Chapter 17
Self-Harm
114
, Chapter 17: Self-Harm
A 24 year old woman was seen in the emergency department after taking an overdose of paracetamol. She
has been having difficulties in her relationship with her boyfriend and has been very tearful over the past two weeks,
with a disturbance in her sleep, appetite and energy level.
Introduction
• Self-harm is intentional self-poisoning or self-injury, irrespective of motivation, commonly associated with the
use of alcohol.
Note: “Self-harm” is the agreed (UK based) term in preference to “deliberate self-harm” 'based on the
heterogeneous nature of the phenomenon and the concerns of service users' (NICE 2004, RCPsych 2004) Ref;
Seminars in Liaison Psychiatry 2nd ed. 2012.
• Self-poisoning
o People who self-poison are more likely to present to hospital than those who self-injure. Overdoses are
therefore the most common form of self-harm found in emergency departments.
o Paracetamol is particularly dangerous because it damages the liver and may lead to the delayed death
of patients who had not intended to die.
• Self-injury
o Self-cutting is the most common form of self-injury.
o Other forms of self-injury include burning, biting, head banging, eye pressing and bone breaking.
Risk factors
Variable Increased risk
Demographics
Age. • In Ireland, the peak age ranges for females and males presenting to emergency departments following self-
harm is 15-19 years for females and 20-24 years for males.
Gender. • Females > males, ~ 1:1 in > 50 year olds.
Marital status. • Divorced > single > widowed (married have the lowest rate).
Socio-economic group. • Lower socio-economic group (i.e. IV or V).
Employment. • Unemployed, school and work-related difficulties (including bullying), financial difficulties and
economic recession.
Living situation. • Living alone (socially isolated), urban living (overcrowded inner cities).
Race. • Asian women > Caucasian women.
Health
Physical health. • Chronic physical illness.
Mental health. • Mood disorder (depression - often associated with a sense of hopelessness, bipolar affective disorder).
• Psychotic disorder (especially schizophrenia).
• Alcohol/substance misuse and dependence: (males are more likely to drink before an episode of self-harm than
females).
• Phobic disorder.
• Personality disorder (borderline personality disorder, dissocial personality disorder).
• Intellectual disability.
Personal factors
Personality factors. • Impulsivity, poor problem solving abilities.
Perceived under- • Perceived underachievement at school or in the workplace.
achievement.
Life events. • Abuse (especially childhood sexual and physical abuse), domestic violence, break-up of a relationship, death
of a significant individual in the person’s life.
Special groups
Prisoners. • Self-harm is more common in prisoners than in the general population
o Increased rate of self-harm in prisoners might be explained by the increased rate of mental illness in
prisoners (e.g. affective disorders, psychotic disorders, drug and alcohol dependence, personality
disorders, neurotic disorders).
o Cutting or scratching are the most common methods of self-harm in prisoners.
Lesch Nyhan • Inherited abnormality of uric acid metabolism (self-injury, including biting and head banging, is the most
syndrome. common and distinctive behavioural problem).
Cornelia de • Mutations in NIPBL, SMC1A and SMC3 genes. Affects both physical and intellectual development.
Lange syndrome. • Self-injury occurs in approximately 44% of cases.
Biochemical • Decreased 5-hydroxyindoleacetic acid (5-HIAA) concentration in cerebrospinal fluid (5-HIAA is the main
disturbance metabolite of serotonin in the human body).
115
Self-Harm
114
, Chapter 17: Self-Harm
A 24 year old woman was seen in the emergency department after taking an overdose of paracetamol. She
has been having difficulties in her relationship with her boyfriend and has been very tearful over the past two weeks,
with a disturbance in her sleep, appetite and energy level.
Introduction
• Self-harm is intentional self-poisoning or self-injury, irrespective of motivation, commonly associated with the
use of alcohol.
Note: “Self-harm” is the agreed (UK based) term in preference to “deliberate self-harm” 'based on the
heterogeneous nature of the phenomenon and the concerns of service users' (NICE 2004, RCPsych 2004) Ref;
Seminars in Liaison Psychiatry 2nd ed. 2012.
• Self-poisoning
o People who self-poison are more likely to present to hospital than those who self-injure. Overdoses are
therefore the most common form of self-harm found in emergency departments.
o Paracetamol is particularly dangerous because it damages the liver and may lead to the delayed death
of patients who had not intended to die.
• Self-injury
o Self-cutting is the most common form of self-injury.
o Other forms of self-injury include burning, biting, head banging, eye pressing and bone breaking.
Risk factors
Variable Increased risk
Demographics
Age. • In Ireland, the peak age ranges for females and males presenting to emergency departments following self-
harm is 15-19 years for females and 20-24 years for males.
Gender. • Females > males, ~ 1:1 in > 50 year olds.
Marital status. • Divorced > single > widowed (married have the lowest rate).
Socio-economic group. • Lower socio-economic group (i.e. IV or V).
Employment. • Unemployed, school and work-related difficulties (including bullying), financial difficulties and
economic recession.
Living situation. • Living alone (socially isolated), urban living (overcrowded inner cities).
Race. • Asian women > Caucasian women.
Health
Physical health. • Chronic physical illness.
Mental health. • Mood disorder (depression - often associated with a sense of hopelessness, bipolar affective disorder).
• Psychotic disorder (especially schizophrenia).
• Alcohol/substance misuse and dependence: (males are more likely to drink before an episode of self-harm than
females).
• Phobic disorder.
• Personality disorder (borderline personality disorder, dissocial personality disorder).
• Intellectual disability.
Personal factors
Personality factors. • Impulsivity, poor problem solving abilities.
Perceived under- • Perceived underachievement at school or in the workplace.
achievement.
Life events. • Abuse (especially childhood sexual and physical abuse), domestic violence, break-up of a relationship, death
of a significant individual in the person’s life.
Special groups
Prisoners. • Self-harm is more common in prisoners than in the general population
o Increased rate of self-harm in prisoners might be explained by the increased rate of mental illness in
prisoners (e.g. affective disorders, psychotic disorders, drug and alcohol dependence, personality
disorders, neurotic disorders).
o Cutting or scratching are the most common methods of self-harm in prisoners.
Lesch Nyhan • Inherited abnormality of uric acid metabolism (self-injury, including biting and head banging, is the most
syndrome. common and distinctive behavioural problem).
Cornelia de • Mutations in NIPBL, SMC1A and SMC3 genes. Affects both physical and intellectual development.
Lange syndrome. • Self-injury occurs in approximately 44% of cases.
Biochemical • Decreased 5-hydroxyindoleacetic acid (5-HIAA) concentration in cerebrospinal fluid (5-HIAA is the main
disturbance metabolite of serotonin in the human body).
115
