Self-harm and suicidal behaviours

  • About

    People who engage in self-harm deliberately hurt their bodies. The term 'self-harm' (also referred to as 'deliberate self-harm' or DSH) refers to a range of behaviours, not a mental disorder or illness (1).  At the milder end of the spectrum, these behaviours include mild to moderate self-injury as a response to emotional pain and, at the more extreme end, attempted suicide (1, 2). The most common methods of self-harm among young people are cutting and deliberately overdosing on medication. Other methods include burning or scalding the body, pinching and scratching oneself, self-hitting and hanging (2).

    In many cases self-harm is not intended to be fatal (2). It is estimated that the number of young people who have engaged in self-harm is 40-100 times greater than those who have actually ended their lives (3). For many young people self-harm is a coping strategy, however maladaptive and damaging, that allows them to continue to live rather than an attempt to end their life (4).

    There is now a general consensus among clinicians and researchers that there is a distinct type of self-harming behaviour, termed non-suicidal self-injury (NSSI) in which the motivation is not intention to die, and that these behaviours should be distinguished from those that are suicidal in nature (5). However research studies typically fail to make this distinction and there is continued debate about terminology and definitions (6). Other terms used to refer to different forms of self-harm include self-injury, cutting, parasuicide and attempted suicide.

    Although many young people might try to hide their self-harming behaviour, there are some obvious and less obvious signs that someone might be self-harming (1). These include:

    Psychological signs:

    • Obvious changes in mood
    • Changes in sleeping and eating patterns
    • Losing interest and pleasure in activities that were once enjoyed 
    • Decreased participation and poor communication with friends and family 
    • Hiding or washing their own clothes and avoiding situations were exposure of arm and legs is required (eg, swimming)
    • Problems in social or intimate relationships
    • Strange excuses provided for injuries
    • Problems with work, school, social or family life

    Physical signs:

    • Unexplained injuries, such as scratches, cuts or burn marks
    • Unexplained physical complaints such as headaches or stomach pains
    • Wearing clothes that cover up arms and legs, even in hot weather


    Burden of youth suicide and self-harm in young people
    Despite a marked decrease in youth suicide rates in the last decade, suicide remains the second highest cause of death among young Australians, following road traffic accidents. In 2008, 19 per 100 000 males aged 20-24 and 9 per 100 000 males aged 15-19 died by suicide (7). For young females, 3 per 100 000 aged 15-19 years, and 5 per 100 000 aged 20-24 died by suicide (7).

    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 only 10% of young people who self-harm will present for hospital treatment (8). Evidence from Australian studies suggest that 6-7% of Australian youth aged 15-24 years engage in self-harm in any 12-month period (8). Lifetime prevalence rates are higher, with 24% of females and 18% of males aged 20-24 and 17% of females and 12% of males aged 15-19 reporting self-harming at some point in their life (9). 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 Australians. It is estimated that 21% of "years life lost" due to premature death among Australian youth in 2004 was due to suicide and self-inflicted injury (10). In addition, non-fatal suicidal behaviour and self-harm are associated with substantial disability and loss of years of healthy life (10).


    Risk factors
    Common risk factors or characteristics for those self-harm are similar to those who complete suicide (11). These include (12):

    • History of self-harm and/or previous suicide attempt
    • Mental or substance use disorders, especially depression
    • Physical illness: terminal, painful or debilitating illness
    • Family history of suicide, substance abuse and/or other psychiatric disorders
    • History of sexual, physical or emotional abuse
    • Socially isolated and/or living alone
    • Bereavement in childhood
    • Family disturbances
    • Unemployment, change in occupational or financial status
    • Rejection by a significant person eg, relationship breakup
    • Recent discharge from a psychiatric hospital

    Experiencing a mental health problem is a risk factor for both self-harm and suicide. Evidence suggests that more than 90% of people who self-harm have a mental disorder, the most common being depression (2). A history of mental illness, in particular depression, as well as the presence of more than one mental disorder are also strong predictors of suicide (13-15).

    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.

