The addictiveness of self-harm

Non-suicidal self-injury (NSSI) has no well-established diagnosis yet. While episodes of self-inflicted injury that occurred only once or a twice are considered NSSI by some researchers and health-care providers, another definition argues that NSSI is a repetitive behavior (Sandman & Hetrick, 1995). NSSI has no diagnosis in the DSM-5 yet, but it is included as a condition for further study and the proposed diagnosis states that NSSI is a repetitive behavior that has occurred “on 5 or more days” in the last year (American Psychiatric Association, 2013).

Most individuals who self-injure quit this behavior after a few years but for approximately 20% of them, the behavior persists for more than five years (Liu, 2017). The behavior can become habitual and persists into adulthood (Stanley, et al., 2010) and is often perceived as addictive by people who self-injure (Buser & Buser, 2013). We may therefore wonder what factors lead to the repetition of NSSI and whether repeated self-harm can be considered an addiction. A good understanding of this behavior and its nature might help finding more appropriate treatment options.


Individuals who self-harm often report addictive qualities to this behavior and several studies show results that seem to validate this hypothesis (Nixon & Cloutier, 2002; Martin, et al., 2013; Buser & Buser, 2013). The DSM-5 (American Psychiatric Association, 2013) suggests individuals may experience a “dependence on repeatedly engaging it” and similarities with substance use disorder (SUD) and behavioral addiction have been pointed out, such as loss of control, tolerance, withdrawal, relapse and continued use despite negative consequences (Buser & Buser, 2013; Blasco-Fontecilla, et al., 2016; Guérin-Marion, Martin, Deneault, Lafontaine, & Bureau, 2018).

People with NSSI often have difficulties to stop the behavior. Similarly to people with substance use disorder and other addictions, they frequently experience ambivalence, that is to say they know their behavior is a problem, they want to stop but still engage in self-harm (Buser & Buser, 2013; Yale University, Ellen Edens, 2020). The DSM-5 also notes that the behavior can “cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning” (American Psychiatric Association, 2013). These aspects have similarities to the loss of control and consequences caused by SUD and addictions in general.

Moreover, people with NSSI often report feeling “urges” to self-harm, having difficulties to resist these urges and suffering from post-cessation dysphoria (Nixon & Cloutier, 2002; Roberts, 2003; Buser & Buser, 2013). The DSM-5 proposed criteria state that people may experience cravings, “a period of preoccupation with the intended behavior that is difficult to control” “prior to engaging in the act” and frequently think about the behavior. Furthermore, tolerance can be experienced by people who self-harm. They often report an escalation of the frequency and severity of NSSI in order to achieve the same effect. They may gradually need more injuries per session, injure themselves more often or cut deeper in order to experience a feeling of relief (Nixon & Cloutier, 2002; Roberts, 2003; Buser & Buser, 2013; American Psychiatric Association, 2013). The switch from needles to razor blades for example, or the use of more methods of self-harm might be a consequence of tolerance. Previous NSSI gets individuals used to pain and fear. As they learn that the behavior will be followed by a reward, become less afraid of injuring themselves and deterrents gradually disappear, the habit requires less effort, becomes more automatic, habitual and repetitive (Gordon, et al., 2010; Blasco-Fontecilla, et al., 2016; Liu, 2017). Individuals who self-harm may exhibit higher pain tolerance (Gordon, et al., 2010; Liu, 2017), however it is unclear whether this high pain tolerance is a cause or a consequence of NSSI (Liu, 2017).

Therefore, non-suicidal self-injury’s addictive features have some similarities to the three C’s of substance use disorder: namely loss of control, consequences and cravings. As the DSM-5 notes, NSSI may resemble an addiction. Yet, while NSSI similarities to addiction is undeniable, its status as an addiction is debatable.


Findings about the addictiveness of non-suicidal self-injury are inconsistent. Some research suggest that individuals may experience physical dependency to opiates released during an episode of self-harm as they have addictive properties (Sandman & Hetrick, 1995; Groschwitz & Plener, 2012). This theory, known as the endorphin theory, is sometimes mentioned by people who self-harm. However, it is often contested. Nixon (2002) notes that “symptoms of endogenous opiate withdrawal (e.g., anxiety, irritability, emotional lability) from self-injury may be difficult to distinguish from the dysphoric states that this population already experiences”. Moreover, Pembroke, Shaw & Thomas (2007) points out the fact that if people who self-harm were addicted to endorphins only, they could not stop for long period as it is sometimes the case. Other research suggest that NSSI might be a behavioral addiction (Buser & Buser, 2013; Blasco-Fontecilla, et al., 2016), but Buser & Buser point out that addictive features are not experienced by every individuals who self-harm, suggesting that NSSI may not always be an addiction, but may become one only for some people. As Blasco-Fontecilla, et al. explain, (2016) some authors “were of the opinion that the repetition of NSSI was better explained by emotional processes than by addiction mechanisms”.

