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Deliberate Self-Harm

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A 13-year-old girl presents to ED after cutting herself with a razor. When asked why, she reveals some of the messages she has received on social media:

“You’re pathetic and don’t deserve to live.”

“If U don’t kill yourself tonight, I’ll do it for U.”

Deliberate self-harm is intentionally hurting oneself and can be done with or without the intention of suicide. Self-harm comes in many forms. Cutting or scratching body parts, punching objects or themselves, overdosing, burning, and swallowing dangerous objects or substances can all be forms of self-harm. These self-harm behaviours profoundly affect young people, their families, and health services. Each person’s reason for self-harm is different, but it is a way to ease the sense of feeling overwhelmed, a form of self-punishment, or a sign of extreme distress.

A Norwegian meta-analysis identified four primary reasons for self-harm among young adults: obtaining release or relief from intense and unbearable feelings, expressing feelings and pain to others when feeling unheard, connecting with others with the same problems, and gaining control to cope with difficult emotions (a helpful mnemonic to remember: Obtain an ECG). Paradoxically, self-harming can help a young person feel better and relieved. Framing self-harm as a relief-seeking mechanism rather than attention-seeking is a helpful way to communicate with caregivers and colleagues.

What can often reinforce self-harm behaviour (almost always driven by unbearable emotional states) are the blame and rejection responses of those surrounding the young person, especially family and friends. Suicide attempts and self-harm are among the strongest predictors of death by suicide in adolescence, increasing the risk 10-fold.

How common is deliberate self-harm?

Deliberate self-harm is increasingly common in early adolescence and a priority public health concern. The first episode of self-harm typically occurs between the ages of 12 and 16, with around 1 in 10 people reporting self-harm in their teenage years. In Australia, the age-specific rate of deliberate self-harm among young people increased from 9.1 per 100,000 in 2009 to 14 per 100,000 in 2020.

Self-harm is more common in girls. For example, in Canada and the UK, there is a high rate of self-harm-related hospitalisation in females aged 15 to 19. In Australia, the trend is similar; from 2008-09 to 2020-21, there was more than a 3-fold increase in the rate of deliberate self-harm hospitalisations in females aged 14 and younger.

There are many risk factors behind deliberate self-harm – biological, social and environmental. Personal factors include adverse childhood experiences, bullying, parental death or divorce. Furthermore, depression and anxiety often co-occur. Between 2003 and 2019, child abuse and neglect during childhood was the leading behavioural risk factor contributing to the burden of suicide and deliberate self-harm in both males and females aged five and over in Australia.

Insecure attachment to caregivers is a strong risk factor for self-harm due to the absence of a learned or developed capacity to self-regulate painful emotions. Moreover, such young people have discovered that depending on others to alleviate distress worsens it.

The most common method of deliberate self-harm is cutting. It is estimated only 1 in 8 cases of self-harm present to the Emergency Department, the most common presentations being self-poisoning. Recent literature suggests that overdosing or a mixed method of self-harm is becoming more common in males and females under the age of 15 years. Between 2008-09 and 2020-21, the most common methods of self-harm resulting in hospitalisation were overdosing by anti-inflammatories (ibuprofen), antipyretics (aspirin, paracetamol), sedatives, psychotropic drugs, or injuries from sharp objects.

The rate of deliberate self-harm in the community is significantly greater than those presenting to hospitals. The repetition rate at one year following a previous hospital presentation is 16%. Due to its concealed nature, it is difficult to predict the recurrence of self-harm worldwide.

Distraction techniques

Distraction techniques for those who self-harm

*The best antidote to self-harm is accessing a supportive or emotionally secure relationship in times of stress and feeling overwhelmed. While this is not always possible, most young people have at least one person in their life whom they can talk to about their feelings.

