Self-harm & Suicide

DOI: 10.13056/acamh.8174

Self-harm is an increasingly recognised phenomenon and one of the strongest predictors of suicide, which continues to be one of the leading causes of death in young people worldwide. Self-harm can take many forms and may present with or without suicidal intent and both in the context of mental disorder, and without.

In this guide we will discuss the epidemiology, risk factors, assessment and management of self-harm and suicide. When we refer to self-harm in this topic guide this is defined as any form of self-injury or self-poisoning, regardless of the presence or absence of suicidal intent. In some cases, evidence will relate to the separate constructs of Non-Suicidal Self Injury (NSSI) or suicide attempts specifically. We will also discuss suicidal ideation (thoughts or plans about suicide) and completed suicide. We will not be discussing self-injury in the context of neurodevelopmental or intellectual difficulties.

 

About the authors

Rosemary Sedgwick
Dr. Rosemary Sedgwick

Dr. Rosemary Sedgwick graduated from Brighton and Sussex Medical School in 2012. She completed Core Psychiatry Training in 2017 and continued on the Maudsley Training Programme as a higher trainee in Child and Adolescent Psychiatry. She has been an NIHR Academic Clinical Fellow in Child and Adolescent Psychiatry at King’s College London and is now working as an NIHR Maudsley BRC Preparatory Fellow. Her research interest is in internet/social media/online gaming and child and adolescent mental health, with a focus on self-harm and suicide.

Dr. Sophie Epstein
Dr. Sophie Epstein

Dr. Sophie Epstein qualified in Medicine from the University of Bristol in 2009 and is currently a higher trainee in Child and Adolescent Psychiatry at South London and Maudsley NHS Foundation Trust. She recently completed a post as a Clinical Researcher at the NIHR Maudsley Biomedical Research Centre (BRC) and is soon to start a Medical Research Council (MRC) Doctoral Fellowship at King’s College London. Her research interests are in child and adolescent mental health, school-based mental health provision and prevention, with a particular focus on self-harm and suicide. Her Fellowship will explore the relationship between poor school attendance and self-harm in adolescents.

Dr. Dennis Ougrin
Dr. Dennis Ougrin

Dr. Ougrin graduated from a medical school in Ukraine in 1998 and came to England to undertake his post-graduate training. He completed his higher training in child and adolescent psychiatry at Guy’s and Maudsley and is currently a consultant Child and Adolescent Psychiatrist leading Supported Discharge Service at South London and Maudsley NHS Foundation Trust. Dr Ougrin is also a clinical senior lecturer at the Institute of Psychiatry, Psychology and Neuroscience. He leads a programme of information exchange between the UK and Ukraine. His main professional interests include prevention of Borderline Personality Disorder and effective interventions for self-harm. He is the author of Therapeutic Assessment, a novel model of assessment for young people with self-harm. He is the chief investigator of a randomised controlled trial of Supported Discharge Service versus Treatment as Usual in adolescents admitted for in-patient care and a principal investigator of a randomised controlled trial comparing intensive mental health intervention versus usual social care in Looked After Children. He also works on developing a modular psychotherapeutic intervention for self-harm and on understanding the pathophysiology of self-harm in young people.

 

  • Introduction

    Worldwide, 10-20% of young people report having self-harmed at least once before the age of 18 (1, 2) and self-harm is one of the strongest risk factors for completed suicide (3). Suicide is the 2nd leading cause of death for young people globally (4, 5) and therefore predictors such as self-harm are of great importance.

    The World Health Organization reported that from the Global School-Based Health Survey the 12-month prevalence of suicidal ideation in females was 16.2% and for males 12.2%.  Suicidal ideation with plans was reported in 8.3% and 5.8% respectively, but with significant heterogeneity amongst countries (6). Lifetime figures for suicidal ideation are as high as 29.9%, with 9.7% having attempted suicide (7).

    Self-harm and suicide are related phenomena which in different countries are defined in slightly different ways. The International Classification of Diseases defines intentional self-harm as: purposely self-inflicted poisoning or injury, including attempted suicide (8), and this definition is most commonly adopted within Europe including the UK and in Australia. This is the definition used within this topic guide.

    The fifth edition of the Diagnostic Statistical Manual of Diseases now includes Non-suicidal self-injury disorder. Non-suicidal self-injury (NSSI) is described as “deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned”(9); this is reflected in the research output from the United States and Canada. This definition does not include self-poisoning. Within this classification, self-harm with any level of suicidal intent is defined as a suicide attempt.

