Self-harm is a term used to span a spectrum of suicidal and
non-suicidal behaviour, with a range of underlying motivations
It is relatively common in adolescence and is practised by
approximately 1 in 5 to 1 in 10 young people (Doyle et al, 2015). It is estimated that every
year there are approximately 220,000 presentations to British
emergency departments by people who have self-harmed (Hawton et al, 2007). Of course, this is only
the tip of the clinical iceberg, and the incidence of
hospital-presenting non-fatal self-harm in England is much lower
than that of community-occurring non-fatal self-harm, at least in
adolescents (Geulayov et al, 2018).
There are a range of reasons why people self-harm including:
- to cope with feeling overwhelmed
- to release tension or experience emotion
- to achieve a sense of control over life
- to reach out to others or to signal that they need help –
understood as a 'cry of pain' rather than a 'cry for help'
- to achieve any of the above without the wish to die
- to achieve any of the above without caring whether the outcome
is death or not
- a specific wish to die by suicide.
Self-harm may be common, and may help many people cope with
unbearable distress, but it also carries substantial risks.
Patients who present to hospital having self-harmed have been shown
to have an elevated risk of subsequent suicide (Carroll et al, 2014) and risk is particularly
high for those who repeat self-harm (Zahl
& Hawton, 2004). Risk appears to be highest in the month
(and year) immediately following hospital presentation (Geulayov et al, 2019). Children who self-harm
are approximately nine times more likely to die from unnatural
causes over a 15-year follow-up period (Morgan et al, 2017). Approximately 0.6%
of young people who self-harm go on to die by suicide, and this
risk is greatest for males, older adolescents, and those who
repeatedly self-harm (Hawton et al,
Risk factors for suicide in those who present to hospital having
self-harmed include male gender, increasing age and area-level
socio-economic deprivation (Geulayov et al,
2019). Presentations involving self-poisoning alone are
associated with the lowest risk of suicide (Geulayov et al, 2019) compared with those who
cut or use more than one method.
Beyond these broad risk factors, there is little that helps
clinicians distinguish those who eventually take their own lives
from those who do not (Mulder et al,
2016). Risk assessment instruments are now understood to have
poor predictive ability (Carter et al,
2017). This may leave clinicians unsure how to approach the
assessment and management of self-harm, and indeed anxious about a
perceived responsibility to predict and prevent suicide.
However, whilst a reduction in suicide risk is a theoretical
goal of interventions for people who self-harm, there are other
secondary goals such as reduction in associated distress, and a
reduction in the risk of repetition.
A range of treatments for self-harm have been investigated, yet
evidence for their effectiveness remains weak or uncertain due to
the relatively small number of trials and the poor methodological
quality of some of these studies (Hawton et
This module will present:
- the results of individual studies evaluating such treatments
for their impact on several outcome measures
- the results of meta-analyses of studies addressing several