Even if it seems everything is fine, you need to continue to follow up as discussed at the time of discharge. Please contact Nationwide Children's Hospital Behavioral Health at if you need to set up an appointment. You may also contact your health care provider for a list of counseling services covered by your health care plan. Skip to Content. Urgent Care. In This Section. Behavioral Health Looking for services or physicians who can help treat this condition?
Click Here. Home Depression. Self-harm and self-injury. Actions for this page Listen Print. Summary Read the full fact sheet. On this page. What is self-harm? Getting support for self-harming behaviour Seeking help for suicidal thoughts How do I know if someone is self-harming? Supporting someone who self-harms Self-harming behaviour is treatable Finding alternatives to self-harm Who is at risk of self-harm?
Why do people self-harm? What are the risks of self-harm? Where to get help. Self-harm is normally a sign that a person is feeling intense emotional pain and distress. Getting support for self-harming behaviour If you are self-harming and you are worried, try to talk to someone you trust — like a friend, family member, doctor, teacher or school counsellor.
You can: See a doctor , counsellor or psychologist. If you have a mental health condition, your GP can work with you to draft up a mental health treatment plan, which can include counselling sessions at a low cost.
Contact eheadspace to talk to a counsellor. You can do this online or over the phone Tel. Visit a headspace centre — there are centres all over Australia where young people 12—25 years can get health advice, information and support — usually free or at a low cost.
You can talk to a counsellor about anything at any time. Call Beyond Blue to talk to a counsellor at any time Tel. Youthbeyondblue also provides youth-friendly information on self-harm. Visit ReachOut for youth-friendly information on self-harm, and online programs to help young people who may have depression and anxiety.
Seeking help for suicidal thoughts Sometimes the distress you feel can be so overwhelming that you may have thoughts about ending your life.
You can also call: Lifeline Tel. Suicide Call Back Service Tel. How do I know if someone is self-harming? Some signs may include: new marks on the body such as bruises, cuts or burns withdrawal from friends, family, school and work a drop in performance at school, work or activities changes in mood, sleep and eating patterns avoidance — not attending activities they once enjoyed or avoiding occasions where their injuries will be exposed such as the beach or pool wearing unsuitable clothing to cover up wounds making excuses for injuries or behaviour being secretive — hiding sharp or dangerous objects.
Supporting someone who self-harms People who self-harm need care, understanding and support in order to recover.
How to talk with someone who self-harms It can be difficult to approach someone who is self-harming. Try the following suggestions: Ask them how things are going or how they are feeling. Let them know you are there if they feel down or stressed. Tell them you are worried about them, and why.
Ask if they are thinking about suicide. If they are, or you think they might be, call your local hospital or mental health service. Or call a helpline such as Lifeline Tel. If they seem upset or angry it may just mean they are feeling ashamed or worried about what you might think.
Encourage them to seek support from a person they trust —such as a GP, teacher or counsellor. Other ways to lower their distress may include: distraction — go for a walk, play a game, watch a movie or listen to their favourite music diversion — find a substitute action that causes no injury such as punching a pillow or squeezing an ice cube deep breathing.
Support people need support too If your child, friend or other family member is self-harming, or you think they might be, seeking support from a mental health professional is important for you too. Finding alternatives to self-harm It can be difficult to break away from self-harm. The person who is self-harming may like to develop their own ways to distract themselves, or use some of these ideas: wear a rubber band around your wrist and snap it when you feel distressed eat an ice-cube — the sensation can take your mind off intense feelings hold an ice-cube in your hand keep a journal and jot down your thoughts exercise — it releases endorphins and can help lift your mood be mindful — do some colouring, try meditation, relaxation or do a craft activity like knitting or painting draw on your body in the areas where you normally hurt punch a pillow make your environment safe — get someone you trust to take away any harmful objects and keep you away from any places where you are likely to harm keep a distraction box — store some things that bring you comfort in a box or bag such as photos, a favourite toy, chewing gum, fiddle toys, craft.
NSSI could thus serve as acts of microsuicide that create an illusion of control of death [ 63 ]. Some adolescents thus say that they have used NSSI to reduce the suicidal ideation against which they struggle [ 58 ]. What elements distinguish NSSI from suicidal behavior? The central difference is that suicide attempts involve a conscious intention to die, through the abolition of consciousness [ 35 , 64 ].
