INTRODUCTION
Nonsuicidal self-injury (NSSI) is a critical issue in adolescent mental health and refers to deliberate harm to one’s body without suicidal intent. NSSI often represents an attempt to cope with difficulties with emotional regulation, extreme stress, or psychological distress. Adolescents may engage in self-injury to reduce negative emotions such as tension, anxiety, and guilt, achieve temporary relief, or to resolve interpersonal conflicts. In some cases, it is carried out as a form of self-punishment [1]. Recent research emphasizes that NSSI can manifest as a wide range of complex behavioral patterns associated with various psychological problems in adolescents [2,3].
While most individuals are fully aware of the purpose of self-injury, and these actions are typically defined as intentional and conscious, there are rare cases where self-injury occurs unintentionally, without conscious awareness or intent. Such cases present characteristics that differ from the conventional definition of self-injury and require distinct clinical understanding and management. This report presents a case demonstrating a pattern that deviates from the traditional definition of self-injury, where self-harm occurs repeatedly without any intent or awareness. It examines the potential causes and pathophysiological mechanisms involved and discusses future clinical approaches and management strategies for similar cases.
CASE REPORT
A 16-year-old male high school student presented with repeated self-inflicted injuries on his forearms over the past 3 weeks, caused by using his fingernails to scratch his skin. The injuries were primarily located on the forearms, with approximately 30 linear abrasions of, 2 to 3 cm in length, observed in both arms. The abrasions appeared to be deep scratches caused by forceful scratching with fingernails, and older wounds had progressed to dark brown pigmentation. The patient reported no recollection of these injuries and denied any intent of self-harm or suicide. He expressed concern after discovering approximately 10 new injuries each morning upon awakening. The patient’s parents observed him scratching his arms vigorously during sleep and reported that he did not wake up, even when they tried to stop him. Despite academic stress and pressure, he maintained good grades and showed no significant symptoms of depression or anxiety. His daily functioning at school and home was well maintained. There was no family history of atopic dermatitis or other allergic or skin conditions. To rule out organic causes, brain magnetic resonance imaging and sleep electroencephalography (EEG) were performed, but no abnormalities were found.
Developmentally, he was the second child in a family with one son and one daughter, and demonstrated advanced language and motor development compared to his peers. He was often praised for being proactive in his studies and for performing daily tasks without prompting. During middle school, he was somewhat introverted, but maintained good interpersonal relationships and consistently achieved high academic performance. The family environment was generally supportive and calm. Although his parents did not emphasize academic achievement, he placed high importance on his academic success since elementary school onward. Six months prior, after entering a prestigious private high school, he reported feeling increased pressure regarding his grades. After entering high school, he ceased all recreational activities 4 weeks before the exams and reduced his sleep to 5 hours per night to focus solely on studying. He also reported striving to act perfectly and appear exemplary, including fulfilling his responsibilities as a school officer.
A psychological evaluation showed that his Full-Scale Intelligence Quotient (FSIQ), measured by the Korean Wechsler Adult Intelligence Scale-Fourth Edition (K-WAIS-IV), was 111, with slightly lower scores in working memory, but overall evenly distributed cognitive function. His memory quotient, assessed using the Rey-Kim Memory Test II, was 108 (70th percentile). The Child’s Depression Inventory score was 14, indicating no significant depressive mood, and the child behavior checklist completed by his parents showed no clinical range items. The Rorschach test suggests a high level of concern for somatic symptoms, with pathological and anatomical responses. The temperament and character inventory assessment showed a novelty seeking T-score of 26 (1st percentile), harm avoidance (HA) T-score of 76 (100th percentile), and social sensitivity T-score of 27 (1st percentile), indicating an extreme L-H-L (methodical/obsessional) temperament, suggesting a stable and perfectionistic tendency.
