Deliberate self-harm (DSH) refers to behaviour through which people deliberately inflict acute harm upon themselves, poison themselves, or try do so, with non-fatal outcome. These behaviours are somehow linked to, but do not result in, death. Common to these behaviours is that they occur in conditions of emotional turmoil. In former days these behaviours were often regarded as failed suicides. However, this view did not appear to be correct, and the great majority of patients in fact do not try to kill themselves. Therefore, the term deliberate self-harm was introduced to describe the behaviour without implying any specific motive.⁽¹⁾ But this too has some disadvantages because there is a temporal association between non-fatal and fatal suicidal behaviour; many people who die by suicide have engaged in DSH before. Thus, Kreitman et al.⁽²⁾ introduced the concept of parasuicide to describe behaviour that, mostly without the intention to kill oneself, communicates a degree of suicidal intent. However, both terms, deliberate self-harm and parasuicide, are still somewhat confusing, because in practice they include people who really have the intent of killing themselves but survive the attempt. The difficulty of finding a good terminology for these behaviours is reflected in differences in research populations in empirical studies: some studies are limited to self-poisoning only (overdose), a few studies are restricted to self-injury (wrist cutting) only, some to self-poisoning and self-injury combined, and some studies include behaviours in which, due to last-moment intervention from others, there was no actual self-harm inflicted at all. In recent years the term self-harm is being used in the United Kingdom and North America since the adjective ‘deliberate’ is not favoured by patients, particularly those who repeatedly engage in acts of self-harm.⁽³⁾

In this chapter, we will use the term deliberate self-harm interchangeably with attempted suicide to refer to non-fatal suicidal behaviours in which there may have been an intention to die, however ambiguous this intention may have been, and irrespective of other intentions that may have been operating at the same time. It should be stressed that in deliberate self-harm many motives may play a role simultaneously, even contradictory motives such as the hope of being rescued and the wish to continue living. Intentions may vary from attention seeking or communication of despair, appeal for help, to a means for stress reduction. Common to these behaviours is that they are motivated by change: people want to bring about changes in their present situation through the actual or intended harm or unconsciousness inflicted upon the body. Deliberate self-harm may be defined as follows.⁽⁴⁾

This definition covers deliberate non-fatal suicidal behaviours. Not included are accidental cases of self-poisoning, accidental overdoses of opiates, or self-harmful acts by persons who do not anticipate the consequences of their actions. It does not include automutilation, which is an habitual, often obsessive act of inflicting (minor) self-harm, mostly without a conscious intent of changing the present situation, as with certain persons with learning disability.

Deliberate self-harm can have very different motivations, varying from an intention to die to a cry for help. These behaviours may be well prepared or carried out impulsively, and may have different physical consequences. The degree of lethality and the degree of medical seriousness of the consequences thus depend upon intention, preparation, knowledge and expectations of the method chosen, and sometimes upon coincidental factors such as intervention from others.

It is often difficult to assess the true intent of DSH. Because of fear for consequences, such as admission to a psychiatric hospital, or because of psychological defence mechanisms, people sometimes deny or conceal their intention to die. They also may exaggerate their intention to die in order to receive help. Sometimes people engage in potentially highly lethal self-harming behaviour without any wish to die, for example when they do not have adequate knowledge of the medication used. People who present at a general hospital with minor self-injury or minor self-poisoning may have had strong intentions to die but had insufficient knowledge of the lethality of the method. Therefore, one cannot always reliably infer what the precise meaning of the behaviour was, either from its overt characteristics or from the person’s self-report. Among a large sample of adolescents aged 15 and 16 years, Rodham et al. found that adolescents who took an overdose more often expressed a wish to die compared to those who engaged in self-cutting.⁽⁵⁾ Motives associated with self-cutting were self-punishment and interruption, i.e. trying to get relief from a terrible state of mind.

In the 1960s and 1970s, there was a sharp increase in the number of people treated in hospitals in Europe, the United States and Australia because of intentional overdoses or self-injury. In the 1980s several studies showed a stabilization.^(6,7) In the early 1990s these numbers increased further in some regions.^(8,9) The absolute number of persons treated for deliberate self-harm in general hospitals, however, does not adequately reflect the size of the problem. These numbers should be calculated against the size and the characteristics of the population in the areas that are being served by the hospitals. Furthermore, in some countries DSH patients are treated by general practitioners when there is no need for hospital admission. In many instances emergency attendance for overdosing is not even registered. Except for Ireland, where a National Registry of Deliberate Self-Harm has been established,⁽¹⁰⁾ there are no national registries that reliably monitor trends in DSH treated in general hospitals. Even though DSH is considered a major problem in the United States, clinical epidemiological research into DSH is uncommon.⁽¹¹⁾ Also, few epidemiological studies on DSH originate from other parts of the world.