Deliberate self-harm (DSH) is a behavior in which a person commits an act with the purpose of physically harming himself or herself with or without a real intent of suicide.1 Youths use a number of DSH methods, most commonly cutting, poisoning, and overdosing (Table 1).1-3 Children generally scratch or bite themselves.
Children and adolescents with intellectual and developmental disabilities are also at risk for various self-injurious behaviors, although they are typically not cognizant of the behavior. Research suggests that persons at high risk for suicide include those who use clandestine means to avoid detection of DSH; those who use highly lethal methods to hurt themselves, such as shooting; those who express a strong or unremitting death wish; and those who have comorbid psychiatric disorders.1,2
DSH prevalence and etiology
Table 2 provides some prevalence figures from recent studies around the world. These data illustrate that DSH is a ubiquitous phenomenon in which research and clinical mental health professionals as well as primary care clinicians have a role.
As our understanding of the mechanisms that underlie DSH improves, better management methods can be implemented. Clinicians are often flummoxed by the seemingly paradoxical self-injurious behavior of children and adolescents. Etiological models are traditionally construed in an attempt to understand suicidality, while the self-harming behavior of a child or adolescent is often viewed as the result of diverse socioeconomic influences (Table 3).
Research has identified various conducive factors (eg, peers, school, family, religious milieu) that affect suicidal ideation and self-derogation in adolescents.1 Recent research links the aggravated effects of bullying (including cyberbullying) to DSH and suicidal ideation.4
TABLE 1: Methods of self-harm1
• Drug overdose
• Battery (hitting)
• Well jumping
• Jumping from bridges, buildings, or other high places
It is not currently helpful to separate DSH into major and minor types, because evaluation and treatment must be individualized for each patient. Predicting the suicidal potential of any patient with DSH is complex; classifying DSH as minor could be tragically misleading. Clearly, more systematic research is needed.
Research reveals that nonsuicidal DSH in adolescents reflects underlying hopelessness and low self-esteem as well as other factors that precipitate attempts to deal with unacceptable inner feelings and/or affect the behaviors of others, such as peers or family members.5 As stress builds over time, the adolescent may resort to self-cutting when a personal threshold occurs after a gradual rise in tension (the “spring-path” mechanism) or because of a “switch-path” mechanism, in which an uncontrollable impulse for self-cutting is “switched” on.1 Switching on is the phenomenon of dissociation during the self-harm act and an uncontrollable need for more deliberate harm (as self-cutting). The self-harm action seeks to provide relief from a “terrible state of mind” and helps release unbearable as well as unremitting inner tension and pain.6
TABLE 2: Prevalence studies in deliberate self-harm behavior
|Nixon41||Adolescents through young adult||Canada||17% DSH; 83% cutting, scratching, hitting|
|Ystgaard42||Adolescents||Norway||6.6% DSH; 74% cutting|
|Morey28||Adolescents||Ireland||9.1% DSH; 66% cutting|
|Yates29||Adolescents||United States||26% - 37% cutting|
|De Leo39||Adolescents||Australia||6.2% (last 12 months of survey)|
|Li44||Adolescents and adults||Taiwan||1% of all injuries; 80% cutting DSH, deliberate self-harm.|
DSH, deliberate self-harm.
In interviews, youths who self-harm note intense, personal efforts to avoid overt suicidal thoughts, resistance to direct suicide action, extreme self-anger or self-disgust, intense distressing feelings, periods of dissociation, personal need to influence others, and attempts to seek aid from others.7,8 Persistent DSH may also be linked to a variety of mental health disorders, including major depression, substance abuse disorders, eating disorders, schizophrenia, and personality disorders.1,9,10
TABLE 3: Deliberate self-harm etiological factors
• Overt depression
• Low self-esteem and sense of persistent hopelessness
• School influence of intimation (such as bullying)
• Family dysfunction and conflict
The type of DSH behavior does not predict the degree, extent, or gravity of potential underlying psychopathology. In some children and adolescents who deliberately self-harm, there are severe family dysfunction and family communication problems.11 Such defects in communication can induce patterns of depersonalization that lead to states of dis-sociation. Other family pathology (including physical and/or sexual abuse, severe neglect, early separation from parents, a milieu of intense parental criticism, and rejection and other patterns of chaos) can result in DSH and youths who run away from home and join the ranks of the homeless.12,13
Misleading information about DSH is common on the Internet. DSH is often described as rationale behavior that represents personal self-expression and reaction to what 21st century’s social networks label as life’s unchangeable and insurmountable challenges. Youth are taught by others on the Internet that DSH is harmless, even good for one’s mental health, and representative of an acceptable expression of personal distress that is simply part of being young.