Primary-aged school children are self-harming

Self-harm is increasing in younger populations, with increased rates among primary school-aged children. An Irish study found that the age of onset for self-harm in young people is lowering, and rates of self-harm are increasing. Self-harm has been identified in children as young as six years old in Australia. Primary-aged children who were experiencing depression or anxiety had few friends, were bullied or were undergoing puberty were found to be more likely to self-harm. Intervention strategies in high schools that address mental health and resilience may not be sufficient. With recent research finding younger people self-harming, prevention strategies are needed much earlier.

The COVID-19 pandemic and digital self-harm

Since the onset of the COVID-19 pandemic, there has been a spike in people suffering from mental health issues. Anxiety, depression, panic, and self-harm behaviours have become more common. The lack of available face-to-face mental health support services, social isolation, disruption to daily routines and future plans, feelings of entrapment, job loss or financial stress in the family exacerbate and cause mental health problems.

The pandemic and its corresponding lockdowns led to kids spending unhealthy amounts of time on the internet. Social media can contribute to poor mental health, especially in adolescents. Increased use during the pandemic was no different. There was sharing of distress, self-harm, dieting and weight loss behaviours on social media, and a rise in eating disorders (binge and restrictive eating parallel to self-harm) in 2020. The increase in screen time meant more teenagers were exposed to harmful content.

Concerningly digital self-harm grew in popularity during the pandemic. Digital self-harm is the online posting, sending or sharing of anonymous hurtful content. In the United States, approximately 5-9% of teenagers have participated in behaviour called “self-trolling” or “self-bullying”. This behaviour is a form of self-harm in which teenagers post anonymous mean comments about themselves on their own public online accounts. Recent studies have identified a strong association between digital self-harm and suicidality.

Over the last year, awareness of digital self-harm exploded. Hashtags and images of self-harm (e.g. cutting) were heavily used on Twitter. Mention of “shtwt,” a coded reference to “self-harm Twitter” increased despite being banned by the platform. Such jargon encouraged individuals to increase the depth and severity of self-inflicted wounds (e.g. “go deeper”), fostering community. Many users also flag themselves as adolescents by posting their age and inviting peers to interact with them online. Due to social media algorithms, young people seeking help to stop harming themselves could find themselves exposed to communities that encourage and celebrate their compulsion to cut themselves.

Deliberate self-harm may be a precursor to a suicide attempt

Previous deliberate self-harm is a strong risk factor for suicide. The risk of a person completing suicide is highest in the six months following an episode of self-harm. In 2014, the suicide rate in Australia and New Zealand of those who previously had hospital-treated deliberate self-harm was 1.6% at one year and 3.9% at five years. Between 2003 and 2019, there was a 13% increase in the overall burden of suicide and self-harm injuries in Australia. Young people accounted for 14% of all deliberate self-harm deaths in 2020. Females experienced a larger increase in the overall burden of suicide and self-harm injuries (28%) than males (8.7%).

There is some overlap between the risk factors for deliberate self-harm and suicide. These include low socioeconomic status, mental health disorders, and drug and alcohol misuse. In addition, the risk of both self-harm and suicide is higher amongst groups of vulnerable young people who experience discrimination, such as refugees and migrants, Aboriginal and Torres Strait Islanders, LGBTIQ, and those in contact with the youth justice system.

Signs a person may be suicidal

Risk factors for teens committing suicide

The Emergency Department needs to be equipped to deal with the challenge

For most, the Emergency Department is the first point of medical contact. Emergency healthcare staff need education and training to engage with children who present with mental health issues. 68% of Irish nurses have inadequate educational preparation for nursing kids with mental health problems, and 66.6% are unsatisfied with their ability to care for young people with mental health conditions.

Healthcare professionals must be vigilant when completing risk assessments of susceptible and vulnerable patients who present with potential self-harm and low mood. ED staff need to be cognizant that behind the physical injuries of self-harm are psychological and emotional pain that should not be dismissed. A formal HEEADSSS psychosocial interview should be completed to address potential underlying factors to prevent further acts of self-harm.

