Direct and indirect self-injury: Is it really all the same?

Alessandra D'Agostino, Marco Boni, Antonella Aportone, Raffaele Pepi, Mario Rossi Monti


Nonsuicidal self-injury commonly refers to the direct and deliberate destruction of body tissue without intent to die (e.g., cutting and burning). However, people may also use indirect ways to mistreat or abuse themselves without altering bodily tissue (e.g., eating disorders and substance abuse). The objective of this study is to explore similarities and differences between direct and indirect forms of self-injury in order to see if a psychopathological continuum of self-injurious behaviors can be observed. Participants were adult psychiatric patients presenting: (a) direct (e.g., cutting) and indirect (e.g., eating disorders) self-injury (Group 1); (b) only indirect (e.g., eating disorders) self-injury (Group 2); (c) neither direct nor indirect self-injury (Group 3). A group of healthy controls (Group 4) was also added, reaching a total of 144 participants. Direct self-harming behaviors, eating disorders, personality disorders, and clinical symptoms were assessed. No significant differences were observed between patients with direct and indirect self-harm and patients with only indirect self-harm in any clinical or personality variable, except for histrionic personality disorder. Results support evidence for the hypothesis that direct and indirect self-harm are related behaviors lying on a same psychopathological continuum, even if, on closer inspection, those who engage in NSSI, in addition to indirect self-injury, do seem to have “something more” from a clinical point of view. More research on larger samples is needed.


Self-injury; Direct self-injury; Indirect self-injury; Cutting; Eating disorders.

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