regulation. New York, Guilford, 2007.
11.
Gross JJ: Handbook of Emotion Regulation. New York, Guilford, in press.
12.
Claes L, Vandereycken W: Self-injurious behavior: differential diagnosis and functional differentiation. Compr Psychiatry 2007;48:137-144.
13.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 5. Arlington, American Psychiatric Association, 2013.
14.
Briere J, Gil E: Self-mutilation in clinical and general population samples: prevalence, correlates, and functions. Am J Orthopsychiatry 1998;68:609-620.
15.
Klonsky ED: Non-suicidal self-injury in United States adults: prevalence, sociodemographics, topography and functions. Psychol Med 2011;41:1981-1986.
16.
Jacobson CM, Gould M: The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res 2007;11:129-147.
17.
Plener PL, Libal G, Keller F, Fegert JM, Muehlenkamp JJ: An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA. Psychol Med 2009;39:1549-1558.
18.
Brunner R, Parzer P, Haffner J, Steen R, Roos J, Klett M, Resch F: Prevalence and psychological correlates of occasional and repetitive deliberate self-harm in adolescents. Arch Pediatr Adolesc Med 2007;161:641-649.
19.
Plener PL, Fischer CJ, In-Albon T, Rollett B, Nixon MK, Groschwitz RC, Schmid M: Adolescent non-suicidal self-injury (NSSI) in German-speaking countries: comparing prevalence rates from three community samples. Soc Psychiatry Psychiatr Epidemiol 2013;48:1439-1445.
20.
Whitlock J: 140. Non-suicidal self-injury in adolescents and young adults: general trends and gender differences. J Adolesc Health 2011;48(suppl):S90.
21.
Toprak S, Cetin I, Guven T, Can G, Demircan C: Self-harm, suicidal ideation and suicide attempts among college students. Psychiatry Res 2011;187:140-144.
22.
Gratz KL, Conrad SD, Roemer L: Risk factors for deliberate self-harm among college students. Am J Orthopsychiatry 2002;72:128-140.
23.
Williams F, Hasking P: Emotion regulation, coping and alcohol use as moderators in the relationship between non-suicidal self-injury and psychological distress. Prev Sci 2010;11:33-41.
24.
Klonsky ED, Oltmanns TF, Turkheimer E: Deliberate self-harm in a nonclinical population: prevalence and psychological correlates. Am J Psychiatry 2003;160:1501-1508.
25.
You J, Leung F, Fu K, Lai CM: The prevalence of nonsuicidal self-injury and different subgroups of self-injurers in Chinese adolescents. Arch Suicide Res 2011;15:75-86.
26.
Yip KS, Ngan MY, Lam I: Pattern of adolescent self-cutting in Hong Kong: reports from school social workers. Int J Adolesc Youth 2003;11:135-156.
27.
Tan ACY, Rehfuss MC, Suarez EC, Parks-Savage A: Nonsuicidal self-injury in an adolescent population in Singapore. Clin Child Psychol Psychiatry 2014;19:58-76.
28.
Baetens I, Claes L, Muehlenkamp J, Grietens H, Onghena P: Non-suicidal and suicidal self-injurious behavior among Flemish adolescents: a web-survey. Arch Suicide Res 2011;15:56-67.
29.
Cerutti R, Manca M, Presaghi F, Gratz KL: Prevalence and clinical correlates of deliberate self-harm among a community sample of Italian adolescents. J Adolesc 2011;34:337-347.
30.
Giletta M, Scholte RHJ, Engels RCME, Ciairano S, Prinstein MJ: Adolescent non-suicidal self-injury: a cross-national study of community samples from Italy, the Netherlands and the United States. Psychiatry Res 2012;197:66-72.
31.
Csorba J, Szélesné EF, Steiner P, Farkas L, Németh A: Symptom specificity of adolescents with self-injurious behavior (in Hungarian). Psychiatr Hung 2005;20:456-462.
32.