Most young people who self-harm are reluctant to seek help beforehand, often citing confidentiality and stigma as barriers. In some cases, self-harm is considered a ‘passing phase’. We must ensure that this is not the case. Carer involvement is critical in their child’s prognosis. Parents must show their support and understanding by listening to their children and safely discussing their feelings and concerns. Remember that self-harm is a relief-seeking process for young people, not attention-seeking. It is crucial to let the young person know they are not alone and encourage them to ask for professional help.

How should we deal with the wounds?

Types of wound closure

References

AIHW (Australian Institute of Health and Welfare). National Suicide and Self-harm Monitoring [Internet]. Australian Government; 2021. Available from: https://www.aihw.gov.au/suicide-self-harm-monitoring/summary/suicide-and-intentional-self-harm.

IHW (Australian Institute of Health and Welfare). The health impact of suicide and self-inflicted injuries in Australia [Internet]. Australian Government; 2021. Available from: https://www.aihw.gov.au/reports/burden-of-disease/health-impact-suicide-self-inflicted-injuries-2019/contents/changes-over-time.

Australian and New Zealand Journal of Psychiatry, 2004. Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm. 38(11-12), pp.868-884.

Borschmann R, Mundy LK, Canterford L, Moreno-Betancur M, Moran PA, Allen NB, Viner RM, Degenhardt L, Kosola S, Fedyszyn I, Patton GC. Self-harm in primary school-aged children: Prospective cohort study. PloS one. 2020 Nov 30;15(11):e0242802.

Brent DA, McMakin DL, Kennard BD, Goldstein TR, Mayes TL, Douaihy AB. Protecting adolescents from self-harm: a critical review of intervention studies. Journal of the American Academy of Child & Adolescent Psychiatry. 2013 Dec 1;52(12):1260-71.

Carroll R, Metcalfe C and Gunnell D (2014) Hospital presenting self-harm and risk of fatal and non-fatal repetition: Systematic review and metaanalysis. PLoS ONE 9: e89944

Fortune, Sarah, et al. “First Responder, Clinician, and Non-Clinical Support Staff Knowledge, Attitudes, and Behaviours towards People Presenting for Emergency Care Following Self-Harm: A Mixed Evidence Synthesis.” Cochrane Database of Systematic Reviews, vol. 2021, no. 12, 2021, https://doi.org/10.1002/14651858.cd014939.

Fitzsimmons, C. Digital self-harm: Rising trend of teens cyberbullying themselves. The Sydney Morning Herald. 2022 August. https://www.smh.com.au/lifestyle/life-and-relationships/digital-self-harm-rising-trend-of-teens-cyberbullying-themselves-20220816-p5ba95.html.

Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, Wang Y, Fu H, Dai J. Mental health problems and social media exposure during COVID-19 outbreak. Plos one. 2020 Apr 16;15(4):e0231924.

Geirdal AØ, Ruffolo M, Leung J, Thygesen H, Price D, Bonsaksen T, Schoultz M. Mental health, quality of life, wellbeing, loneliness and use of social media in a time of social distancing during the COVID-19 outbreak. A cross-country comparative study. Journal of Mental Health. 2021 Mar 4;30(2):148-55.

Griffin E, McMahon E, McNicholas F, Corcoran P, Perry IJ, Arensman E. Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007–2016. Social psychiatry and psychiatric epidemiology. 2018 Jul;53(7):663-71.

Harris IM, Beese S, Moore DPredicting future self-harm or suicide in adolescents: a systematic review of risk assessment scales/toolsBMJ Open 2019;9:e029311. doi: 10.1136/bmjopen-2019-029311

Hawton K, Lascelles K, Brand F, Casey D, Bale L, Ness J, Kelly S, Waters K. Self-harm and the COVID-19 pandemic: A study of factors contributing to self-harm during lockdown restrictions. Journal of psychiatric research. 2021 May 1;137:437-43.

Hawton K, Saunders KE, O’Connor RC. Self-harm and suicide in adolescents. Lancet. 2012 Jun 23;379(9834):2373-82. doi: 10.1016/S0140-6736(12)60322-5. PMID: 22726518.