Accordingly, while the suicidal act is seeking death, the objective of NSSI injury seems to be to relieve unbearable emotions, by seeking to modify rather than abolish the state of consciousness. Recourse to multiple methods of self-injury with a low risk of death and a high frequency of acts the frequency of NSSI is substantially higher than that of suicide attempts; teens can average 20 to 30 NSSI acts a year underlines the function that NSSI behaviors serve: emotional self-regulation and relief from psychological pain [ 35 ].
The reasons adolescents give to justify their self-injurious behavior can be classified as intrapersonal—to seek relief from negative effects or on the contrary to seek feelings to reduce their experience of anhedonia—or interpersonal—to communicate their malaise, ask for help, or escape from a difficult situation [ 10 , 17 , 32 , 34 , 65 — 68 ].
Nonetheless, intentionality appears to be a theoretical difference, difficult to clarify clinically: it complicates the question. It is difficult for mental health professionals to assess clinically what adolescents think and say about death, especially their the adolescents' own, for these thoughts and accounts depend on their character, education, and culture.
Young people most often mix together their seeking of relief and their ideas of death [ 67 , 69 ]. Differentiating NSSI from suicidal behavior in clinical practice on the basis of intentionality is therefore complex. These behaviors appear to have multifactorial determinants [ 66 ] that might be more easily accessible by considering a continuum of self-injurious behavior that includes both NSSI and suicidal behavior. Seeking a more thorough theoretical comprehension of this topic, several authors have set themselves the task of understanding why and how NSSI is a predictive factor for suicidal behavior for some patients but not for others.
Integrated models have proposed several readings of the link between NSSI and suicide. Some began by envisioning the concept of a continuum or spectrum [ 3 , 70 , 71 ], considering NSSI and fatal suicides as two ends of the same spectrum, two different manifestations of the same behavior.
NSSI may represent an antechamber to suicide; it is this alarm value that requires particular attention [ 35 ]. This analysis is based on one of the first models for understanding the association between NSSI and suicide: the gateway theory [ 3 , 13 , 70 ].
As seen above, NSSI is a highly predictive risk factor for suicidal behavior [ 26 , 28 , 54 , 57 , 72 ]. This theory is supported by both retrospective and prospective studies, after adjustment for other risk factors [ 13 , 31 , 44 , 54 ].
NSSI might therefore be a single and independent risk factor for subsequent suicidal behavior. Several points support this hypothesis: the strong co-occurrence of these two types of behaviors underlies their association [ 14 , 26 , 73 , 74 ]; NSSI also begins early, according to the epidemiologic data [ 13 , 18 , 23 , 25 , 29 , 41 ] and thus appears to precede suicidal behavior.
NSSI triples the risk of subsequent but also concomitant suicidal behavior [ 44 ]. It is nonetheless thought of as a one-way predictive factor, with suicide attempts not considered to predict risk of NSSI [ 13 , 26 , 58 ]. NSSI is accordingly considered a gateway toward more severe forms of self-injury. A second model assumes the existence of a third variable, the presence of which links NSSI and suicidal behavior the Third Variable theory.
The variables to be taken into account might include a depressive state, suicidal ideation, personality disorder, low self-esteem, or unsupportive family [ 3 , 15 , 16 ]. For example, the presence of borderline personality disorder simultaneously increases the risk of NSSI and of suicidal behavior. Thus consideration of this variable would make it possible to use NSSI to predict suicide attempts [ 14 ].
NSSI also appear to be strongly predictive of suicidal behavior among a population of depressed adolescents [ 76 ]. The identification of a group of NSSI patients at risk of suicide would therefore depend on the presence of a third variable. They have major theoretical and clinical limitations and have been undermined by some recent studies [ 13 , 26 , 54 ]; new models have therefore become necessary.
Towards this end, Joiner [ 11 ] developed an integrated model of self-injurious behaviors and was able to develop different explanations for why individuals whose life course had until then been marked by NSSI would attempt suicide. It is based on an original approach: pain tolerance.
Other authors have since supported and added to this model [ 77 — 79 ]. Joiner [ 11 ] conserved the concept of a continuum ranging from NSSI to suicidal behavior, but added a variable coming from neurosciences—modulation of pain [ 80 ], which is driven by the endogenous opioid and endocannabinoid pathways [ 81 ].
The repetition of NSSI might accordingly disrupt the pathways involved in the stress-induced analgesia that leads to the phenomenon of pain tolerance [ 82 ]. The author thus suggests that when a person cannot imagine or represent his or her own death, NSSI appears to be an acceptable alternative. NSSI could thus be considered a way of acquiring a capability for suicide.