     

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

    2. Skegg K. Self-harm. Lancet. 2005 Oct 22-28;366(9495): 1471-1483.

    3. Fox C, Hawton K. Deliberate self-harm in adolescence. 2004. Jessica Kingsley Publishers: London.

    4. Nock MK, Prinstein MJ, et al. Revealing the form and function of self-injurious thoughts and behaviours: A real-time ecological assessment study among adolescents and young adults. J Abnormal Psychol. 2009 118(4): 816-827.

    5. Kelly CM, Jorm AF, et al. Development of mental health first aid guidelines for deliberate non-suicidal self-injury: a Delphi study. BMC Psychiatry. 2008 Jul 23;8: 62.

    6. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behaviours among adolescents: a critical review of the literature. Arch Suicide Res. 2007;11(2): 129-147.

    7. Australian Bureau of Statistics. Causes of death. 2008 Cat. no. 3303.0. ABS: Canberra.

    8. De Leo D, Heller TS. Who are the kids who self-harm? An Australian self-report school survey. Med J Aust. 2004 Aug 2;181(3): 140-144.

    9. Martin G, Swannell SV, et al. Self-injury in Australia: a community survey. Med J Aust. 2010 Nov 1;193(9): 506-510.

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

    11. Hawton K, James A. Suicide and deliberate self harm in young people. BMJ. 2005 Apr 16;330(7496): 891-894.

    12. World Health Organisation. Preventing suicide: a resource for general physicians. 2000. WHO: Geneva.

    13. Beautrais AL. Risk factors for suicide and attempted suicide amongst young people. Aust NZ J Psychiatry. 2000 Jun;34(3): 420-36.

    14. Rey JM, Dudley MJ. Depressed youth, suicidality and antidepressants. Med J Aust. 2005 182(8): 378-9.

    15. Schmidt P, Muller R, et al. Suicide in children, adolescents and young adults. Forensic Sci Int. 2002 Jul 17;127(3): 161-7.

  • Assessment

    Self-harm and suicide are behaviours, not psychiatric disorders, therefore neither is classified in the DSM-IV-TR (1) or the ICD-10 (2). Similarly, suicidal ideation is quite 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 recognized that they often occur in the context of a diagnosable mental disorder. Studies consistently report that young people who complete suicide or who make a serious suicide attempt often have a recognisable mental disorder at the time, such as depression, anxiety, conduct disorder and substance misuse (3). Internationally, research suggests that as many as 90% of people who complete suicide have a diagnosable DSM-IV mental disorder at the time of their death (4). Often these disorders are unrecognized and/or untreated.

    Assessment Tools

    To assess whether a young person is engaging in self-harm or suicidal behaviour, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person life including their:

    • Home and Environment; 
    • Education and Employment; 
    • Activities; 
    • Drugs and Alcohol; 
    • Relationships and Sexuality; 
    • Conduct Difficulties and Risk-Taking; 
    • Anxiety and Eating; 
    • Depression and Suicide; 
    • Psychosis and Mania

    To assess specifically for the self-harming and suicidal behaviours, a comprehensive assessment by a mental health professional trained in clinical assessment is required. The assessment should comprehensively evaluate the young person's social, motivational and psychological factors specific to the self-harming behaviour, their current suicidal intent, level of hopelessness, as well as a full assessment of mental health problems (5). The assessment of suicidal risk requires direct questioning of the young person's wish to die, the frequency and intensity of any suicidal thoughts, if they have any plans to act on these thoughts, if they have access to any means to end their life, and if they have tried previously to end their life (5-7).  Currently, there are no screening tools that are helpful in formulating an assessment of a young person's level of risk (6).


    References
    1. DSM-IV classification of psychiatric disorders

    2. ICD-10 classification of psychiatric disorders

    3. Crowley P, Kilroe J, et al. Youth suicide prevention: Evidence briefing. 2004. Health Development Agency: Dublin.

    4. Skegg K. Self-harm. Lancet. 2005 Oct 22-28;366(9495): 1471-1483.

    5. Guidelines for Self-harm (UK). 2004 National Institute of Health and Clinical Excellence (NICE).

    6. Hider P. Youth suicide prevention by primary healthcare professionals: A critical appraisal of the literature. 1998. New Zealand Health Technology Assessment, Department of Health and General Practice: Christchurch.