Fikke LT, Melinder A, Landrø NI: Executive functions are impaired in adolescents engaging in non-suicidal self-injury. Psychol Med 2011;41:601-610.
33.
Zetterqvist M, Lundh LG, Dahlström Ö, Svedin CG: Prevalence and function of non-suicidal self-injury (NSSI) in a community sample of adolescents, using suggested DSM-5 criteria for a potential NSSI disorder. J Abnorm Child Psychol 2013;41:759-773.
34.
Asgeirsdottir BB, Sigfusdottir ID, Gudjonsson GH, Sigurdsson JF: Associations between sexual abuse and family conflict/violence, self-injurious behavior, and substance use: the mediating role of depressed mood and anger. Child Abuse Negl 2011;35:210-219.
35.
Hasking P, Momeni R, Swanell S, Chia S: The nature and extent of non-suicidal self-injury in a non-clinical sample of young adults. Arch Suicide Res 2008;12:208-218.
36.
Nock MK, Prinstein MJ: A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol 2004;72:885-890.
37.
Chapman AL, Gratz KL, Brown MZ: Solving the puzzle of deliberate self-harm: the experiential avoidance model. Behav Res Ther 2006;44:371-394.
38.
Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993.
39.
Linehan MM, Bohus M, Lynch TR: Dialectical behavior therapy for pervasive emotion dysregulation: theoretical and practical underpinnings; in Gross JJ (ed): Handbook of Emotion Regulation. New York, Guilford, 2007, pp 581-605.
40.
Nock MK: Actions speak louder than words: an elaborated theoretical model of the social functions of self-injury and other harmful behaviors. Appl Prev Psychol 2008;12:159-168.
41.
Klonsky ED: The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev 2007;27:226-239.
42.
Rottenberg J, Gross JJ: When emotion goes wrong: realizing the promise of affective sciences. Clin Psychol (New York) 2003;10:227-232.
43.
Ekman P: Emotions Revealed: Recognizing Faces and Feelings to Improve Communication and Emotional Life. New York, Times Books, 2003.
44.
Scherer KR: What are emotions? And how can they be measured? Soc Sci Inf 2005;44:695-729.
45.
Tellegen A, Watson D, Clark LA: On the dimensional and hierarchical structure of affect. Psychol Sci 1999;10:297-303.
46.
Watson D, Tellegen A: Toward a consensual structure of mood. Psychol Bull 1985;98:219-235.
47.
Barrett LF, Russell JA: The structure of current affect: controversies and emerging consensus. Curr Dir Psychol Sci 1999;8:10-14.
48.
Gross JJ: Emotion regulation; in Lewis M, Haviland-Jones JM, Barrett LF (eds): Handbook of Emotions. New York, Guilford, 2008, pp 497-512.
49.
Mauss IB, Levenson RW, McCarter L, Wilhelm FH, Gross JJ: The tie that binds? Coherence among emotion experience, behavior, and physiology. Emotion 2005;5:175-190.
50.
Frijda NH: The Emotions. Cambridge, Cambridge UP, 1986.
51.
Gross JJ: The emerging field of emotion regulation: an integrative review. Rev Gen Psychol 1998;2:271-299.
52.
Jones IH, Congiu L, Stevenson J, Strauss N, Frei DZ: A biological approach to two forms of human self-injury. J Nerv Ment Dis 1979;167:74-78.
53.
Claes L, Klonsky ED, Muehlenkamp JJ, Kuppens P, Vandereycken W: The affect-regulation function of non-suicidal self-injury in eating disordered patients: which affect states are regulated? Compr Psychiatry 2010;51:386-392.
54.
Chapman AL, Dixon-Gordon KL: Emotional antecedents and consequences of deliberate self-harm and suicide attempts. Suicide Life Threat Behav 2007;37:543-552.
55.
Sim L, Adrian M, Zeman J, Cassano M, Friedrich WN: Adolescent deliberate self-harm: linkages to emotion regulation and family emotional climate. J Res Adolesc 2009;19:75-91.
56.