Hawton K, Harriss L. Deliberate Self-Harm in Young People: Characteristics and Subsequent Mortality in a 20-Year Cohort of Patients Presenting to Hospital.[CME]. Journal of Clinical Psychiatry. 2007 Oct 15;68(10):1574.

Headspace. Understanding self-harm – for health professionals [Internet]. Australia. Available from: https://headspace.org.au/professionals-and-educators/health-professionals/resources/self-harm/.

Ministry of Justice. Safety in the children and young people secure estate: update to December 2021 [Internet]. United Kingdom: 2022. Available from:  https://www.gov.uk/government/statistics/safety-in-the-children-and-young-people-secure-estate-update-to-december-2021/safety-in-the-children-and-young-people-secure-estate-update-to-december-2021#contact-points.

Mitchell RJ, Seah R, Ting HP, Curtis K, Foster K. Intentional self‐harm and assault hospitalisations and treatment cost of children in Australia over a 10‐year period. Australian and New Zealand journal of public health. 2018 Jun;42(3):240-6.

Network Contagion Research Institute. Online communities of adolescents and young adults celebrating, glorifying and encouraging self-harm and suicide are growing rapidly on Twitter [Internet]. United States: 2022. Available from: https://networkcontagion.us/reports/8-29-22-online-communities-of-adolescents-and-young-adults-celebrating-glorifying-and-encouraging-self-harm-and-suicide-are-growing-rapidly-on-twitter/.
Patchin JW, Hinduja S, Meldrum RC. Digital self‐harm and suicidality among adolescents. Child and adolescent mental health. 2022 Jul 10.

Skinner R, McFaull S, Draca J, Frechette M, Kaur J, Pearson C, Thompson W. Suicide and self-inflicted injury hospitalizations in Canada (1979 to 2014/15)-HPCDP: Volume 36-11, November 2016 Health Promotion and Chronic Disease Prevention in Canada.

Stänicke LI, Haavind H, Gullestad SE. How do young people understand their own self-harm? A meta-synthesis of adolescents’ subjective experience of self-harm. Adolescent Research Review. 2018 Jun;3(2):173-91.

Townsend ML, Jain A, Miller CE, Grenyer BF. Prevalence, Response and Management of Self-harm in School Children Under 13 Years of Age: A Qualitative Study. School Mental Health. 2022 Feb 15:1-0.

Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Interventions for self-harm in children and adolescents. Cochrane Database of Systematic Reviews 2021, Issue 3. Art. No.: CD013667. DOI: 10.1002/14651858.CD013667.pub2.

Xiong J, Lipsitz O, Nasri F, Lui LM, Gill H, Phan L, Chen-Li D, Iacobucci M, Ho R, Majeed A, McIntyre RS. Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of affective disorders. 2020 Dec 1;277:55-64.

Zetterqvist, M. The DSM-5 diagnosis of nonsuicidal self-injury disorder: a review of the empirical literature. Child Adolesc Psychiatry Ment Health 9, 31 (2015). https://doi.org/10.1186/s13034-015-0062-7.

Authors

  • Jessica Wong is a paediatric trainee in Perth, Western Australia. She is interested in adolescent medicine and haematology. Her favourite cartoon character is Winnie the Pooh.

  • Kate Roche is from Ireland and is currently a Paediatric trainee in Perth, Western Australia. She enjoys running, hiking and swimming.

  • Tara McCormack is a Paediatric and General Nurse working in a Major Trauma Hospital in Sydney. She has a keen interest in human factors, addiction and well-being. When not studying she’s often trying to run another marathon. She/Her.

  • Nicolene is a Paediatrician for the Adolescent Medical Service at the Perth Children's Hospital, Western Australia. She has worked in South Africa, UK, Scotland, and Abu Dhabi. She is the clinical lead for developing Alcohol & Other Drug adolescent guidelines at the Perth Children's Hospital. She/Her.

  • Kate is a paediatric trainee with an interest in wound and scar management for adolescent patients.

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