Deliberate Self-Harm in Adolescents

  • Catherine Miller
  • Christian Pariseau


Occurrences of deliberate self-harm (DSH) are commonly encountered when caring for adolescents, especially in mental healthcare settings. Defined as the intentional damage of body tissues without suicidal intent, DSH is officially included as a symptom of borderline personality disorder. However, DSH also occurs along with many other mental health conditions and also in nonclinical populations. The lifetime prevalence of DSH in adolescents and young adults varies greatly depending on the population studied, and is noted to be up to 80 % in some psychiatric inpatient populations. Because DSH is a marker for increased risk of future suicide attempts and can cause distress and injury, clinicians need to be able to provide thorough assessment of the behavior, monitor for suicidality, and refer for or provide proper treatment. This chapter covers how self-harm is defined and reviews the epidemiology of this behavior. Theories of the psychological function and the currently understood pathophysiology, along with recommended clinical approaches, assessment, and treatment strategies, are discussed.


Suicide Attempt Borderline Personality Disorder Childhood Sexual Abuse Cerebral Spinal Fluid Dialectical Behavioral Therapy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Andover, M. S., & Gibb, B. E. (2010). Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients. Psychiatry Research, 178(1), 101–105. doi: 10.1016/j.psychres.2010.03.019.PubMedCrossRefGoogle Scholar
  2. Ballard, E., Bosk, A., & Pao, M. (2010). Invited commentary: Understanding brain mechanisms of pain processing in adolescents’ non-suicidal self-injury. Journal of Youth and Adolescence, 39(4), 327–334. doi: 10.1007/s10964-009-9457-1.PubMedCrossRefGoogle Scholar
  3. Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. The American Journal of Psychiatry, 156(10), 1563–1569. Retrieved from EBSCOhost.PubMedGoogle Scholar
  4. Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 631–638. doi: 10.1176/appi.ajp.2007.07040636.PubMedCrossRefGoogle Scholar
  5. Brausch, A. M., & Gutierrez, P. M. (2010). Differences in non-suicidal self-injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39(3), 233–242. doi: 10.1007/s10964-009-9482-0.PubMedCrossRefGoogle Scholar
  6. Cassano, P., Lattanzi, L., Pini, S., Dell’Osso, L., Battistini, G., & Cassano, G. B. (2001). Topiramate for self-mutilation in a patient with borderline personality disorder. Bipolar Disorders, 3(3), doi:10.1034/j.1399-5618.2001.030306.x.CrossRefGoogle Scholar
  7. Chengappa, K., Ebeling, T., Kang, J. S., Levine, J., & Parepally, H. (1999). Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. The Journal of Clinical Psychiatry, 60(7), 477–484. Retrieved from EBSCOhost.PubMedCrossRefGoogle Scholar
  8. Chengappa, K. R., Rathore, D., Levine, J., Atzert, R., Solai, L., Parepally, H., et al. (1999). Topiramate as add-on treatment for patients with bipolar mania. Bipolar Disorders, 1(1), 42–53. Retrieved April 20, 2011.PubMedCrossRefGoogle Scholar
  9. Claes, L., Houben, A., Vadereycken, W., Bijttebier, P., & Muehlenkamp, J. (2010). Brief report: The association between non-suicidal self-injury self-concept and acquaintance with self- injurious peers in a sample of adolescents. Journal of Adolescent Health, 33(5), 775–778.Google Scholar
  10. Clarkin, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delaney, J. C., & Kernberg, O. F. (2001). The development of a psychodynamic treatment for patients with borderline personality disorder: A preliminary study of behavioral change. Journal of Personality Disorders, 15(6), 487–495. doi: 10.1521/pedi.15.6.487.19190.PubMedCrossRefGoogle Scholar
  11. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. The American Journal of Psychiatry, 164(6), 922–928. doi: 10.1176/appi.ajp.164.6.922.PubMedCrossRefGoogle Scholar
  12. DSM-III-R. (2000). American Psychiatric Association’s diagnostic and statistical manual of mental disorders (3rd ed.). PsycCRITIQUES, 35(3), doi: 10.1037/028425.