? Nonsuicidal deliberate self-harm (DSH) in adolescents reflects underlying hopelessness and low self-esteem as well as other factors that precipitate attempts to deal with unacceptable inner feelings and/or impact the behaviors of others, such as peers or family members.
? Early intervention may prevent or at least reduce chronic DSH behavior that if left untreated may become impervious to treatment.
? The key to successful interventions is the development of positive coping mechanisms, the reduction of relief underlying stress, and improvement in communication skills.
DSH and the risk of suicide
Although the underlying causes of DSH vary widely, all youths with evidence of DSH must be carefully evaluated for risk of suicide.14 If the underlying factors are not eliminated (such as psychiatric problems or long-term conflicts with peers or parents), acts of DSH can become repetitive (even inveterate) and can involve severe self-mutilation.14 In addition, depression and suicidal ideation may increase.14 Suicide is usually the result of chronic problems in self-cutters; however, acute reactions can also lead to suicide in some situations, such as those marked by impulsivity or use of lethal methods.
Over time, the overall risk of suicide increases after a self-harm episode; this risk increases 1.7% after 5 years, 2.4% at 10 years, and 3.0% at 15 years.15 Approximately 5% of patients who present to an emergency department after self-harm commit suicide within 9 years of the self-harming incident.2 Males with bulimia and males who experience analgesia during self-cutting are espe-cially vulnerable for overt suicide.16 Youths who cut their wrists are at higher risk for suicide than arm-cutters, although the latter is associated with more dissociation. Children who have been sexually abused are at increased risk for self-cutting behavior, eating disorders, and suicidal ideation.12
DSH and intellectual disability
Self-harming behavior in patients with intellectual disability is a common and difficult behavior for clinicians to understand and effectively address. It can be part of overall aggressive behavior that is directed toward others or inward.17 One study found that DSH behaviors eventually develop in 10% of children and adolescents with intellectual disability.18 Other studies have shown a prevalence of 1.7% to 41%.19 In this population, self-injurious behavior often includes skin-picking, head banging, eye gouging, and similar mutilation behaviors.
Remember that patients with intellectual disability have suicidal thoughts and can complete suicide; indeed, those at risk for suicide share similar neurogenetic factors whether they have an intellectual disability or normal intelligence.20,21 A careful evaluation is necessary to identify underlying factors that can be a complex combination of neurobiological and psychosocial/environmental phenomena (ie, DSH may be an adverse effect of psychopharmacology).22,23 A change in routine, presentation of difficult tasks, or an inability to perform tasks can precipitate self-mutilation in all patients who have an intellectual disability.24 Other factors related to DSH in adults with intellectual disability include low functional ability level, not living with a family caregiver, visual disability, and comorbid attention-deficit/hyperactivity disorder (ADHD).19
It is critical for clinicians to try to understand what the patient with DSH is trying to communicate and to provide early treatment. Ongoing studies are looking at the development of specific aggression profiles to direct specific treatment for patients with aggressive behavior, including DSH.25 Remission of DSH can occur in adults with intellectual disability, and current research is seeking underlying factors that can encourage remission in self-injurious behavior.19 Studies are also looking at a management model of early intervention and prevention.22,26
DSH management perspectives
All patients who exhibit recent or chronic self-harming behaviors need a careful and meticulous evaluation to determine the best individualized management strategies. In many, a recurrent motif develops; statistical analysis using hurdle models may help identify these malignant patterns.27
Early intervention may prevent or at least reduce chronic DSH behavior that if left untreated may become impervious to treatment. The risk of completed suicide increases over time with repeated DSH. Ignoring DSH may lead to suicide that might have been prevented.