A strong association has been found between the use of a high number of NSSI methods, a high frequency of NSSI, and the risk of suicide attempts by self-injuring adolescents [ 60 ]. NSSI might thus enable the person to become accustomed and thus desensitized to the fear and pain of physically hurting oneself [ 11 , 13 ].
The more varied the means of NSSI and the more frequent its episodes, the greater the increase in capability for self-injury and then for suicide [ 59 ]. Reinforcing this theory, Muehlenkamp and Gutierrez [ 18 ] show that self-injuring adolescents describe less fear of suicidal acts than those without this NSSI history. The self-injuring adolescents also appear to show greater pain tolerance during standardized tasks than control subjects [ 13 , 83 , 84 ].
We can thus ask whether NSSI is a means of pain desensitization [ 85 ] or if these self-injurers have a greater constitutional tolerance than others [ 83 ]. Finally, the association between NSSI and the acquisition of capability for suicide may be associated with the severity of nonsuicidal self-injurious behavior. Subjects with severe forms of NSSI may be at higher risk of acquiring this capability [ 13 ].
Several authors see NSSI as a strategy of emotional adaptation and regulation [ 59 , 65 ]. If this strategy fails, the adolescent must undertake more severe forms of self-injury, which become progressively closer to suicidal behavior [ 15 ]. Nonetheless, here, NSSI is considered as one of many behaviors that can contribute to the acquisition of this capability and can accordingly increase the risk of suicide.
Among them, drug or alcohol abuse and exposure to violence, such as combat experience, can also favor a gradient in self-injury [ 13 , 78 ]. Joiner's model [ 11 ] thus has a much wider theoretical reach: it makes it possible to analyze the relation of numerous behaviors and impulsive actions.
The variable of capability for suicide has direct clinical interest for both primary and secondary prevention. Identifying a subtype of patients at higher risk would make it possible to provide graduated management and more supportive care to the patients at the greatest risk of suicidal acts [ 60 ]. Our literature review has allowed us to explore diverse aspects of the relation between NSSI and suicidal behavior.
All of these behaviors directed against the self share the same terrain of fragility and risk factors; they are also statistically correlated. NSSI thus appears to be a risk factor predictive of subsequent suicidal behavior. This result has been used in the development of several integrated models, the most recent of which includes the concept of acquiring the capability for suicide through NSSI. Most of the studies on this subject begin by distinguishing NSSI and suicidal behaviors according to the intention to die.
This intention appears to us to be central but also very difficult to assess in clinical situations. The definition of behaviors with and without death as their intention has made it possible to set up groups of patients accessible to research.
Nonetheless, the assessment of adolescents with such different profiles and clinical histories seems close to impossible to us. NSSI and suicide attempts thus appear to be behaviors on a single continuum of self-injury. We think that a distinction based on the intentionality of the action does not justify the conclusion that a desire for death was not present during NSSI nor does it differentiate NSSI from suicidal behavior.
The question is what a desire to die can mean to young people. Behind intentionality lies the question of the representation of one's own death at this age.
Adolescence is not only a period of construction and transition, but also the stage when awareness of death develops. Adolescents are confronted with the need to grieve for the immortality of their childhood.
The concept of death appears to follow a developmental progression [ 86 ], as found in children. Representations of childhood overlap with adult representations, those transmitted by environment, culture, and religion. It is thus both frequent and normal for adolescents to think about death. Adolescents regularly develop interests in symbols of death and in music groups that convey these symbols.
These thoughts can be considered to be a necessary psychological development: with puberty, the feeling of death, anxiety about death, and ideas of death, seen as irreversible, universal and inevitable, fuse to approach knowledge of death [ 87 — 89 ]. The objective is to understand, become familiar with, and ascertain the limits of life and death. Nonetheless, one's own death is unthinkable: according to some authors, death is an ontological impasse [ 90 ]. It makes no sense, has no meaning in itself, and may not be entirely accessible to human reason.
The issue of adolescence is thus to construct a symbolic representation of death in order to control it or at least to defuse its threat [ 87 , 91 ]. Adolescents when they are performing a self-directed act, are no longer in a symbolic elaboration but in an action that expresses their inability to imagine death [ 87 ]. The act short-circuits the thought. There would thus be neither a desire nor an absence of desire to die during the act.
Seeking to assess the intentionality underlying the act thus appears contradictory. In NSSI as in suicide attempts, the act short-circuits the thought. Before the act, death is thought, symbolized: it may appear fascinating, attractive, or not. After the act, it becomes urgent to create a narrative of the event. This is the moment when intentionality appears to be constructed, in an attempt to give a meaning to the act. At this stage, adolescents may or may not allow themselves to talk about suicidal behavior.