  13. DSM-III-R. (1990). American Psychiatric Association’s diagnostic and statistical manual of mental disorders (4th ed.). PsycCRITIQUES, 35(3), doi:  10.1037/028425.
  14. Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Dent, J., et al. (1999). Manual-assisted cognitive-behavior therapy (MACT): A randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychological Medicine, 29(1), 19–25.PubMedCrossRefGoogle Scholar
  15. Ferrerri, M. M., Loze, J., Rouillon, F., & Limosin, F. (2004). Clozapine treatment of a borderline personality disorder with severe self-mutilating behaviours. European Psychiatry, 19(3), 177–178. doi: 10.1016/j.eurpsy.2003.11.004.PubMedCrossRefGoogle Scholar
  16. Fikke, L. T., Melinder, A. A., & Landrø, N. I. (2011). Executive functions are impaired in adolescents engaging in non-suicidal self-injury. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 41(3), 601–610. doi: 10.1017/S0033291710001030.CrossRefGoogle Scholar
  17. Glenn, C. R., & Klonsky, E. (2010). The role of seeing blood in non-suicidal self-injury. Journal of Clinical Psychology, 66(4), 466–473. Retrieved from EBSCOhost.PubMedGoogle Scholar
  18. Graff, H., & Mallin, R. (1967). The syndrome of the wrist cutter. The American Journal of Psychiatry, 124(1), 36–42. Retrieved from EBSCOhost.PubMedGoogle Scholar
  19. Gratz, K. L. (2007). Targeting emotion dysregulation in the treatment of self-injury. Journal of Clinical Psychology, 63(11), 1091–1103. doi: 10.1002/jclp.20417.PubMedCrossRefGoogle Scholar
  20. Gratz, K. L., Conrad, S., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. The American Journal of Orthopsychiatry, 72(1), 128–140. doi: 10.1037/0002-9432.72.1.128.PubMedCrossRefGoogle Scholar
  21. Griengl, H., Sendera, A. A., & Dantendorfer, K. K. (2001). Naltrexone as a treatment of self- injurious behavior: A case report. Acta Psychiatrica Scandinavica, 103(3), 234–236. doi: 10.1034/j.1600-0447.2001.00087.x.PubMedCrossRefGoogle Scholar
  22. Gutierrez, P., Osmann, A., Barrios, F., & Kopper, B. (2001). Development and initial validation of the self-harm behavior questionnaire. Journal of Personality Assessment, 77, 475–490.PubMedCrossRefGoogle Scholar
  23. Hawton, K., Townsen, E., Arensman, E., Gunnell, D., Hazell, P., House, A., et al. (1999). Psychosocial and pharmacological treatments for deliberate self harm. Cochrane Database of Systematic Reviews, 3. Retrieved April 20, 2011.Google Scholar
  24. Karr, P. L., Muehlenkamp, J. J., & Turner, J. M. (2010). Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. Journal of the American Board of Family Medicine, 23(2), 240–259.CrossRefGoogle Scholar
  25. Klonsky, E. (2007a). Non-suicidal self-injury: An introduction. Journal of Clinical Psychology, 63(11), 1039–1043. doi: 10.1002/jclp.20411.PubMedCrossRefGoogle Scholar
  26. Klonsky, E. (2007b). The functions of deliberate self-injury: A review of the evidence. Clinical Psychology Review, 27(2), 226–239. doi: 10.1016/j.cpr.2006.08.002.PubMedCrossRefGoogle Scholar
  27. Klonsky, E., & Glenn, C. R. (2009). Assessing the functions of non-suicidal self-injury: Psychometric properties of the inventory of statements about self-injury (ISAS). Journal of Psychopathology and Behavioral Assessment, 31(3), 215–219. doi: 10.1007/s10862-008-9107-z.CrossRefGoogle Scholar