    The heterogeneity of terminology is a contributor to the varying estimates of prevalence around suicidal behaviours, although it appears that prevalence of both NSSI and self-harm are similar in community samples (2). Self-harm with and without suicidal intent are both important risk factors for suicide, and intent can be difficult, even for young people themselves, to determine. It is therefore important that all acts of self-harm are thoroughly explored and addressed with young people.

  • What we already know

    Risk factors for self-harm

    Self-harm is more common in females, whereas completed suicide is more common in males (1). Seventy nine percent of all suicides occur in low- and middle-income countries (4). There are many identified risk factors for self-harm and suicidal behaviours as follows:

     Social

    • Low socio-economic status
    • Parental death
    • Parental mental health problems
    • Adverse childhood experiences
    • History of physical and sexual abuse
    • Bullying
    • Low school connectedness
    • Family discord
    • Interpersonal difficulties
    • Living apart from family or in foster care
    • Loneliness
    • Family and friends who self-harm
    • Internet/Social media use
    • Lesbian, Gay, Bisexual, Transgender (LGBT) youth are at greater risk of self-harm

    Psychological

    • Mental disorder
    • Substance misuse
    • Low self-esteem
    • Hopelessness
    • Personality traits (e.g. perfectionism, impulsivity)
    • Sleep disturbance

    (1, 6, 7, 10-15)

    Risk factors for completed suicide

    Research on completed suicide is challenging due to the, fortunately, low prevalence. In high-income countries, girls more commonly make suicide attempts, but boys are more likely to die by suicide (16, 17). This could be related to a number of factors, including the lethality of methods, as it is known that violent methods are much stronger predictors of suicide than non-violent methods (18). In the UK violent methods, such as hanging, tend to be greater in males (15). But in lower socio-economic index regions there is a higher female-to-male ratio of completed suicide (19). This may be due to higher levels of suicidal behaviour, or access to lethal means such as pesticides; which accounts for an estimated 30% of suicides worldwide (20). There are also some special groups. For example, young adult women who self-harm by cutting and are hospitalised, are at particular risk of future suicide (18). Other factors such as family history of suicide, poor educational attainment and familial separations (i.e. by divorce or death) are risk factors for suicide, as well as a history of self-harm (1)

    Aetiology and why people self-harm

    Self-harm occurs less frequently in children under 12, and becomes increasingly common during adolescence (1, 21). However, the majority of these young people do not continue to self-harm into adulthood (22). Self-harm behaviours may be associated with a particular life event, stressor, or episode of mental disorder, or may be more pervasive and become a regular and repeated occurrence.

    Self-harm does not occur exclusively in the context of mental disorder and as outlined above there are many known psychosocial risk factors. It is however associated with a range of mental disorders including anxiety, depression and attention deficit hyperactivity disorder (ADHD) (1, 22). Substance use, sleep disturbances and personality traits of intellect/openness are also important predictors (15), along with young people having family and friends who self-harm (23). NSSI and suicidal behaviours are key features of Borderline Personality Disorder, but its diagnosis in adolescents has been deemed controversial in the past due to concerns about its validity and the potential for it being stigmatising (24). It is increasingly recognised that the disorder can be diagnosed in adolescence and there may be differing developmental trajectories, providing an opportunity for early intervention and treatment (25, 26).

    There are unfortunately some stigmatising and unhelpful views which persist about self-harm, such that those that self-harm are ‘manipulative’ or ‘attention-seeking’. Why people initially self-harm may stem from a wide variety of situations and exposures, which are often complex. This can include communicating distress to others, a form of coping-mechanism, or to regulate emotions. Repeated self-harm is one of the strongest known risk factors for suicide (27) and roughly a third who die by suicide use the same method for their last self-harm and for suicide (28). Self-harm is not something that should be disregarded by professionals or carers and should be viewed as a sign of underlying distress or dysfunction which requires further assessment, as it may well be that a young person has no other means to communicate these difficulties.

    Methods of self-harm and suicide

    There is variability in methods of self-harm according to the availability of means and exposures and the method of self-harm does not necessarily predict the method of suicide. In high-income countries, self-cutting and self-poisoning with medication are amongst the most common methods of self-harm (1). However, methods such as charcoal burning (29) or ingestion of pesticides (30) are more widespread in other countries, particularly China.

    Drug-poisoning is commonly used in suicide attempters, however completed suicides most often result from other more lethal methods such as pesticide/chemical poisoning, hanging or firearms (31-33).