Numerous elements can interfere with this process of meanings. In the first place, the reaction of family and friends and the relational value they give to the act appear central.
We know the communicative value given to self-injury, which is sometimes interpreted as aggression or rejection [ 1 , 92 ]. But the cultural environment must also be taken into account, and the taboo of suicide, whether legal, moral or religious, can influence this psychological work [ 93 — 96 ].
Finally, the influence of psychopathologic processes, such as depression, cognitive disorders, and addictions, plays a role [ 8 , 13 , 76 ]. All of these dimensions—psychopathologic, cultural, religious, and philosophic—are necessary to understand self-injurious acts.
Additional studies thus appear necessary to examine this question in greater detail, to take into account the complexity of the context, and to explore further the subjective experience reported by patients. Qualitative studies are perfectly adapted for the in-depth study and detailed understanding of these complex questions of behaviors [ 97 ]. It is possible to associate the difficulties presented by adolescents who self-harm with defective mentalization [ 98 ].
Mentalization is understood here as the capacity to understand oneself and to understand others by deducing the mental states that underlie their apparent behavior: their thoughts, beliefs, intentions, motivations, and goals. This fundamental psychological process is at the interface of numerous mental disorders, so that this theory may find a generic application in psychiatric care [ 99 — ].
In the case of the adolescents we study here, their inability to represent death may thus be accessible to the methods of treatment proposed, for example, for borderline personality disorders mentalization-based treatment [ 98 ]. The principal work of the therapist in this treatment is to encourage their patients' curiosity, their continual questioning of their own mental state, of the way they do things.
The therapist's task is to aid adolescents in understanding how to find a meaning in their experience. We propose to apply this treatment technique to the management of adolescents who self-harm, to promote their capacity to represent NSSI behavior or suicidal acts and the emotional states associated with them, and accordingly to modify the meaning of these acts. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field.
Abstract Nonsuicidal self-injury NSSI and suicidal behaviors, both important issues in adolescent health care, are frequently associated and possibly clinically related.
Funding: The authors received no specific funding for this work. Method This is thus a narrative systematic review of the topic of the associations between suicidal and NSSI behaviors in adolescents. This inductive systematic work includes six steps: Definition of the research question and the objectives Manual literature review to select the principal papers on the topic and to construct key words and inclusion and exclusion criteria Systematic review and identification and selection of studies Analyzing the papers, extracting their data and identifying their themes Generating a thematic analysis and structuring the synthesis Writing the paper Our clinical experience with adolescents presenting self-injurious behaviors has led us to question the heterogeneity of their profiles and the apparent associations between NSSI and suicide step 1.
Papers were selected only if they met the following criteria: Published in English Between January and January Considered the association between NSSI and suicide Adolescent and young adulthood population 11 to 25 years when specified All methodologies were included quantitative as well as qualitative or mixed studies.
Finally, the following studies were excluded: Studies focusing on specific medical conditions such as psychosis, autism, mental disabilities, or chronic somatic suffering diabetes or chronic pain for example After elimination of duplicates, we obtained references Fig 1. Download: PPT. Results In all, we examined 64 studies that questioned relations between NSSI and suicidal behaviors in adolescence and young adulthood.
The shared risk factors. First, NSSI and suicidal behavior share some risk factors [ 8 , 49 ]: among the psychiatric comorbidities: depression, borderline personality disorder [ 8 , 20 ], substance abuse, posttraumatic stress disorder, impulsivity, externalizing behaviors [ 8 , 30 , 50 ], attention deficits, with or without hyperactivity, and conduct disorders [ 4 ].
The contribution of intergroup comparisons. Is NSSI a risk factor for suicide or not? Intentions underlying NSSI and suicidal behaviors. Integrated Models Seeking a more thorough theoretical comprehension of this topic, several authors have set themselves the task of understanding why and how NSSI is a predictive factor for suicidal behavior for some patients but not for others.
The Gateway theory. The Third Variable theory. Joiner's theory: Pain tolerance and capability for suicide. Discussion Our literature review has allowed us to explore diverse aspects of the relation between NSSI and suicidal behavior. Implications for practice It is possible to associate the difficulties presented by adolescents who self-harm with defective mentalization [ 98 ]. Supporting Information. S1 File. Description of the method. S1 Table.
Characteristics of studies.
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