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Self-harm
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Exam Tips
- In OSCEs, prioritize immediate medical safety and compassionate engagement before detailed risk formulation.
- Do not use risk scales alone to decide discharge or treatment; perform a full psychosocial assessment.
- Ask directly about suicidal intent, planning, access to means, hopelessness, and protective factors.
- Most self-poisoning requires urgent ED assessment; use NPIS/TOXBASE support when ingestion details are unclear.
- Prescribing pearl: there is no medication that specifically treats self-harm; treat underlying disorders and limit quantities in overdose risk.
- Use a visual explanation of the maintenance cycle (trigger -> arousal -> self-harm -> brief relief -> shame -> recurrence); see Figure: emotion dysregulation cycle in standard psychiatry teaching resources.
Definition
Self-harm is any intentional self-poisoning or self-injury, regardless of whether the person intended to die, and is usually a marker of significant psychological distress. Clinically, it includes both suicide attempts (some intent to die) and non-suicidal self-injury (no intent to die), and the same person may move between these states over time.
Pathophysiology
Self-harm is best understood using a biopsychosocial model. Predisposing factors (genetic vulnerability, trauma, attachment disruption, neurodevelopmental conditions, chronic mental illness, social adversity) interact with acute triggers (interpersonal conflict, loss, shame, intoxication, legal or financial stress). In many patients, self-harm is negatively reinforced: rising affective arousal (anxiety, anger, dissociation, emotional numbness) is followed by self-injury/poisoning, then short-lived relief, then guilt/shame and recurrent distress, which increases future risk. Neurobiologically, impaired fronto-limbic regulation, heightened threat reactivity, impulsivity, and serotonergic dysfunction are proposed contributors; alcohol/drug use can further reduce inhibition and increase lethality. Suicide risk is dynamic rather than fixed, so longitudinal context and current stressors are more informative than one-off scoring tools.
Risk Factors
- Age/sex pattern: self-harm peaks in women 16-24 years and men 25-34 years; completed suicide rates are highest in middle-aged adults and are higher in men
- Previous self-harm (strongest predictor of repetition and future suicide)
- Current or past mental illness: depression, bipolar disorder, psychosis, PTSD, personality disorder, anxiety disorders
- Substance misuse (alcohol and drugs), including intoxication at the time of act
- Socioeconomic deprivation, unemployment, housing instability, debt, gambling-related harms
- Social isolation, minority stress (ethnicity, sexuality, gender identity), stigma
- Adverse life events: relationship breakdown, domestic abuse, bereavement (especially suicide bereavement), trauma history
- Neurodevelopmental disorders (for example autism spectrum condition, ADHD traits/impulsivity)
- Chronic physical illness, pain, disability, or functional decline
- Criminal justice involvement, especially imprisonment
Clinical Features
Symptoms
- Recent self-poisoning or self-injury, often after acute interpersonal or psychosocial stress
- Hopelessness, entrapment, emotional overwhelm, shame, or self-criticism
- Suicidal thoughts, fluctuating intent, or statements of wanting to escape unbearable distress
- Urges to self-harm, dissociation, agitation, insomnia, anxiety, low mood
- History of recurrent episodes, escalating frequency or severity, reduced help-seeking
Signs
- Physical evidence of injury: lacerations (commonly forearms), burns, ligature marks, bruising, or swallowed foreign body complications
- Signs of overdose/toxicity: reduced GCS, vomiting, abdominal pain, tachycardia, hypotension, arrhythmia, seizures
- Old scars at different healing stages suggesting repetition
- Mental state findings: depressed affect, psychomotor agitation/retardation, thought content of hopelessness, psychotic symptoms where present
- Safeguarding indicators: neglect, abuse/coercion risk, unsafe home environment
Investigations
Urgent physical assessment (ABCDE, observations, GCS):Identifies immediate physiological instability and need for emergency treatment/admission
Comprehensive psychosocial assessment (including suicide intent, protective factors, supports, safeguarding):Clarifies drivers of self-harm, dynamic suicide risk, and need for specialist mental health input
12-lead ECG:May show QT prolongation, QRS widening, arrhythmia, or be normal depending on substance
Blood tests: FBC, U&E, creatinine, glucose, LFT, clotting, venous/arterial blood gas, lactate:Detects metabolic acidosis, renal/hepatic injury, electrolyte disturbance, hypoglycaemia, or organ dysfunction after poisoning
Serum paracetamol level at 4 hours or later after ingestion (or immediately if time unknown):Used with treatment nomogram/risk assessment to determine need for acetylcysteine
