Recurrent self-harm

Chapter 6
Recurrent self-harm

Rohan Borschmann1 and Paul Moran2

1 Clinical Psychologist, Institute of Psychiatry, King’s College London, London, UK

2 Reader/Honorary Consultant Psychiatrist, Institute of Psychiatry, King’s College London, London, UK

What is self-harm?

Self-harm is an act with a non-fatal outcome in which an individual deliberately initiates behaviour (such as self-cutting), or ingests a substance, an illicit drug or non-ingestible substance or object, with the intention of causing harm to themselves [1]. Considerable variation is observed within this range of behaviours, and self-harm often includes self-cutting, overdosing, burning, scalding, swallowing dangerous objects or substances, picking/scratching, biting, hair pulling, head-banging, bruising, or any combination of these [2, 3].

While any act of self-harm may or may not be associated with the intent to die, non-suicidal self-injury (NSSI) is defined as an act of self-harm that is deliberate, contains no desire to die, and is for purposes not socially sanctioned such as tattooing or piercing the body for adornment [4, 5]. While NSSI can provide short-term relief from distress, it can have negative emotional, physical, and social consequences [4]. Emotionally, it can evoke more complex feelings of guilt and shame toward oneself [6]. Physically, it can lead to infection, scarring, or reduced functioning. Socially, it can be associated with stigma and exclusion from peer groups, which may contribute to the cycle starting again [4]. Despite being extensively researched (mostly in North America), NSSI does not appear as a disorder in either the Diagnostic and Statistical Manual of Mental Disorders (4th edition; DSM-IV) or the International Statistical Classification of Diseases and Related Health Problems (10th ed.; ICD-10) and is not a diagnostic criterion of any current depressive or anxious disorder. This lack of nosological recognition is to be acknowledged in the forthcoming DSM-V, with NSSI being classified as a syndrome in its own right [4], a move that has received a mixed reception [7, 8]. Critics of the NSSI construct have highlighted the fact that, despite the apparent lack of suicidal intent in people engaging in NSSI, it is strongly correlated with subsequent suicide [8]. For example, self-cutting (the most common method of NSSI) is a behavior that is often regarded as being of limited seriousness by clinical services [8]; however, research suggests that self-cutting resulting in hospital treatment is actually associated with a greater risk of eventual suicide than self-poisoning in both adults [9] and adolescents [10].

Many acts of body modification or destruction of one’s bodily tissue have cultural or social meaning and are not linked to a desire to die or to relieve distress (or even to experience any pain). In the Western world, such behaviours may include tattooing, piercing on the head or body, and practices such as stretching one’s earlobes as a display of bodily art. At the more extreme end, it has been documented that native tribesmen of the Ivory Coast plunge knives several inches into their abdomens during New Year celebrations in the belief that bad spirits will be driven away as a result of this act [5]. In some Pacific Island tribes, it is not uncommon for relatives of the newly deceased to engage in acts of self-mutilation (including cutting off their fingertips, extracting teeth, tattooing their tongues, and/or cutting off their ears) as a mark of respect for the deceased [5]. Despite the severity (and potential risk of accidental death) of these behaviours, it would be inappropriate to give them a psychiatric label as they are in keeping with local cultural norms. The remainder of this chapter will be focusing on self-harm that is not socially sanctioned and does not have cultural significance for the individual.

Prevalence and correlates of self-harm in the general population

Self-harm occurs in all cultures and is especially prevalent in young people, a group in whom rates of self-harm have risen in recent years [11, 12]. Approximately 4 percent of general adult populations report engaging in self-harm [6], and it is common among adolescents [13–15]. and college students [16–18]. Peak onset of self-harm coincides with the onset of puberty [19]. and about 10 percent of teenagers report having engaged in some form of self-harm [20], although longitudinal research indicates that 90 percent of teenagers who self-harm stop the behaviour as they enter into adulthood [21]. In the general population, self-harm is generally more common among women than men; among lesbian, gay, and bisexual people [22, 23]; among those living in areas of socio-economic deprivation [24]; and in those identifying with “Gothic” subculture In the UK, Asian women are at higher risk of self-harm compared to their white counterparts, but there have been few studies comparing rates of self-harm among people of Caribbean, African, and other minority ethnic groups. The World Health Organization (WHO) reported that self-inflicted injuries accounted for approximately 800,000 deaths worldwide in 2001 [26]. Prevention of self-harm (along with suicide) is now included in health policy initiatives in several countries and is part of the Health-For-All targets of the WHO [27]. Self-harm is associated with substantial costs to health services, as it often results in admissions to emergency departments and subsequent psychiatric or general admissions, in addition to loss of productivity [28, 29]. In the UK, self-harm is one of the most common reasons for acute admission to hospital [30, 31], accounting for up to 200,000 hospital attendances each year in the UK [29], 40–50 percent of which are repeat episodes [32]. The vast majority of hospital admissions for self-harm relate to overdoses [33].