Laye-Gindhu A, Schonert-Reichl KA: Non-suicidal self-harm among community: understanding the ‘whats' and ‘whys' of self-harm. J Youth Adolesc 2005;34:447-457.
57.
Klonsky ED: The functions of self-injury in young adults who cut themselves: clarifying the evidence for affect-regulation. Psychiatry Res 2009;166:260-268.
58.
Kemperman I, Russ MJ, Shearin E: Self-injurious behavior and mood regulation in borderline patients. J Pers Disord 1997;11:146-157.
59.
Kamphuis JH, Ruyling SB, Reijntjes AH: Testing the emotion regulation hypothesis among self-injuring females: evidence for differences across mood states. J Nerv Ment Dis 2007;195:912-918.
60.
Kleindienst N, Bohus M, Ludäscher P, Limberger MF, Kuenkele K, Ebner-Priemer UW, Chapman AL, Reicherzer M, Stieglitz R-D, Schmahl C: Motives for nonsuicidal self-injury among women with borderline personality disorder. J Nerv Ment Dis 2008;196:230-236.
61.
Haines J, Williams CL, Brain KL, Wilson GV: The psychophysiology of self-mutilation. J Abnorm Psychol 1995;104:471-489.
62.
Brain KL, Haines J, Williams CL: The psychophysiology of self-mutilation: evidence of tension reduction. Arch Suicide Res 1998;4:227-242.
63.
Reitz S, Krause-Utz A, Pogatzki-Zahn EM, Ebner-Priemer U, Bohus M, Schmahl C: Stress regulation and incision in borderline personality disorder: a pilot study modeling cutting behavior. J Pers Disord 2012;26:606-615.
64.
Nock MK, Prinstein MJ, Sterba SK: Revealing the form and function of self-injurious thoughts and behaviors: a real-time ecological assessment study among adolescents and young adults. J Abnorm Psychol 2009;118:816-827.
65.
Armey MF, Crowther JH, Miller IW: Changes in ecological momentary assessment reported affect associated with episodes of nonsuicidal self-injury. Behav Ther 2011;42:579-588.
66.
Paul T, Schroeter K, Dahme B, Nutzinger D: Self-injurious behavior in women with eating disorders. Am J Psychiatry 2002;159:408-411.
67.
Kumar G, Pepe D, Steer RA: Adolescent psychiatric inpatients' self-reported reasons for cutting themselves. J Nerv Ment Dis 2004;192:830-836.
68.
Gordon KH, Selby EA, Anestis MD, Bender TW, Witte TK, Braithwaite S, van Orden KA, Bresin K, Joiner TE Jr: The reinforcing properties of repeated deliberate self-harm. Arch Suicide Res 2010;14:329-341.
69.
Muehlenkamp JJ, Engel SG, Wadeson A, Crosby RD, Wonderlich SA, Simonich H, Mitchell JE: Emotional states preceding and following acts of non-suicidal self-injury in bulimia nervosa patients. Behav Res Ther 2009;47:83-87.
70.
Russ MJ, Roth SD, Lerman A, Kakuma T, Harrison K, Shindledecker RD, Hull J, Mattis S: Pain perception in self-injurious patients with borderline personality disorder. Biol Psychiatry 1992;32:501-511.
71.
Russ MJ, Roth SD, Kakuma T, Harrison K, Hull JW: Pain perception in self-injurious borderline patients: naloxone effects. Biol Psychiatry 1994;35:207-209.
72.
Franklin JC, Hessel ET, Aaron RV, Arthur MS, Heilbron N, Prinstein MJ: The functions of nonsuicidal self-injury: support for cognitive-affective regulation and opponent processes from a novel psychophysiological paradigm. J Abnorm Psychol 2010;119:850-862.
73.
Ochsner K, Gross JJ: The neural architecture of emotion regulation; in Gross JJ (ed): Handbook of Emotion Regulation. New York, Guilford, 2007, pp 87-109.
74.