    Assessment and management of self-harm and suicide risk

    Despite the high prevalence of self-harm, the majority of young people who self-harm are not known to professionals, with as few as 12% of self-harm episodes in young people presenting to hospital (34). This presents a major problem for societies and limits the number of young people reached by interventions.

    The World Health Organization recommends that both specialist and non-specialist health providers seeing children over 10 years old with either a diagnosed mental disorder, interpersonal conflict, loss, or a severe life event, should be asked about thoughts and plans to self-harm (35). If the current presentation is with self-harm it is important to assess thoroughly past self-harm, the risk of further self-harm and suicide risk, alongside thorough psychosocial assessment. Young people use a number of methods to self-harm and may at different times have suicidal intent, or not. It is therefore important to ask about intent. Evidence suggests that, contrary to people’s apprehensions, talking about suicidality may in fact reduce thoughts about suicide and may lead people to seek help (36). This should therefore be an important area of enquiry in young people and mental health professionals should routinely screen for suicidal ideation and current or past self-harm.

    Prevention

    It is a minority of young people who self-harm, who present to hospital (37), which makes prevention challenging on an individual level. Population-level interventions that restrict access to means are required and there is increasing interest in the role of school-based interventions for mental health (see ‘areas of uncertainty’).

    Another widely used prevention strategy is safety planning. There is limited evidence in children, but in adults, safety planning interventions have been found to reduce suicidal behaviours and improve engagement (38). In acute presentations, safety planning, in collaboration with the young person and relevant carers, should include: clear follow up plans, useful contacts, strategies on how to communicate distress and coping skills. This should be reviewed and discussed regularly in future contacts. Restricting access to means is also an important aspect of safety planning and prevention, particularly of impulsive suicide attempts, hopefully providing some time to both reflect and for the crisis to pass.

    Public health interventions to restrict access to means have been successful in some regions and include placing barriers at common jumping sites, detoxifying domestic gas and the banning of certain pesticides, or restricting their purchase (39). Legislative measures, safer firearm storage and improved firearm safety are all methods by which firearm-related suicides can be reduced (40); particularly relevant to the United States, where firearms are the most common method of suicide (41).

    Media guidance on reporting of suicide is another important intervention. This guidance explains the importance of not sensationalising or over-simplifying the reasons for suicide or providing details on methods of suicide or self-harm. It also suggests that within the report, information about sources of support is provided (42).

    Social environment, i.e. family, peers, school and neighbourhood connectedness, can be protective factors against self-harm. Connectedness with others is protective, though it appears that peer-connectedness is not as important when compared to relationships with supportive adults, highlighting the importance of family and school involvement. (43)

    Treatment

    When self-harm occurs in the context of a mental disorder, the disorder itself should be treated, alongside management of the self-harm.

    In terms of the management of self-harm, there are no evidence-based pharmacological interventions, however psychological interventions show promise, in particular Dialectical Behavioural Therapy (DBT), Mentalisation Based Therapy (MBT), and Cognitive Behavioural Therapy (CBT) (44). While these interventions show evidence of effect in reducing self-harm, their impact on reducing suicide attempts specifically is limited, and no one therapy can be recommended as superior.

    It is well acknowledged that families are hugely important in the managing of risk and treatment of self-harm, and interventions with a family component are associated with a reduction in self-harm (44). As a result, most CBT, DBT, and related manuals, have incorporated family components. The Safe Alternatives for Teens and Youths (SAFETY), a “cognitive-behavioural DBT-informed family treatment”, has been shown to be effective in preventing suicide attempts (45). Systemic Family Therapy was not found to reduce hospital attendance for self-harm (46). Social support interventions such as the Youth-Nominated Support Team Intervention-Version II, which incorporates psychoeducation and the adolescent’s nomination of a ‘caring adult’, has shown promising results in reducing mortality in suicidal adolescents’ post-hospitalisation, but its wider usefulness requires further study (47, 48).

    Hospital admission for any child or adolescent is uncommon, but there are occasions when risk of self-harm and suicide cannot be managed safely outside this setting and therefore hospital admission may be considered, with or without use of statutory frameworks for compulsory detention. However, hospitalisation of adolescents with repeated self-harm, can have adverse effects and therefore all efforts should be made to provide treatment in an outpatient setting where possible. In some areas, intensive treatment alternatives to hospital admission may be available, and this has been shown to be an effective way of managing young people (49). This is particularly important due to the fact that the period immediately after discharge from hospital is a time when young people are at high risk of suicide (50).