Why do people engage in recurrent self-harm?

Self-harm is not an illness; rather, it is a behavioural disorder that should alert clinicians to one or more underlying emotional problems. The functions of self-harm are extremely varied and include both internal and external factors [5, 34–36], including (but not limited to):

  • Emotional regulation (i.e., to alleviate acute negative feelings)
  • Self-punishment
  • Sensation-seeking
  • Distraction
  • Expressing anger
  • Attempting to “feel something”
  • Attempting to escape from an intolerable situation
  • Attempting to communicate with, or to influence, others
  • To assert one’s autonomy or establish a boundary between self and other
  • To generate excitement

A person who self-harms repeatedly might not always do so for the same reason each time, nor by the same method. Thus, assumptions about intent should not be made on the basis of a previous pattern of self-harm; each act must be assessed separately to determine the motivation behind it [37]. Paradoxically, the purpose of some acts of self-harm is to preserve life; a concept many health professionals may find difficult to understand [37]. The precipitants of self-harm are extremely varied [38–40], although common problems preceding acts of self-harm typically include social problems, difficulties with a partner or family member, finances, physical health, employment or studies, housing, or alcohol or drug misuse [25, 41, 42]. For many people, self-harm is a habitual coping mechanism and there is some evidence that these behaviours often continue even after personal problems have been resolved [43, 44]. It can provide immediate short-term relief, but often at considerable cost (such as permanent scars or damage to internal organs).

Furthermore, individuals often report more than one motivation for self-harming and different forms of self-harm can serve different functions [22]. For example, while taking an overdose may provide escape from a difficult situation, cutting oneself may serve to regulate dysphoric affect [36]. Rodham and colleagues [45] reported that self-cutters think about self-harming for a shorter period than self-poisoners before initiating the behaviour. They suggested that taking an overdose requires more time and planning than cutting oneself and, as such, may indicate a more serious intent and be more likely to require medical attention [45]. Recent research by Hawton and colleagues [46] has suggested that different forms of self-harm place people at different levels of risk for subsequent completed suicide, with cutting paradoxically posing a greater risk than self-poisoning.

Clinicians’ attitudes toward self-harm

Individuals who self-harm are often viewed in a negative light by healthcare staff, particularly in emergency settings [47–52]. In turn, people who self-harm frequently describe their contact with health services as being difficult and characterised by ignorance, negative attitudes, and even punitive behaviour by health professionals [53]. One of the main reasons cited for such attitudes is that emergency practitioners do not always have sufficient time or resources to provide appropriate care for individuals presenting with self-inflicted injuries, leading to frustration toward these individuals [54]. and an extreme, punishing care (e.g., suturing without sufficient local anesthetic) [55]. Previous NICE guidelines regarding the treatment and management of self-harm [53] acknowledged that the experience of care for people who self-harm is often unacceptable and included recommendations about how members staff should relate to these individuals.

How often is there a “formal” underlying psychiatric disorder?

Most people who attend an emergency department following an act of self-harm will meet criteria for one or more psychiatric diagnoses at the time they are assessed [56]. The ICD-10 includes a diagnostic criterion for emotionally unstable personality disorder (EUPD) of “recurrent threats or acts of self-harm” [57]. Due to the very nature of the disorder, individuals with EUPD (otherwise classified as borderline personality disorder [BPD] in DSM-IV) are at an increased and ongoing risk of crises and self-harming behaviours [58–60]. Notwithstanding, the majority of individuals who engage in self-harming behaviour do not meet diagnostic criteria for EUDP. In addition, as many as a third of individuals with BPD do not self-harm [61]. On the other hand, depression and anxiety are very common correlates of self-harm [62, 63]. as are drug and alcohol misuse [64, 65].

What is the prognosis for people who repeatedlyself-harm?

Self-harm is strongly associated with subsequent suicide [66]. In the UK, research has shown that approximately 1 percent of individuals presenting at emergency departments following an episode of self-harm go on to commit suicide within a year, with this figure rising to 3–5 percent within 10 years, 8.5 percent within 22 years and 10 percent across the lifespan [67, 68]. A prospective study of nearly 8,000 casualty attenders presenting following an episode of self-harm found that at 4-year follow-up, there was a 30-fold increase in suicide risk in the attenders compared with the general population [9]. Suicide rates were highest within the first 6 months after the index self-harm episode. For every completed suicide in the UK, it is estimated that 30 acts of self-harm take place [69] and, following an act of self-harm, the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population [66, 70]. Approximately half of all people who commit suicide have a history of self-harm, with approximately 20–25 percent having had an episode within the preceding year [68]. As well having an increased risk of suicide, people who present to emergency departments after self-harm are at subsequent increased risk of both accidental death and also death from natural causes [71]. They are more likely to have compromised physical health and they experience a reduced life expectancy with disease of the circulatory and digestive systems being major contributors to years of life lost [72].