Studies also note that most persons involved with DSH are secretive or hidden from psychiatric scrutiny.28 Only 50% of youths who self-harm seek professional help. Always be on the lookout for hidden DSH and ask questions if the evaluation reveals suspicious clues (eg, skin trauma consistent with self-cutting or other self-injury). Remember that youths engaged in DSH are at heightened risk for many high-risk behaviors, including unprotected sexual activity and illicit drug use.
Traditional intensive interventions include identification of DSH behavior; group therapy; school-based programs; hospitalization; art therapy; and psychopharmacological treatment for underlying disorders, such as depression, anxiety, ADHD, and psychosis.29 A meta-analysis of suicide data from 18 studies unfortunately concluded that there is no proven evidence that current management of DSH prevents eventual, or later, suicide.30 Thus, more research is needed to identify successful interventions for treating children and adolescents with DSH.
The key to successful intervention is the development of positive coping mechanisms, the reduction or relief of underlying stress, and improvement in communication skills.5,31 Positive or auspicious outcomes are enhanced by having therapy during times of crises, a trusting relationship between patient and clinician, appropriate treatment of comorbid psychiatric illnesses, and if possible, support from family members and friends.2 With the encouragement of a trusted clinician, a youth may be able to reduce episodes of DSH, which will allow time for CNS maturation and an eventual end to such abstruse, capricious, or arbitrary behavior.
Therapists can develop prevention programs that enhance the ability of those who self-harm to successfully manage stress in their lives and learn techniques of effective problem solving. Although little is known about adolescents’ views on DSH prevention, some have suggested that social network systems can be added to telephone hotlines to help prevent or mitigate DSH behavior.21
Management of self-injurious behavior in youths with intellectual disability
Management approaches for youths with intellectual disability and self-injurious behavior are rooted in psychological measures, including behavior modification (as differential reinforcement, extinction, punishment, response interruption, and redirection); giving the patient comforting or preferred items; placing the patient in protective helmets and/or gloves; and judicious use of psychopharmacological agents (eg, anticonvulsants, antipsychotics, antidepressants).26,32,33 Primary treatment with an antipsychotic is not recommended unless the underlying cause of the self-injurious behavior is the result of a psychotic disorder.25,34 Punishment-based therapies are not recommended. Research on optimal management is under way.32
The role of restraint or other aggressive interventions (eg, hitting, confining the patient to a room, refusing to allow play time) in the management of patients who self-harm remains questionable. Some current research focuses on the ethics of restraint versus the need to develop optimal practice standards for restraint with minimal harm to the patient with intellectual disability.35
DSH is a relatively common and pervasive, yet often surreptitious, phenomenon that may start in childhood and escalate in adolescence and young adulthood. Repeated DSH is linked to eventual suicide.1,36 Adolescent girls seem more vulnerable to this behavior than adolescent boys. Key components of DSH behavior are negative emotion and saturnine self-derogation. Etiological factors behind DSH include attempts to resist suicidal thoughts, expression of disgust or self-anger, attempts to seek help from others, a desperate desire to remove periods of dissociation, and audacious wishes to influence others.7,8
Study findings indicate an association between DSH and drug and alcohol abuse and eating disorders. Research is seeking to categorize various subgroups, such as major versus minor, types 1 through 4, those with serious versus minimal injury, as well as others. Fortunately, most are not at high risk for completed suicide.37 All DSH behavior should be taken seriously by the psychiatrist, and comprehensive evaluation as well as individualized management should be provided.38
Research should look at ways to improve primary, secondary, and tertiary prevention as well as methods of intervention.1,39,40 Effective interventions will prevent DSH from becoming a repetitive pattern that can result in suicide.
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