Deliberate Self-Harm

Definitions

It is easy to confuse deliberate self-harm and suicide, so it is important to define both clearly at the outset:

Deliberate Self-Harm (DSH) is an acute, non-fatal act of self-harm carried out deliberately. It encompasses a spectrum of intent and lethality — from acts with high suicidal intent and high lethality, to acts with low suicidal intent and low lethality (often serving a function of emotional regulation, expressing distress, or communicating suffering).

Suicide is defined as an act with a fatal outcome that is deliberately initiated and performed by the person in the knowledge or expectation of its fatal outcome.

Forms of Self-Harm

Self-harm can present in a variety of ways:

• Overdosing on tablets (most common method in the UK, particularly paracetamol and over-the-counter preparations)
• Cutting or lacerating the skin
• Burning the body
• Banging the head
• Throwing the body against a hard surface
• Punching or hitting themselves
• Inserting objects into the body
• Swallowing inappropriate objects
• Hair-pulling, scratching, or other repetitive self-injurious behaviours

Epidemiology

In the UK, several thousand people take their own lives each year. Suicide accounts for approximately 1% of all deaths. Male suicides outnumber female suicides, while deliberate self-harm is more common among women. Most suicides occur in the age range of 22–54 years. Cases of deliberate self-harm are approximately 30 times more common than completed suicide.

An important statistic that every clinician should know: approximately 10% of patients admitted to hospital following deliberate self-harm will die by suicide within 10 years. A thorough psychosocial assessment at the time of presentation may prevent future deaths.

Risk Factors for Suicide

• Male gender (men are 3 times more likely to die by suicide than women)
• Advancing age (in men); younger age (in women for DSH)
• Unemployment or financial difficulties
• Concurrent mental illness — particularly depression, schizophrenia, bipolar disorder, borderline personality disorder, and alcohol dependence
• Previous suicide attempt (the single strongest predictor of completed suicide)
• Alcohol and drug misuse
• Low socioeconomic status
• Previous psychiatric treatment
• Certain occupations with access to means — doctors, farmers, pharmacists, veterinarians
• Low social support or living alone
• Significant adverse life events (bereavement, relationship breakdown, legal problems)
• Institutionalisation (e.g. prison, armed forces)
• Family history of suicide or self-harm
• Access to lethal means (firearms, stockpiled medication)
• Terminal physical illness or chronic pain

Protective Factors Against Suicide

• Family support, peer support, and strong emotional connections
• Access to good professional support and mental health care
• Abstinence from illicit drugs and alcohol
• Stable employment
• Insight into their mental illness and good understanding of their condition
• Compliance with medication and treatment
• Identification and resolution of key unresolved issues
• Good coping skills and resilience
• Presence of a safety plan
• Reasons for living — children, religious beliefs, future goals

Risk Assessment

Risk assessment in all patients presenting to psychiatric services is of paramount importance. All hospitals have their own risk assessment tools. Two commonly used standardised scales are:

Beck's Suicide Intent Scale and the Pierce Suicide Intent Scale.

Pierce Suicide Intent Scale — Assessment Domains

The Pierce Scale and nearly all risk assessment tools evaluate the following domains relating to the circumstances surrounding the self-harm act:

Circumstances Preceding the Act

• Isolation: Was someone present, or was the patient completely alone?
• Timing: Was the act timed so that intervention was possible or unlikely?
• Precautions against rescue: What level of precautions did the patient take to avoid being found?
• Acting to get help: Did the patient notify anyone or seek help after the act?
• Final acts in anticipation of death: Was a will made or were final arrangements carried out?
• Presence of a suicide note: Was a note left?

Self-Report Domains

• Lethality: Did the patient believe their actions would or would not kill them?
• Stated intent: Did they want to die?
• Premeditation: Was the act planned in advance?
• Reaction to the act: Is there remorse? Are they sad they survived?
• Predictable outcome: Was survival or death the expected result?
• Medical risk: Would the act have been fatal without medical intervention?

Higher scores on these scales correspond to higher suicidal intent and greater risk. These tools guide (but should not replace) clinical judgement.

