Nonsuicidal self-injury in Indian adolescents: Nonexistent or unacknowledged?

NSSI includes a range of behaviors that cause direct and deliberate harm to self (Nock, 2009) generally in response to distressing negative affective states (Nock, 2010). Even though NSSI has garnered a lot of interest in Western countries due to its dramatic nature and its emotional, social and physical implications, this is a neglected entity in LMICs including India. There are a variety of possible reasons for the neglect of this phenomenon in LMICs, ranging from true differences in prevalence (which could possibly be low in LMICs), lack of awareness among clinicians resulting in it being under-diagnosed, the service delivery model wherein only major psychiatric illnesses come to the notice of the public mental health, research resource limitations or societal and stigma related factors.

There is limited research in the area of NSSI in India, which interestingly is home to the largest adolescent population in the world. A recent systematic review of mental health studies conducted in adolescents in India over last 10 years (Aggarwal & Berk, 2014) shows six published studies looking at self-injurious behaviors with no studies exploring NSSI. The studies included in the review have mostly concentrated on suicidal behaviors (SBs) and have estimated the prevalence and have tried to identify the risk factors for SBs. There are no qualitative studies in Indian context describing the adolescents’ understanding of these behaviors, their perception of help or experiences of the family members of services. Empirical research (Favazza, 1996) indicates that as many as 40% of those who engage in self-injury have thoughts about suicide while inflicting the injury, and approximately 50%–85% of people who injure themselves have attempted suicide at least once during their lifetime (Peterson, Freedenthal, Sheldon, & Andersen, 2008). Even though the evidence (Muehlenkamp, Claes, Havertape, & Plener, 2012) suggests a strong correlation between suicidality and self-injurious behavior, clinicians worldwide agree that there are essential qualitative and phenomenological differences distinguishing SB from NSSI. It has been suggested (American Psychiatric Association, 2012) that NSSI can better be understood as a signal of psychological distress, which could increase risk for suicide.

The attempts (Zetterqvist, Lundh, Dahlström, & Svedin, 2013) to elucidate pathogenesis and purpose NSSI could be serving in adolescents have shown that affect regulation and interpersonal functions could be foremost. According to Nock (2008), the social functions of NSSI need to be acknowledged in adolescent samples within the context of adaptive self-help, and NSSI has been suggested (Hilt, Cha, & Nolen-Hoeksema, 2008) to serve multiple and complex interpersonal functions ranging from helping them feel more connected to others, getting attention and avoiding activities and/or other people (both positive and negative reinforcements). The stark differences in social factors between HICs and LMICs makes LMICs a potential natural experiment setting to study the social factors and its relationship with NSSI more closely. For example, the social networks in India are far more dense and proximal as compared to many Western countries, and these differences could translate in differences in working and communication styles, more suited to such networks.

Any effective treatment for NSSI needs to be grounded in a collaborative understanding of the purpose the behavior is serving, risk and protective factors that underlie these behaviors and the perceptions of care. A range of interventions including dialectical behavior therapy (DBT), developmental group therapy and cognitive behavior therapy (CBT) have been studied in adolescents with NSSI with varying evidence base (Gonzales & Bergstrom, 2013). Not surprisingly, the interventions that have shown to be most useful in reducing NSSI in adults or groups of both adolescents and adults (Gonzales & Bergstrom, 2013) include psychosocial assessment in the emergency department, therapeutic assessment by mental health providers, working to discover the meaning of NSSI to the individual patient, continuity of care, encouraging secondary education and providing patient education including first-aid training. More cross-cultural research in this area in LMICs will help to compare and contrast prevalence rates of NSSI in these countries and identify context-specific risk and protective factors to better understand the pathophysiology of NSSI, assist in establishing new and more effective interventions, tailor interventions to different cultural contexts, establish the efficacy of abovementioned interventions in different social contexts and contribute to devising preventive strategies to improve the mental health of adolescents worldwide.