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Understanding self-harm – for health professionals

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About

People who engage in self-harm deliberately hurt their bodies. The term 'self-harm' (also referred to as 'deliberate self-injury' or parasuicide) refers to a range of behaviours, not a mental disorder or illness (1). The most common methods of self-harm among young people are cutting and deliberately overdosing on medication (self-poisoning). Other methods include burning the body, pinching or scratching oneself, hitting or banging body parts, hanging, and interfering with wound healing (2).

In many cases self-harm is not intended to be fatal, but should still be taken seriously. While it might seem counter-intuitive, in many cases, people use self-harm as a coping mechanism to continue to live rather than end their life (3). For many young people, the function of self-harm is a way to alleviate intense emotional pain or distress, or overwhelming negative feelings, thoughts, or memories. Other reasons include self-punishment, to end experiences of dissociation or numbness, or as a way to show others how bad they feel (2,3).

Many young people might try to hide their self-harming behaviour, and only approximately 50% of young people who engage in self-harm seek help (4). Often, this is through informal sources such as friends and family, rather than professionals.

While every person is different, there are some warning signs that someone might be self-harming. Aside from obvious signs such as exposed cuts or an overdose requiring intervention, some less obvious signs could include (5):

Psychological signs:

  • Dramatic changes in mood
  • Changes in sleeping and eating patterns
  • Losing interest and pleasure in activities that were once enjoyed
  • Social withdrawal - decreased participation and poor communication with friends and family
  • Hiding or washing their own clothes separately
  • Avoiding situations where their arms or legs are exposed (eg, swimming)
  • Dramatic drop in performance and interactions at school, work, or home
  • Strange excuses provided for injuries

Physical signs:

  • Unexplained injuries, such as scratches or cigarette burns
  • Unexplained physical complaints such as headaches or stomach pains
  • Wearing clothes that are inappropriate to weather conditions (e.g. long sleeves and pants in very hot weather)
  • Hiding objects such as razor blades or lighters in unusual places (e.g. at the back of drawers)

Onset, prevalence, and burden of suicide and self-harm in young people

The most recent 'Causes of death' publication from the Australian Bureau of Statistics (ABS) indicates that in 2012, suicide was the leading cause of death for young people aged 15-24, followed closely by road traffic accidents (6). In 2012, 70 males aged 15-19 years and 144 males aged 20-24 years died by suicide (6). For young females, 59 aged 15-19 years and 51 aged 20-24 years died by suicide (6). (The number of reported suicide deaths is likely to be underestimated for young people. These figures should be interpreted with caution as they are subject to an ABS revision process which could see them change, see Explanatory note 92 and 94 (7) for further information).

The number of young people who die by suicide in Australia each year is relatively low compared with the number who self-harm. It is difficult to estimate the rate of self-harm as evidence suggests that less than 13% of young people who self-harm will present for hospital treatment (4). Evidence from Australian studies suggest that 6-8% of young people aged 15-24 years engage in self-harm in any 12-month period (8,9). Lifetime prevalence rates are higher, with 17% of Australian females and 12% of males aged 15-19 years, and 24% of females and 18% of males aged 20-24 years reporting self-harm at some point in their life (10). The mean age of onset is approximately 17 years (10).  While suicide is more common among young men, self-harm is more common among young women.

Taken together, suicide and self-harm account for a considerable portion of the burden of disability and mortality among young people. In those aged 10-24 years, self-harm is the seventh leading contributor to the burden of disease in both males and females (11). It is estimated that 21% of "years life lost" due to premature death among Australian youth was due to suicide and self-inflicted injury (12). In addition, non-fatal suicidal behaviour and self-harm are associated with substantial disability and loss of years of healthy life (12).