History of Deliberate Self-Harm

Taking a thorough history is fundamental to the assessment of any patient who has self-harmed. The history should cover:

• Circumstances leading to the self-harm:
  • What happened? What method was used and how much?
  • What triggered the event — was there a precipitating stressor?
  • Was a suicide note left?
  • Did the patient expect to be found?
• Family and personal history: Relationship problems, abuse, mental illness in the family, and other personal history relevant to understanding the risk
• Intent behind the act: Wish to die, wish to escape from life stressors, wish to communicate distress, or a mix of these
• Present feelings and future intent:
  • How do they feel now?
  • Do they still wish to die?
  • Feelings about the future — hopeless or hopeful?
  • Thoughts that life is not worth living
  • Current plans for suicide or further self-harm — if plans exist, explore what, when, and how in detail

Management

Medical Treatment

Medical stabilisation takes priority. Management depends on the specific method of self-harm. For overdoses, consult TOXBASE (the online poisons information database) for specific management protocols. Common scenarios include:

• Paracetamol overdose: N-acetylcysteine (NAC) treatment based on plasma paracetamol levels and time since ingestion; hepatology input if required
• Opioid overdose: Naloxone, airway management
• Cutting wounds: Appropriate wound care, suturing, or closure as indicated
• Burns: Burns assessment and management

Psychosocial Treatment

The psychosocial assessment is the most important aspect of the psychiatric management of DSH. NICE CG133 recommends:

• Identify risks and psychological issues associated with further self-harm
• Offer a comprehensive needs assessment to all patients who self-harm
• Upon discharge, inform the GP and relevant mental health services of the plan
• Do not discharge a patient solely on the basis of low risk and the absence of a formal mental illness — every patient who has self-harmed deserves a full psychosocial assessment
• If the patient is very distressed, offer a brief admission to a psychiatric ward or crisis house
• For patients at risk of repetition, arrange intensive follow-up — crisis team intervention, outpatient review with a psychiatrist, and a care coordinator or community psychiatric nurse (CPN). Later, offer CBT-based interventions (e.g. dialectical behaviour therapy for repeated self-harm in the context of emotionally unstable personality disorder, or CAMS — Collaborative Assessment and Management of Suicidality)
• Develop a safety plan with the patient before discharge: identify warning signs, coping strategies, social supports, and crisis contact numbers

Therapeutic Approaches Available

• Talking with a non-professional: Peer support or speaking with an anonymous listener (e.g. Samaritans — 116 123) can help
• Self-help groups: People with lived experience of self-harm can provide peer emotional support
• Help with relationships: If a relationship difficulty is the primary precipitant, couples therapy or relationship counselling may be indicated
• Talking therapies: CBT, problem-solving therapy, cognitive analytic therapy (CAT), dialectical behaviour therapy (DBT) — particularly effective for recurrent self-harm in emotionally unstable personality disorder
• Family meetings: A structured family meeting with a therapist can address relationship dynamics that contribute to self-harm
• Group therapy: Professionally facilitated group work helps patients process experiences with the support of others who have faced similar challenges

Clinical Case Example

Consider a 30-year-old male presenting to A&E following paracetamol ingestion. He ingested the tablets approximately 4 hours ago. He states that he wants to die and refuses to give consent for blood tests (including paracetamol levels). He is unwilling to provide any further history.

Key question: Can he receive medical treatment without his consent?

The answer lies in assessing mental capacity. Under the Mental Capacity Act 2005, every adult must be presumed to have capacity unless it is established otherwise. However, a patient in the immediate aftermath of a potentially life-threatening self-harm attempt may have impaired capacity, particularly if there is evidence of acute distress, intoxication, psychosis, or significant cognitive impairment. If capacity is assessed and found to be lacking, clinicians can proceed with treatment in the patient's best interests.

Mental Capacity Assessment

Under the Mental Capacity Act 2005, a patient has capacity to make a specific decision if they are able to:

• Understand information relevant to the decision — in simple, plain language: what the treatment is, its purpose, why it is proposed
• Understand the principal benefits, risks, and alternatives of the proposed treatment
• Understand the consequences of refusing the proposed treatment
• Believe the information provided (not delusionally distorted)
• Retain the information for long enough to make an effective decision
• Weigh up the information and use it in their decision-making process
• Communicate their decision through any means available

Capacity assessment must be decision-specific and time-specific — a patient may lack capacity regarding one decision but retain capacity for another. If capacity is absent in an emergency, treatment may proceed in the patient's best interests under Section 5 of the Mental Capacity Act 2005.

Summary

• DSH results in non-fatal injury carried out with high or low suicidal intent and lethality
• Risk assessment is essential — categorise the patient as high, medium, or low risk and manage accordingly
• Manage the whole patient, not just the presenting complaint — a holistic, multidisciplinary approach is essential
• Never discharge without an adequate safety plan, GP notification, and — where appropriate — crisis team follow-up
• Always assess mental capacity in patients who refuse medical treatment following self-harm