Ray RD, Wilhelm FH, Gross JJ: All in the mind's eye? Anger rumination and reappraisal. J Pers Soc Psychol 2008;94:133-145.
75.
Gross JJ, Thompson R: Emotion regulation: conceptual foundations; in Gross JJ (ed): Handbook of Emotion Regulation. New York, Guilford, 2007, pp 3-24.
76.
Hilt LM, Cha CB, Nolen-Hoeksema S: Nonsuicidal self-injury in young adolescent girls: moderators of the distress-function relationship. J Consult Clin Psychol 2008;76:63-71.
77.
Najmi S, Wegner DM, Nock MK: Thought suppression and self-injurious thoughts and behaviors. Behav Res Ther 2007;45:1957-1965.
78.
Hulbert C, Thomas R: Predicting self-injury in BPD: an investigation of the experiential avoidance model. J Pers Disord 2010;24:651-663.
79.
Niedtfeld I, Schulze L, Kirsch P, Herpertz S, Bohus M, Schmahl C: Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury. Biol Psychiatry 2010;68:383-391.
80.
Weierich MR, Nock MK: Posttraumatic stress symptoms mediate the relation between childhood sexual abuse and nonsuicidal self-injury. J Consult Clin Psychol 2008;76:39-44.
81.
Armey MF, Crowther JH: A comparison of linear versus non-linear models of aversive self-awareness, dissociation, and non-suicidal self-injury among young adults. J Consult Clin Psychol 2008;76:9-14.
82.
Brodsky BS, Cloitre M, Dulit RA: Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder. Am J Psychiatry 1995;152:1788-1792.
83.
Haas B, Popp F: Why do people injure themselves? Psychopathology 2006;39:10-18.
84.
Muehlenkamp JJ, Claes L, Smits D, Peat CM, Vandereycken W: Non-suicidal self-injury in eating disordered patients: a test of a conceptual model. Psychiatry Res 2011;188:102-108.
85.
Zanarini M, Laudate C, Frankenburg F, Reich D, Fitzmaurice G: Predictors of self-mutilation in patients with borderline personality disorder: a 10-year follow-up study. J Psychiatr Res 2011;45:823-828.
86.
Russ MJ, Shearin EN, Clarkin JF, Harrison K, Hull JW: Subtypes of self-injurious patients with borderline personality disorder. Am J Psychiatry 1993;150:1869-1871.
87.
Ludäscher P, Valerius G, Stiglmayr CE, Mauchnik J, Lanius RA, Bohus M, Schmahl C: Pain sensitivity and neural processing during dissociative states in patients with borderline personality disorder with and without comorbid posttraumatic stress disorder: a pilot study. J Psychiatry Neurosci 2010;35:177-184.
88.
Nock MK, Prinstein MJ: Contextual features and behavioral functions of self-mutilation among adolescents. J Abnorm Psychol 2005;114:140-146.
89.
Carleton RN, Abrams MP, Asmundson GJG: The Attentional Resource Allocation Scale (ARAS): psychometric properties of a composite measure for dissociation and absorption. Depress Anxiety 2010;27:775-786.
90.
Wells A, Davies MI: The Thought Control Questionnaire: a measure of individual differences in the control of unwanted thoughts. Behav Res Ther 1994;32:871-878.
91.
Leibenluft E, Gardner DL, Cowdry RW: The inner experience of the borderline self-mutilator. J Pers Disord 1987;1:317-324.
92.
Roseman IJ, Wiest C, Swartz TS: Phenomenology, behaviors, and goals differentiate discrete emotions. J Pers Soc Psychol 1994;67:206-221.
93.
Nelissen RMA, Zeelenberg M: When guilt evokes self-punishment: evidence for the existence of a Dobby Effect. Emotion 2009;9:118-122.
94.
Glassman LH, Weierich MR, Hooley JM, Deliberto TL, Nock MK: Child maltreatment, non-suicidal self-injury, and the mediating role of self-criticism. Behav Res Ther 2007;45:2483-2490.
95.