Toxicology-directed tests (for example salicylate level, ethanol level, pregnancy test where relevant):Confirms co-ingestants and guides antidote/supportive management
Wound and injury assessment (including tendon/nerve/vascular exam; imaging if deep injury/foreign body suspected):Defines tissue damage and whether surgical repair is required
Management
Lifestyle Modifications
- Provide compassionate, non-judgemental care; validate distress and preserve dignity/cultural sensitivity
- Immediate safety planning: collaborative means restriction (for example secure medicines, sharps, ligatures), crisis contacts, and agreed warning signs
- Involve family/carers with consent; if high risk or safeguarding concerns, escalate according to legal/professional duty
- Urgent ED referral for most self-poisoning episodes and any medically significant injury
- Arrange rapid follow-up (typically within 48 hours in primary care/mental health pathways) and clear contingency plan
- Offer communication adaptations for people who struggle to verbalize distress (written plans, visual cues, pre-agreed phrases)
Pharmacological Treatment
Antidote for paracetamol overdose
- Acetylcysteine IV: 300 mg/kg total over 21 hours (usual 2-bag regimen: 200 mg/kg over 4 hours, then 100 mg/kg over 16 hours)
Start promptly when indicated by timing/level/risk factors or when timing is uncertain with suspected toxic ingestion. Monitor for anaphylactoid reactions (rash, wheeze, hypotension) and pause/restart with appropriate treatment if needed.
Treatment of co-existing depressive illness (not a direct anti-self-harm drug)
- Sertraline oral 50 mg once daily initially; increase in steps (usual maintenance 50-200 mg daily)
- Fluoxetine oral 20 mg once daily initially; may increase after several weeks (usual 20-60 mg daily)
Use only when a diagnosable depressive/anxiety disorder is present. In under-25s and early treatment phases, monitor closely for emerging suicidal thoughts/behaviour. Prescribe limited quantities in overdose risk; avoid medications with high toxicity in overdose where possible.
Short-term sedation for severe acute agitation in emergency settings
- Lorazepam 0.5-1 mg oral/SL (or 1-2 mg IM/IV in monitored settings), repeated cautiously according to response
Use the minimum effective dose for the shortest duration. Avoid/limit with alcohol or opioid co-use, respiratory compromise, or frailty due to respiratory depression and oversedation risk.
Surgical / Interventional
- Wound toilet and closure where appropriate (steri-strips/sutures/glue based on wound type)
- Tendon, nerve, or vascular repair for deep lacerations
- Endoscopic or surgical retrieval/management for ingested sharp or obstructive foreign bodies
- Burn surgery input for deep dermal/full-thickness injuries
Complications
- Repetition of self-harm (around 1 in 6 may re-present within a year after an ED episode)
- Suicide (elevated short- and long-term risk, especially with repeated acts, male sex, physical comorbidity, or stated intent)
- Acute liver failure after paracetamol overdose, potentially requiring transplantation
- Permanent scarring, tendon/nerve injury, chronic pain, and functional impairment
- Medication toxicity complications (arrhythmia, seizures, aspiration, renal injury)
- Psychosocial deterioration: relationship breakdown, educational/employment loss, stigma
Prognosis
Prognosis is variable and strongly influenced by repetition, psychiatric comorbidity, substance misuse, and social context. Many people improve with timely psychosocial intervention and sustained follow-up, but recurrence is common and suicide risk remains above population baseline for years, so active longitudinal safety planning is essential.
Sources & References
✅NICE Guidelines(1)
- Self-harm[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1074)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1043)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1066)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 229)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1728)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1041, 1042)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1044)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1042)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1691)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1812)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1055)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1054)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 324)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2807, 2808)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3042, 3043)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3319, 3320)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 3320, 3321)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2530, 2531)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 478, 479)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 947, 948)[context]