Risk factors

In adolescents, the risk factors for self-harm are similar to suicide. These include (2):

Sociodemographic factors

  • Sex (female for self-harm and male for suicide)
  • Low socioeconomic status
  • Lesbian, gay, bisexual, or transgender sexual orientation

Significant life events and family adversity

  • Parental separation
  • Adverse childhood experiences
  • History of physical or sexual abuse
  • Family history or mental disorder or suicidal behavior
  • Bullying
  • Interpersonal difficulties

Psychiatric and psychological factors

  • Mental disorder (in particular, depression, anxiety, and ADHD)
  • Misuse of drugs and alcohol
  • Low self-esteem
  • Poor social problem-solving skills
  • Perfectionism
  • Hopelessness

Experiencing a mental health problem is a risk factor for both self-harm and suicide. Evidence suggests that the majority of people who present to hospital following an act of self-harm will meet diagnostic criteria for one or more psychiatric diagnoses at the time of assessment (1). Of these, more than two-thirds would be diagnosed as having depression. While not all young people who self-harm or contemplate suicide have a mental health problem, these behaviours do suggest the experience of psychological distress.

Personality disorders are commonly associated with self-harm in young people, and self-harm is a diagnostic feature of borderline personality disorder (2). However, most people who self-harm do not meet the diagnostic criteria for a personality disorder and it is unhelpful to assume that someone has a personality disorder based on self-harming behavior alone without conducting a thorough assessment (1).

 

References

1. Self-harm. (2004) National Institute for Health and Clinical Excellence (NICE) CG 16, United Kingdom

2. Hawton, K., Saunders, K. E., & O'Connor, R. C. (2012). Self-harm and suicide in adolescents. The Lancet, 379(9834), 2373-2382.

3. Klonsky, E. D. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226-239.

4. Rowe, S. L., French, R. S., Henderson, C., Ougrin, D., Slade, M., & Moran, P. (2014). Help-seeking behaviour and adolescent self-harm: A systematic review. Australian and New Zealand Journal of Psychiatry, 48(12), 1083-1095.

5. Self-harm: Australian treatment guide for consumers and carers. 2009 Royal Australian and New Zealand College of Psychiatrists.

6. Australian Bureau of Statistics (2014). Causes of death, Australia 2012 Cat. no. 3303.0. ABS: Canberra.

7. Australian Bureau of Statistics. Causes of death, Australia, 2012 Explanatory notes, ABS: Canberra.

8. De Leo, D., & Heller, T. S. (2004). Who are the kids who self-harm? An Australian self-report school survey. Medical Journal of Australia, 181(3), 140-144.

9. Moran, P., Coffey, C., Romaniuk, H., Olsson, C., Borschmann, R., Carlin, J. B., & Patton, G. C. (2012). The natural history of self-harm from adolescence to young adulthood: a population-based cohort study. The Lancet, 379(9812), 236-243.

10. Martin, G., Swannell, S. V., Hazell, P. L., Harrison, J. E., & Taylor, A. W. (2010). Self-injury in Australia: a community survey. Medical Journal of Australia, 193(9), 506.

11. Gore, F. M., Bloem, P. J., Patton, G. C., Ferguson, J., Joseph, V., Coffey, C., ... & Mathers, C. D. (2011). Global burden of disease in young people aged 10-24 years: a systematic analysis. The Lancet, 377(9783), 2093-2102.

12. Australian Institute of Health and Welfare. Youth Australians: their health and wellbeing. 2007 Cat. no. PHE 87. Canberra: AIHW

Assessment

Self-harm and suicide are behaviours, not psychiatric disorders, therefore neither is classified in the DSM-5 (1) or the ICD-10 (2). Similarly, suicidal ideation is relatively common and in itself is not a psychiatric disorder and therefore, is also not classified in diagnostic systems. However, while self-harm and suicidal behaviour do not constitute psychiatric diagnoses in and of themselves, it is widely recognised that they often occur in the context of a diagnosable mental disorder.

Studies consistently report that young people who suicide or make a serious suicide attempt often have a recognisable mental disorder at the time, such as depression, anxiety, conduct disorder or substance misuse (3,4).