During the initial 2 weeks of clinical assessment, wearing gloves during sleep was recommended to prevent further arm lesions. However, when he stopped wearing gloves, the unintentional self-harming behavior recurred nightly. The patient was diagnosed with masked depression and facial dermatitis, and a 12-week course of escitalopram (5 to 10 mg) was initiated. Concurrently, cognitive behavioral therapy (CBT) sessions were conducted weekly for 8 weeks to address depression and perfectionistic tendencies. During this period, no self-harming behavior was observed, and his anxiety about academic performance decreased, allowing his treatment at the hospital to conclude. Supportive counseling by a psychologist continued due to his excessive perfectionism and academic pressure. However, 6 months later, he returned to the clinic with approximately 30 new injuries to his arms and neck from scratching with his nails during sleep, which had occurred before an upcoming school exam. The wounds were deeper than before, with two requiring suturing due to repeated injuries in the same area. Repetitive self-harm prevented proper wound healing and caused significant pigmentation, necessitating additional dermatological treatment. He reported no suicidal or self-harming intent and both he and his parents reported that his school and daily life were well maintained. However, he expressed severe anxiety about exams and grades and reported being afraid of falling asleep due to the unintentional self-harm. Despite the continued use of escitalopram (10 mg), aripiprazole (2 mg), and melatonin (2 mg) along with protective measures such as gloves and arm sleeves, new lesions continued to appear daily for 4 weeks. After discussing the situation with the parents, the medical team advised the patient to take a break from school, leading to his decision to leave high school. Subsequently, the patient was homeschooled, and self-harm during sleep ceased. Medication treatment concluded 16 weeks after the recurrence. The patient later passed the high school equivalency exam and entered college. No further self-harming behavior was observed during the 2-year follow-up period.
Ethical statement
The study was approved by the Institutional Review Boards of Samsung Changwon Hospital (2024-09-013). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent by the patients was waived due to a retrospective nature of our study.
DISCUSSION
This case report presents the rare instance of a 16-year-old male adolescent exhibiting unintentional self-harming behavior during sleep, characterized by repeated injuries to his arms and neck without conscious intent or awareness. Although the patient demonstrated a tendency toward stability and perfectionism, he did not display prominent symptoms of depression or anxiety. His impairments in daily and social functioning were mild, distinguishing this case from typical self-injurious behavior. In such cases, psychiatric diagnoses are often unclear. According to the diagnostic criteria for NSSI in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5 TR) [1], it specifies “self-injurious behavior without suicidal intent,” which involves a deliberate attempt to cause physical harm. In this case, the lack of intent for self-injury, although not clearly linked to emotion regulation, aligns with NSSI, in that it may represent a physical manifestation of severe stress.
Clinically, a differential diagnosis was necessary to rule out organic factors in this case. The occurrence of self-injurious behaviors during sleep without awareness suggests the possibility of a sleep disorder. Among sleep-related behavioral disorders, non-rapid eye movement sleep behavior disorder presents with similar symptoms [4]. However, no abnormalities were found on the sleep EEG in this case. The onset of self-harming behavior coincided with increased academic pressure following the patient’s transition to high school, suggesting a potential link between psychological stress and unintentional self-injury. His perfectionistic traits and high HA scores may have played a significant role in his behavior. Maladaptive perfectionism is known to have a strong correlation with NSSI [5]. This form of perfectionism is characterized by overly critical self-evaluations, concerns about making mistakes, and a fear of negative evaluation by others. Research indicates that these traits can significantly increase the risk of engaging in self-harming behaviors, as they often lead to heightened psychological distress, emotional dysregulation, and difficulties in coping with perceived failures or setbacks. The patients’ tendency to suppress emotions may have resulted in minimal expression of depression or anxiety and a limited impact on daily functioning. The combination of these personality traits and stress factors may trigger unintentional self-injurious behavior during sleep [6].
Although the patient received medication and CBT, the self-harming behavior continued to recur. The persistence of unintentional self-harm behaviors during sleep, despite medication and protective measures, suggests that existing therapeutic approaches may not have been sufficient. The fact that the patient’s self-injurious behavior ceased after deciding to leave high school to relieve academic pressure strongly supports the link between stress and self-injury. In this case, no clear organic causes were identified. Instead, academic stress and perfectionism played crucial roles. The absence of significant impairments in daily functioning or mood symptoms such as depression or anxiety suggests that stress management and psychological support could be critical therapeutic approaches for similar cases.
This case provides an opportunity to expand our understanding of how unintentional self-harm behaviors are related to psychological stress, perfectionism, and emotion-suppressing tendencies. Self-injurious behaviors that occur without conscious awareness may require a different approach in terms of pathophysiology and therapeutic management. This case highlights the need for a thorough psychological evaluation and careful assessment of stress factors in patients presenting with similar symptoms in clinical practice. In conclusion, this case emphasizes the necessity for a more integrated and individualized approach to evaluate and treat unintentional self-injurious behaviors, particularly highlighting the importance of managing psychological stress in adolescence.
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