  28. Klonsky, E., & Moyer, A. (2008). Childhood sexual abuse and non-suicidal self-injury: Meta analysis. The British Journal of Psychiatry, 192(3), 166–170. doi: 10.1192/bjp.bp.106.030650.PubMedCrossRefGoogle Scholar
  29. Klonsky, E., & Muehlenkamp, J. J. (2007). Self-injury: A research review for the practitioner. Journal of Clinical Psychology, 63(11), 1045–1056. doi: 10.1002/jclp.20412.PubMedCrossRefGoogle Scholar
  30. Klonsky, E., Oltmanns, T. F., & Turkheimer, E. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. The American Journal of Psychiatry, 160(8), 1501–1508. doi: 10.1176/appi.ajp.160.8.1501.PubMedCrossRefGoogle Scholar
  31. Koons, C. R., Robins, C. J., Tweed, J., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., et al. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32(2), 371–390. doi: 10.1016/S0005-7894(01)80009-5.CrossRefGoogle Scholar
  32. Laye-Gindhu, A., & Schonert-Reichl, K. A. (2005). Nonsuicidal self-harm among community adolescents: Understanding the ‘Whats’ and ‘Whys’ of self-harm. Journal of Youth and Adolescence, 34(5), 447–457. doi: 10.1007/s10964-005-7262-z.CrossRefGoogle Scholar
  33. Lester, D. (1972). Self-mutilating behavior. Psychological Bulletin, 78(2), 119–128. doi: 10.1037/h0033066.PubMedCrossRefGoogle Scholar
  34. Levy, K. N., Kelly, K. M., & Meehan, K. B. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040.PubMedCrossRefGoogle Scholar
  35. Levy, K. N., Yeomans, F. E., & Diamond, D. (2007). Psychodynamic treatments of self-injury. Journal of Clinical Psychology, 63(11), 1105–1120.PubMedCrossRefGoogle Scholar
  36. Linehan, M. M., Armstrong, H. E., Suarez, A., & Allmon, D. (1991). Cognitive–behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12), 1060–1064. Retrieved from EBSCOhost.PubMedCrossRefGoogle Scholar
  37. Linehan, M. M., Comtois, K., Brown, M. Z., Heard, H. L., & Wagner, A. (2006). Suicide attempt self-injury interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury. Psychological Assessment, 18(3), 303–312. doi: 10.1037/1040-3590.18.3.303.PubMedCrossRefGoogle Scholar
  38. Linehan, M. M., Comtois, K., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757–766. doi: 10.1001/archpsyc.63.7.757.PubMedCrossRefGoogle Scholar
  39. Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1994). ‘Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients’: Erratum. Archives of General Psychiatry, 51(5), 422. Retrieved from EBSCOhost.CrossRefGoogle Scholar
  40. Lloyd-Richardson, E. E. (2008). Adolescent nonsuicidal self-injury: who is doing it and why? Journal of Developmental and Behavioral Pediatrics, 29(3), 216–218.PubMedCrossRefGoogle Scholar
  41. Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristic and functions on non-suicidal self-injury in a community sample of adolescents. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 37(8), 1183–1192. doi: 10.1017/S003329170700027X.CrossRefGoogle Scholar
  42. Muehlenkamp, J. J., & Gutierrez, P. M. (2004). An investigation of differences between self- injurious behavior and suicide attempts in a sample of adolescents. Suicide and Life-Threatening Behavior, 34(1), 12–23. doi: 10.1521/suli. Scholar
  43. Muehlenkamp, J. J., Walsh, B. W., & McDade, M. (2010). Preventing non-suicidal self-injury in adolescents: The signs of self-injury program. Journal of Youth and Adolescence, 39(3), 306–314. doi: 10.1007/s10964-009-9450-8.PubMedCrossRefGoogle Scholar