Baumeister RF: Masochism as escape from self. J Sex Res 1988;25:28-59.
96.
Sher L, Stanley B: The role of endogenous opioids in the pathophysiology of self-injurious and suicidal behavior. Arch Suicide Res 2008;12:299-308.
97.
Bresin K, Gordon KH: Endogenous opioids and nonsuicidal self-injury: a mechanism of affect regulation. Neurosci Biobehav Rev 2013;37:374-383.
98.
Stanley B, Sher L, Wilson S, Ekman R, Huang YY, Mann JJ: Non-suicidal self-injurious behavior, endogenous opioids and monoamine neurotransmitters. J Affect Disord 2010;124:134-140.
99.
Harris RE, Zubieta JK, Scott DJ, Napadow V, Gracely RH, Clauw DJ: Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on μ-opioid receptors (MORs). Neuroimage 2009;47:1077-1085.
100.
Nixon MK, Cheng M, Cloutier P: An open trial of auricular acupuncture for the treatment of repetitive self-injury in depressed adolescents. Can Child Adolesc Psychiatr Rev 2003;12:10-12.
101.
Agarwal LJ, Berger CE, Gill L: Naltrexone for severe self-harm behavior: a case report. Am J Psychiatry 2011;168:437-438.
102.
Griengl H, Sendera A, Dantendorfer K: Naltrexone as a treatment of self-injurious behavior: a case report. Acta Psychiatr Scand 2001;103:234-236.
103.
McGee MD: Cessation of self-mutilation in a patient with borderline personality disorder treated with naltrexone. J Clin Psychiatry 1997;58:32-33.
104.
Sonne S, Rubey R, Brady K, Malcolm R, Morris T: Naltrexone treatment of self-injurious thoughts and behaviors. J Nerv Ment Dis1996;184:192-195.
105.
Norelli LJ, Smith HS, Sher L, Blackwood TA: Buprenorphine in the treatment of non-suicidal self-injury: a case series and discussion of the literature. Int J Adolesc Med Health 2013;25:323-330.
106.
Glenn CR, Klonsky ED: The role of seeing blood in non-suicidal self-injury. J Clin Psychol 2010;66:466-473.
107.
Bradley MM, Codispoti M, Cuthbert BN, Lang PJ: Emotion and motivation I: defensive and appetitive reactions in picture processing. Emotion 2001;1:276-298.
108.
Friedman BH: An autonomic flexibility-neurovisceral integration model of anxiety and cardiac vagal tone. Biol Psychol 2007;74:185-199.
109.
Solomon RL: The opponent-process theory of acquired motivation: the costs of pleasure and the benefits of pain. Am Psychol 1980;35:691-712.
110.
Joiner TE Jr: Why People Die by Suicide. Cambridge, Harvard UP, 2007.
111.
Gratz KL, Tull MT: The relationship between emotion dysregulation and deliberate self-harm among inpatients with substance use disorders. Cognit Ther Res 2010;34:544-553.
112.
Muehlenkamp JJ, Kerr PL, Bradley AR, Adams Larsen M: Abuse subtypes and nonsuicidal self-injury: preliminary evidence of complex emotion regulation patterns. J Nerv Ment Dis 2010;198:258-263.
113.
Ohmann S, Schuch B, König M, Blaas S, Fliri C, Popow C: Self-injurious behavior in adolescent girls: association with psychopathology and neuropsychological functions. Psychopathology 2008;41:226-235.
114.
Bloom CM, Holly S: Toward new avenues in the treatment of nonsuicidal self-injury. J Pharm Pract 2011;24:472-477.
115.
Sachsse U, von der Heyde S, Huether G: Stress regulation and self-mutilation. Am J Psychiatry 2002;159:672.
116.
Kaess M, Hille M, Parzer P, Maser-Gluth C, Resch F, Brunner R: Alterations in the neuroendocrinological stress response to acute psychosocial stress in adolescents engaging in nonsuicidal self-injury. Psychoneuroendocrinology 2011;37:157-161.
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