Assessment Tools

While a number of tools/checklists/scales for risk assessment and management are available, these have poor predictive ability and should not be used in isolation to make treatment decisions (5). To assess whether a young person is engaging in self-harm or suicidal behaviour, a comprehensive clinical interview by a mental health professional is required.

General principals during an assessment (5,6):

  • Initiate a therapeutic relationship by demonstrating acceptance of the person and empathy
  • Engender hope when possible
  • Explore the meaning of self-harm for that person
  • Clarify current difficulties
  • Observe their mental state (both verbal and non-verbal features)

A psychosocial assessment should include an assessment of needs and risks. These could include questions about the person's (5,6):

  • Social and family circumstances
  • Significant relationships that might be supportive or might represent a threat
  • History of mental health difficulties
  • Current mental health difficulties
  • Use of drugs or alcohol
  • Past suicidal intent or self-harm (e.g. methods, frequency)
  • Current self-harm (e.g. methods, frequency)
  • Current desire to die
  • Current suicidal ideas
  • Current suicidal plans
  • Current suicidal intent
  • Access to means to end their life
  • Coping mechanisms and strengths (e.g. things that the person has used successfully in the part to cope with other difficult situations)

 

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.

2. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.

3. Wagner, B. M. (2009). Suicidal behavior in children and adolescents. Yale University Press.

4. Fleischmann, A., Bertolote, J. M., Belfer, M., & Beautrais, A. (2005). Completed suicide and psychiatric diagnoses in young people: a critical examination of the evidence. American Journal of Orthopsychiatry, 75(4), 676.

National Institute for Health and Clinical Excellence. Self-harm: longer-term management. (Clinical guideline CG133). 2012.

Morriss, R., Kapur, N., & Byng, R. (2013). Assessing risk of suicide or self harm in adults. BMJ, 347, f4572.

Treatment

Before deciding upon the most appropriate treatment for a young person who is self-harming or engaging in suicidal behaviours, the management plan should address the young person's immediate safety.

A safety plan is an agreement made between you and the young person who is suicidal that involves actions to keep them safe. It consists of a written list of coping techniques and sources of support the person can use to alleviate the crisis (1).

The young person should be engaged as much as possible in making decisions about a safety plan. When developing the plan, focus on what the young person should be doing, rather than what they shouldn't. The plan should also be for a length of time that the young person feels they can cope with, so that they can feel able to fulfill the agreement and have a sense of achievement (2).

As part of the development of a safety plan, a decision needs to be made as to whether hospitalisation is required, or if the young person can utilise existing support networks, such as family and friends, in carrying out their safety plan. A safety plan should include (1):

  • The young person's early warning signs
  • Coping techniques that might help them feel better
  • People and social settings that provide a distraction
  • People they can contact for help
  • Professionals or agencies they can contact for help, and
  • How they can make the environment safe

A template of a safety plan is available here.

A recent systematic review and meta-analysis (3) found that dialectical behaviour therapy (DBT), cognitive behavioural therapy (CBT), and mentalization-based therapy (MBT) were the most effective interventions for young people who had made a suicide attempt or had self-harm behaviours. Cognitive behavioural therapy with an integrated problem-solving component has also been found to help with underlying factors that might maintain self-harm, such as depression, hopelessness, and problem-solving skills (4). However, these findings must be taken with caution as they are from single trials, and replication of these results is a research priority.

UK Guidelines for self-harm (5,6) suggest the following aims and objectives in the treatment of self-harm:

  • Rapid assessment of physical and psychological need
  • Effective measures to minimise pain and discomfort
  • Timely initiation of treatment, irrespective of the cause of self-harm
  • Harm reduction (from injury and treatment; short-term and longer-term)
  • Rapid and supportive psychosocial assessment (including risk assessment and comordibity)
  • Prompt referral for further psychological, social and psychiatric assessment and treatment when necessary
  • Prompt and effective psychological and psychiatric treatment when necessary
  • An integrated and planned approach to the problems of people who self-harm, involving primary and secondary care, mental and physical healthcare personnel and services, and appropriate voluntary organisations
  • Ensuring that the special issues that apply to children and young people who have self-harmed are properly addressed, such as child protection issues, confidentiality, consent and competence.