  44. Nafisi, N., & Stanley, B. (2007). Developing and maintaining the therapeutic alliance with self-injuring patients. Journal of Clinical Psychology, 63(11), 1069–1079. doi: 10.1002/jclp.20414.PubMedCrossRefGoogle Scholar
  45. Nock, M. K., Elizabeth, E. B., Photos, V. I., & Michel, B. D. (2007). Self-injurious thoughts and behaviors interview: Development, reliability, and validity in an adolescent sample. Psychological Assessment, 19(3), 309–317.PubMedCrossRefGoogle Scholar
  46. Nock, M. K., Joiner, T. R., Gordon, K. H., Lloyd-Richardson, E., & Prinstein, M. J. (2006). Non- suicidal self-injury among adolescents: Diagnostic correlates and relation to suicide attempts. Psychiatry Research, 144(1), 65–72. doi: 10.1016/j.psychres.2006.05.010.PubMedCrossRefGoogle Scholar
  47. Nock, M. K., & Prinstein, M. J. (2004). A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology, 72(5), 885–890. doi: 10.1037/0022-006X.72.5.885.PubMedCrossRefGoogle Scholar
  48. Prossin, A. R., Love, T. M., Koeppe, R. A., Zubieta, J., & Silk, K. R. (2010). Dysregulation of regional endogenous opioid function in borderline personality disorder: Correction. The American Journal of Psychiatry, 167(8), 925–933. Retrieved from EBSCOhost.PubMedCrossRefGoogle Scholar
  49. Ross, S., & Heath, N. (2002). A study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31(1), 67–77. doi: 10.1023/A:1014089117419.CrossRefGoogle Scholar
  50. Roth, A. S., Ostroff, R. B., & Hoffman, R. E. (1996). Naltrexone as a treatment for repetitive self-injurious behavior: An open-label trial. The Journal of Clinical Psychiatry, 57(6), 233–237.PubMedGoogle Scholar
  51. Stanley, B., Sher, L., Wilson, S., Ekman, R., Huang, Y., & Mann, J. (2010). Non-suicidal self- injurious behavior, endogenous opioids and monoamine neurotransmitters. Journal of Affective Disorders, 124(1–2), 134–140. doi: 10.1016/j.jad.2009.10.028.PubMedCrossRefGoogle Scholar
  52. Tyrer, P., Thompson, S., Schmidt, U., Jones, V., Knapp, M., Davidson, K., et al. (2003). Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: The POPMACT study. Psychological Medicine, 33(6), 977–986. ISSN 0033-2917.PubMedCrossRefGoogle Scholar
  53. Walsh, B. (2007). Clinical assessment of self-injury: A practical guide. Journal of Clinical Psychology, 63(11), 1057–1068. doi: 10.1002/jclp.20413.PubMedCrossRefGoogle Scholar
  54. Whitlock, J., Eckenrode, J., & Silverman, D. (2006). Self-injurious behaviors in a college population. Pediatrics, 117, 1939–1948.PubMedCrossRefGoogle Scholar
  55. Whitlock, J., Lader, W., & Conterio, K. (2007). The Internet and self-injury: What psychotherapists should know. Journal of Clinical Psychology, 63(11), 1135–1143. doi: 10.1002/jclp.20420.PubMedCrossRefGoogle Scholar
  56. Whitlock, J., Muehlenkamp, J., & Eckenrode, J. (2008). Variation in nonsuicidal self-injury: Identification and features of latent classes in a college population of emerging adults. Journal of Clinical Child and Adolescent Psychology, 37(4), 725–735. doi: 10.1080/15374410802359734.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Center for Adolescent HealthLucile Packard Children’s Hospital at Stanford UniversityMountain ViewUSA
  2. 2.Pediatric, Adolescent and Young Adult MedicineUniversity of Michigan PediatricsAnn ArborUSA

Personalised recommendations