Economic costs

Self-harm is associated with significant economic costs to health services and society in general. Extrapolating from data gathered from three clinical centres in the UK, Hawton and colleagues [29] estimated that there were 220,000 episodes of self-harm dealt with by hospitals in England each year, with 40–50 percent of self-harm hospital episodes being related to repeat episodes [32]. Approximately 15 percent of individuals presenting at an emergency department following self-harm will present again within 12 months and even more will self-harm again without presenting [73]. As one might expect, recurrent self-harm has a cumulative effect on service costs, with the number of self-harm episodes being correlated with increased healthcare and social services costs [74]. The indirect costs of self-harm have not been quantified; however, they include absenteeism from work [53] and considerable strain on families and careers [75].


While there are no proven effective treatments for recurrent self-harm, many interventions and guidelines for managing and preventing repetition of self-harm have been proposed The common goals of such interventions typically include reducing the repetition of self-harm and the desire to self-harm, preventing suicide, and improving social functioning and quality of life, while exerting minimal adverse effects [76]. In routine clinical practice, service users will receive a wide range of psychological interventions that may or may not focus primarily on their self-harm; addressing self-harm may occur in series or in parallel with other interventions the service user is receiving. The 2011 NICE guidelines on the management and prevention of self-harm [37] state that the key aims and objectives in the treatment of an individual who has self-harmed should include the following:

  • Prompt assessment of physical and psychological need
  • Effective engagement of the individual
  • Prompt measures to minimise pain and discomfort
  • Implementation of harm reduction strategies
  • Prompt and supportive psychosocial assessment (including a risk assessment)
  • Provision of information about the long-term treatment, management and risks associated with self-harm
  • Provision of 3–12 sessions of a psychological intervention specifically structured for people who self-harm with the specific aim of reducing self-harm; this intervention may include cognitive-behavioural, psychodynamic or problem-solving elements
  • Psychological, pharmacological and psychosocial interventions for any associated conditions (including BPD, depression, bipolar disorder, or schizophrenia)
  • Prompt referral for further psychological, social, and psychiatric assessment and treatment when necessary

The guideline also recommends producing an integrated and planned approach to the problems precipitating the self-harming behaviour. These include the development of a care plan and a risk management plan in conjunction with the individual, their family, carers, or significant others, with printed copies provided for the individual and other key healthcare professionals.

As far as the acute management of self-harm is concerned, any attendance to an emergency department following an episode of self-harm should result in a psychosocial assessment of needs, regardless of the method of self-harm used [77]. Despite the publication of national guidelines, there continues to be considerable variation in the level of support offered to individuals presenting at emergency departments after an episode of self-harm. For example, hospital services tend to offer less help to individuals who have cut themselves even though they are far more likely to repeat than those who have self-poisoned [77]. Effective interventions for managing self-harm must also take into account the subjective goals of the individual engaging in self-harm, as these may vary considerably [77]. For example, while one individual’s goal might be to permanently stop self-harming, recover from any underlying psychiatric disorder, and have a better quality of life, another individual’s goal might be simply to reduce the frequency of self-harm or even to reduce the harm associated with each act of self-harm [37]. For others, the goal might be to improve their level of social or occupational functioning. As such, interventions aimed at reducing the repetition of self-harm may focus on the actual behaviours themselves, or they may take a more holistic approach by examining an individual’s close relationships, cognitions, and social factors [37]. Qualitative research indicates that service users may have a preference for specialist community-based interventions that acknowledge that the management of self-harm may not necessarily involve its prevention [78].

There is little convincing evidence for the efficacy of interventions for self-harm [68]. However, several promising candidate interventions exist and these can be divided into three main categories: psychological interventions, psychosocial service-level interventions, and pharmacological interventions. A brief summary of each follows.

Psychological interventions

The rationale for most psychological interventions is that most self-harm is precipitated by emotional difficulties and interventions. Most psychological interventions are aimed at improving social functioning as well as reducing self-harming behaviour [53, 79]. Self-harm is associated with a wide variety of psychological problems and, as such, psychological interventions need to take account of this complexity. One key aim of many psychological interventions is to reduce self-harm through understanding the specific contributing factors in each individual [37].

Problem-solving therapy

May 29, 2017 | Posted by in PSYCHIATRY | Comments Off on Recurrent self-harm
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