References

1. Stanley, B., & Brown, G. K. (2012). Safety planning intervention: a brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19(2), 256-264.

2. Mental Health First Aid Australia. Suicidal thoughts and behaviours: first aid guidelines (Revised 2014). Melbourne: Mental Health First Aid Australia; 2014.

3. Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. R. (2015). Therapeutic Interventions for Suicide Attempts and Self-Harm in Adolescents: Systematic Review and Meta-Analysis. Journal of the American Academy of Child & Adolescent Psychiatry, 54(2), 97-107.

4. Brausch, A. M., & Girresch, S. K. (2012). A review of empirical treatment studies for adolescent nonsuicidal self-injury. Journal of Cognitive Psychotherapy, 26(1), 3-18.

5. National Institute for Health and Clinical Excellence. Self-harm. (Clinical guideline CG16). 2004.

6. National Institute for Health and Clinical Excellence. Self-harm: longer-term management. (Clinical guideline CG133). 2012.

[SD1]http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf

[SD2]http://www.headspace.org.au/what-works/evidence-maps

[SD3]http://www.sciencedirect.com/science/article/pii/S1077722911000630

[SD4]https://mhfa.com.au/sites/mhfa.com.au/files/MHFA_suicide_guidelinesA4%202014%20Revised.pdf

[SD5]http://www.ncbi.nlm.nih.gov/pubmed/25617250

[SD6]http://www.ingentaconnect.com/content/springer/jcogp/2012/00000026/00000001/art00001

[SD7]http://www.nice.org.uk/guidance/cg16/evidence/cg16-selfharm-full-guideline-2

 

Guidelines

The following authoritative guidelines provide evidence-based information about the practical treatment of self-harm and suicidal behaviours:

Mental Health First Aid Australia. Suicidal thoughts and behaviours: first aid guidelines (Revised 2014). Melbourne: Mental Health First Aid Australia; 2014.

Mental Health First Aid Australia. Non-suicidal self-injury: first aid guidelines (Revised 2014). Melbourne: Mental Health First Aid Australia; 2014.

National Institute for Health and Clinical Excellence. Self-harm: longer-term management. (Clinical guideline CG133). 2012.

Royal Australian and New Zealand College of Psychiatrists. (2009). Self-harm: Australian treatment guide for consumers and carers.

Birmaher, B., Brent, D., & AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1503-1526.

National Institute for Health and Clinical Excellence. Self-harm. (Clinical guideline CG16). 2004.

Australasian College of Emergency Medicine and Royal Australian and New Zealand College of Psychiatrists. (2000). Guidelines for the management of deliberate self harm in young people.

More Information

Centre of Excellence in Youth Mental Health. MythBuster: Sorting fact from fiction on self-harm.  2010. Melbourne: Orygen Youth Health Research Centre.

Centre of Excellence in Youth Mental Health. MythBuster: Suicidal Ideation. 2009. Melbourne: Orygen Youth Health Research Centre.

Robinson, J., Hetrick, S. E., & Martin, C. (2011). Preventing suicide in young people: systematic review. Australian and New Zealand Journal of Psychiatry, 45(1), 3-26.

Hawton, K. K., Townsend, E., Arensman, E., Gunnell, D., Hazell, P., House, A., & Van Heeringen, K. (2009). Psychosocial and pharmacological treatments for deliberate self harm. The Cochrane Library.

Laye-Gindhu, A., & Schonert-Reichl, K. A. (2005). Nonsuicidal self-harm among community adolescents: Understanding the "whats" and "whys" of self-harm. Journal of Youth and Adolescence, 34(5), 447-457