    7. World Health Organisation. Preventing suicide: a resource for general physicians. 2000. WHO: Geneva.

  • 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, in the context of establishing a therapeutic relationship (1). 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 (1). A comprehensive safety plan should cover the following steps:

    1. The young person's early warning signs
    2. Coping strategies they could try to feel better
    3. People and social settings that provide a distraction
    4. People they can contact for help
    5. Professionals or agencies they can contact for help, and 
    6. How they can make the environment safe. 

    A template of a safety plan is available here.

    Currently, there is insufficient research regarding which interventions are most effective for responding to deliberate self-harm behaviours (2). A systematic review evaluated the evidence for interventions with young people at risk of self-harm or suicide and is the only higher-quality evidence available in this area that is youth-specific. While the evidence is extremely limited, cognitive-behavioural interventions (CBT) appeared to show some promise (3). Given that not much is known about the effectiveness of interventions to reduce self-harm (4), it is recommended that any underlying mental health problems, such as depression, are appropriately treated so that the young person may feel more able to cope and therefore less likely to engage in self-harming behaviours (5).

    UK Guidelines for Self-Harm (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.

    The evidence map provides reference details for studies of prevention and treatment interventions for self harm and suicide behaviours and risk in young people. 

    References
    1. Hider P. Youth suicide prevention by primary healthcare professionals: A critical appraisal of the literature. 1998. New Zealand Health Technology

    2. Hawton KKE, Townsend E, et al. Psychosocial and pharmacological treatment for deliberate self-harm. Cochrane Database Syst Rev. 1999;(4): CD001764.

    3. Robinson J, Hetrick SE, et al. Preventing suicide in young people: systematic review. Aust NZ J Psychiatry. 2010 Jan;45(1): 3-26.

    4. Burns J, Dudley M, et al. Clinical management of deliberate self-harm in young people. Aust NZ J Psychiatry. 2005 Mar;39(3): 121-128.

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

    6. Guidelines for Self-harm (UK). 2004 National Institute of Health and Clinical Excellence (NICE)

     

  • Guidelines

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

    Australasian Guidelines for the Management of Deliberate Self-harm in Young People. 2000 Australasian College for Emergency Medicine

    Guidelines for the Assessment and Treatment of Child and Adolescent Suicidal Behavior. 2001 American Academy of Child and Adolescent Psychiatry

    Guidelines for Self-harm (UK). 2004 National Institute of Health and Clinical Excellence (NICE)

    Detection and Management of Young People at Risk of Suicide: Guidelines for Primary Care Providers. 1999 Royal New Zealand College of General Practitioners

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

    Non-suicidal self-injury: First aid guidelines. 2008 Mental Health First Aid Training and Research Program, Orygen Youth Health Research Centre

  • More info

    Robinson J, Hetrick SE, et al. Preventing suicide in young people: systematic review. Aust NZ J Psychiatry. 2010 Jan;45(1): 3-26.

    Burns J, Dudley M, et al. Clinical management of deliberate self-harm in young people. Aust NZ J Psychiatry. 2005 Mar;39(3): 121-128.

    Crowley P, Kilroe J, et al. Youth suicide prevention: Evidence briefing. 2004. Health Development Agency: Dublin.

    Gue B, Hartall C. Efficacy of suicide prevention programs for children and youth. 2002. Alberta Heritage Foundation for Medical Research: Edmonton, Canada.

    Hider P. Youth suicide prevention by primary healthcare professionals: A critical appraisal of the literature. 1998. New Zealand Health Technology Assessment, Department of Health and General Practice: Christchurch.

    Ploeg J, Ciliska D, et al. A systematic overview of adolescent suicide prevention programs. Can J Public Health. 1996 Sep-Oct;87(5): 319-324.

    Steele MM, Doey T. Suicidal behaviour in children and adolescents: Treatment and prevention. Can J Psychiatry. 2007 Jun;52(6 Suppl 1): s35-35.

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

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