Self-harm has several functions and is often said to be used to regulate negative emotions and to release tension. Unlike substance use disorder, self-harm may be mainly negatively reinforced, that is to say be used as a way to avoid or reduce negative feelings, and not as a way to feel positive feelings. Therefore, NSSI might be limited to a specific context only, when the individual experiences negative feelings, and be craved only in those situations. A study found that cravings in NSSI was significantly lower than in SUD since it was mainly experienced in case of negative emotions (Nixon & Cloutier, 2002; Gordon, et al., 2010; Victor, Glenn, & Klonsky, 2012; Liu, 2017; Guérin-Marion, Martin, Deneault, Lafontaine, & Bureau, 2018). We might surmise that the withdrawal feelings that is reported by some individuals is more due to the lack of coping mechanism in a negative situation than to the addictive properties of self-harm. It might explain why, as mentioned above, some people can stop for a long period of time, possibly because they feel better and have less need to self-harm. While emotion regulation remains the function that is the most linked to frequent NSSI, some studies find that the sensation-seeking function is greatly linked to the maintenance of self-harm as well, which suggests that NSSI can also be positively reinforced, although probably to a lesser extent (Stanley, et al., 2010; Martin, et al., 2013; Guérin-Marion, Martin, Deneault, Lafontaine, & Bureau, 2018). It might be why some individuals report feeling a “buzz” when they self-harm. This theory is supported by the DSM-5 proposed criteria as well. Gordon, et al. (2010) suggest NSSI may be “more likely to become habitual through positive reinforcement”.


To conclude, while self-harm can have addictive features, it is not necessarily an addiction. Treating it as an addiction only might be ineffective since it is often primarily an emotion-regulation behavior. Yet, NSSI is complex and according to Guérin-Marion et al. (2018), “greater endorsement of addictive features is associated with more frequent NSSI, a longer duration of NSSI, unintentionally severe injury and comorbid suicidal ideation”. It may therefore be important to learn to recognize these addictive features in order to help those at greater risk, to know whether or not an individual is addicted to self-harm and find appropriate, effective treatments to each situation. Counselling models used to treat substance use disorder and process addictions such as motivation interviewing (MI) might be used to help some people with NSSI. MI is a non-judgmental empathetic approach of interaction that uses a patient’s ambivalence, acknowledges the positive functions of an unhealthy behavior while also highlighting its negative consequences and aims at enhancing the patient’s motivation to change (Buser & Buser, 2013; Yale University, Ellen Edens, 2020). It may be disappointing to some that this article does not inform whether or not NSSI is an addiction. As we have seen studies are inconsistent but it is a reminder that each individual who self-harms is different and does so for different reasons, and we should therefore avoid generalization.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo, L., Perteguer-Barrio, R., & de Leon, J. (2016). The Addictive Model of Self-Harming (Non-suicidal and Suicidal) Behavior. Frontiers in Psychiatry, 7(8).

Buser, T. J., & Buser, J. K. (2013, April). Conceptualizing Nonsuicidal Self-Injury as a Process Addiction: Review of Research and Implications for Counselor Training and Practice. Journal of Addictions & Offender Counseling, 34, pp. 16-29.

Gordon, K. H., Selby, E. A., Anestis, M. D., Bender, T. W., Witte, T. K., Braithwaite, S., . . . Joiner Jr., T. E. (2010). The Reinforcing Properties of Repeated Deliberate Self-Harm. Archives of Suicide Research, 14(4), pp. 329-341.

Groschwitz, R. C., & Plener, P. L. (2012). The Neurobiology of Non-suicidal Self-injury (NSSI): A review. 3, pp. 24-32.

Guérin-Marion, C., Martin, J., Deneault, A.-A., Lafontaine, M.-F., & Bureau, J.-F. (2018, June). The functions and addictive features of non-suicidal self-injury: A confirmatory factor analysis of the Ottawa self-injury inventory in a university sample. Psychiatry Research, 264, pp. 316-321.

Liu, R. T. (2017). Characterizing the course of non-suicidal self-injury: A cognitive neuroscience perspective. Neuroscience and Biobehavioral Reviews.

Martin, J., Cloutier, P. F., Levesque, C., Jean-François, B., Marie-France, L., & K., N. M. (2013). Psychometric Properties of the Functions and Addictive Features Scales of the Ottawa Self-Injury Inventory: A Preliminary Investigation Using a University Sample. Psychological Assessment, 25(3), pp. 1013-1018.

Nixon, M. K., & Cloutier, P. F. (2002, November). Affect Regulation and Addictive Aspects of Repetitive Self-Injury in Hospitalized Adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 41(11), pp. 1333-1341.

Pembroke, L., Shaw, C., & Thomas, P. (2007, May). Biological reductionism of self-harm. Mental Health Practice, pp. 16-17.

Roberts, N. (2003, August). Adolescent Self–Mutilatory Behavior: Psychopharmacological Treatment. Child and Adolescent Psychopharmacology News, 8(5), pp. 10-12.

Sandman, C. A., & Hetrick, W. P. (1995). Opiate Mechanisms in Self-Injury. Mental Retardation and Developmental Disabilities Research Reviews, 1(2), pp. 130-136.

Stanley, B., Sher, L., Wilson, S., Ekman, R., Huang, Y.-y., & Mann, J. J. (2010, July). Nonsuicidal Self-Injurious Behavior, Endogenous Opioids and Monoamine Neurotransmitters. J Affect Disord, 124(1-2), pp. 134-140.

Victor, S. E., Glenn, C. R., & Klonsky, E. D. (2012, May 15). Is non-suicidal self-injury an “addiction”? A comparison of craving in substance use and non-suicidal self-injury. Psychiatry Res, 197(1-2), pp. 73-77.

Yale University, Ellen Edens. (2020). Module 1: “How can I show compassion toward patients with substance use disorders?”. Addiction Treatment: Clinical Skills for Healthcare Providers. Retrieved from