  • Areas of uncertainty

    Less established risk factors and exposures

    The rise of social media and the internet has caused concern and while there is evidence that suggests aspects of online activity may increase self-harm and suicide, there is also the potential for the internet to serve as a means of seeking positive interactions and support (12).

    Ideas and knowledge about self-harm and suicide may be transferred in many ways, including social contacts, schools, the media, or digital means. The potential for contagion effects of self-harm is concerning, though at present little is known about this phenomenon. Concern about exposure to suicide-related content, both in the media and online, is prevalent. This is not a new phenomenon and was outlined by Schmidtke and Hafner in 1988 (51), but more recently the 2017 television series “13 Reasons Why” attracted particular concerns, for fear it glamorised suicide. Research evidence is inconclusive, with evidence both that the exposure to fictional suicide media content such as this results in contagion and some that refutes this claim (52, 53). More research will be required into the nuance of these types of exposures and those that may be particularly vulnerable. It is important that parents and professionals are aware of what digital and media content young people are accessing, and then discuss this with them and consider restricting access in some situations. The 13 Reasons Why Toolkit is an example of a response to these concerns and provides guidance for young people, parents, professionals and educators.

    Alternative subcultures, such as goth or emo do appear to be associated with greater risk of self-harm and suicide (54, 55), though the direction of association or specifics about what aspects of these subcultures are harmful require further research.

    Suicide theory

    There has been development of a number of ‘ideation to action’ suicide theories which are hoped to provide a framework by which to better understand suicide risk. This includes the ‘Interpersonal Theory’ of suicide, the ‘Three-step Theory’, the ‘Integrated Motivational-volitional Model’, and the ‘Fluid Vulnerability Theory’; all of which have undergone varying degrees of investigation (56). These theories are based on the concept that thoughts about suicide and suicidal acts are distinct processes, and that factors that influence the development of suicidal thoughts are different to those which lead to the transition from thoughts to acts.

    There is some evidence to suggest that altered pain tolerance is associated with self-harm, though it is not yet clear whether this is a consequence or cause of the behaviour (57). This may have a role in ‘habituation’ to self-harm, increasing the capability to make a successful suicide attempt (58). This may be through psychological or biological mechanisms and requires more research. However, there is already evidence that those who self-harm have higher pain thresholds and that these people also have higher levels of personality features such as introversion, neuroticism and lower self-worth (59).

    Prevention

    Different types of school-based prevention programme have been developed which fit into the categories of universal prevention (delivered to whole school populations), selective prevention (delivered to groups identified as being at higher risk) and indicated prevention (delivered to those already known to engage in self-harm behaviour aimed at reducing its severity and frequency). Many of these programmes do not as of yet have clear evidence for their effectiveness, however, two universal interventions have shown promise. There has been some success shown with the Youth Aware of Mental Health Programme, which in the SEYLE Randomized Control Trial showed effectiveness in both reducing severe suicidal ideation and suicide attempts compared with controls (60) and in the Signs of Suicide (SOS) prevention programme which had promising results in reducing suicidal thoughts and behaviours (61, 62).

  • What's in the pipeline?

    As there are many reasons young people may self-harm there is potential in trying to address particular aspects of the aetiology of self-harm. For example, by addressing self-criticism through novel interventions such as Autobiographical Self Enhancement Training. This has shown some potential positive effects, but limited effect on suicidality (63).

    Digital platforms are so commonly used by young people and a wealth of information may be shared online. Electronic health records also hold a great deal of unstructured information on self-harm and suicide risk. There is the potential, using novel technological advancements, such as Natural Language Processing, to detect risk of self-harm and suicide in both digital platforms (64) and in routinely collected electronic health records (65); which could lead to better detection of young people at risk and targeting of interventions.

     

  • Useful Organisations and Resources

    The following provide further useful information and resources about self-harm. Please be aware that not all resources will have undergone formal evaluation.  Some resources are country-specific and therefore may not applicable to other settings. The authors cannot guarantee that the following resources will remain up-to-date.

     

    For health professionals:

    National Institute for Health and Care Excellence (NICE) (United Kingdom) guidance:

     

    Resources:

    • CBT Workbook: Cutting Down: A CBT workbook for treating young people who self-harm by Lucy Taylor
    • Worksheets to accompany the handbook

    Resources for non-health professionals:

    Information for young people:

    For parents and carers:

    • Download Coping with self-harm A Guide for Parents and Carers

    Safety planning:

    Media recommendations for suicide:

    Mental Health Apps

    • There are a number of mental health apps available via the UK National Health Service (NHS) website, some specifically for managing self-harm.

     

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