Risk factors and correlates of deliberate self-harm behavior

Journal of Psychosomatic Research 66 (2009) 477–493

Risk factors and correlates of deliberate self-harm behavior: A systematic review

Herbert Fliege⁎, Jeong-Ran Lee, Anne Grimm, Burghard F. Klapp

Department of Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin Berlin, Germany

Received 9 May 2008; received in revised form 20 October 2008; accepted 21 October 2008

Abstract

The goal is to recognise intentional, non-suicidal self-harm as a distinct clinical condition worthy of investigation. Research on the links between demographics and mental health is rigorously reviewed. We combed through reference lists, as well as databases such as Medline, PsycINFO, and PSYNDEX (German psychological literature). We focused on cases of self-inflicted physical harm rather than suicide. Risk factors and correlates of deliberate self-harm behavior

Only research that evaluated both suicidal and nonsuicidal self-harm was considered. The findings showed that 59 primary studies fulfilled the requirements. Anyone can intentionally hurt themselves, but teenagers and young adults are particularly vulnerable. Gender evidence is intricate. Predictors have only been tested in 5 studies with a prospective design (6 months to 10 years). The most common research designs are retrospective and cross-sectional. Not a single (detached) longitudinal study has

⁎ Corresponding author. Charité Universitätsmedizin Berlin, Depart- ment of Psychosomatic Medicine and Psychotherapy, Charitéplatz 1, D- 10117 Berlin, Germany. Tel.: +49 30 450 553097; fax: +49 30 450 553989.

E-mail address: herbert.fliege@charite.de (H. Fliege).

0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2008.10.013

a fresh occurrence. Distal/proximal, individual/environmental, and state/trait evidence all contribute to understanding the relationships between variables. Current self-harm behaviour has been linked to a history of sexual abuse in children in a number of studies. Self-injurers, whether adolescents or adults, are more likely to feel anxious, depressed, and violent than the general population. Risk factors and correlates of deliberate self-harm behavior

In two studies, researchers find that traumatic experiences in infancy interact with present-day characteristics including emotional repression, low self-esteem, and dissociation to increase the risk of self-injury. The conclusion is that there is moderately good evidence for distant, biographical stresses. Protective variables have been studied even less frequently than proximal stresses. Many correlations have been discovered, but the data are not yet sufficient to label them as risk factors. We require longitudinal research. All rights reserved 2009 Elsevier Inc.

Self-injurious behaviour, deliberate self-harm, risk factors, correlations, and a systematic literature review on these topics are all discussed.

Introduction

An increasing number of clinical studies are examining deliberate self-harm as a separate phenomenon [1-3]. Physical harm, potential interference with medical and therapeutic processes [4-9]. Aggression towards one’s own body has been cited as a symptom of severe psychopathology in some studies [6,10].

An Explanation of Self-Injury

Deliberate self-harm behaviour [11] is the most used phrase in the literature for acts of self-destruction [3]. It is the deliberate infliction of physical pain on oneself that results in functional tissue loss [5,6,11,12]. Both direct and indirect methods of self-harm fall under this umbrella category [13]. Risk factors and correlates of deliberate self-harm behavior

It is generally agreed that the following should be left out of the definition: (a) phenomena that are explicit symptoms or classificatory criteria of other disorders, like eating disorders or substance abuse; (b) routine behaviours, like unhealthy eating habits or lack of exercise; and (c) psychological self-harm, like knowingly entering into a debasing partnership. The latter is occasionally examined within the framework of BPD [14]. Nonetheless, agreement is hard to come by.

as to how to classify different levels of frequency, severity (e.g., delicate self-cutting vs. auto-mutilation), or specific forms of deliberate self-harm, such as self-poisoning. Another complex issue is how to distinguish between deliberate self-harm and suicidal behavior.

Prominent definitions of deliberate self-harm behavior exclude suicidal intention [5,12,15]. This understanding prevails in U.S. publications, whereas the term self-harm generally includes behaviors irrespective of a suicidal intention in the UK, thus encompassing self-harm behaviors with and without suicidal intention. Risk factors and correlates of deliberate self-harm behavior

This discrepancy limits cross-national study comparability. There is some comorbid- ity between suicidal and nonsuicidal self-harm, and deliber- ate self-harm is prognostic for suicide attempts [14,16–21]. However, there appear to be some important differences between self-harmwith the intent to die and self-harmwith no intent to die [22]. Studies have revealed a distinction between the psychological functions of suicidal and nonsuicidal self- harm behavior [13]. APA Format

This distinction is based on the criterion of intention, which is difficult to operationalize. Suicidal intentions may be ambivalent, dissimulated, or concealed. Thus, intention is more difficult to measure reliably than observable behavior [16]. Skegg [3] proposes assessing self- harm behavior descriptively and many authors have adopted the approach of assessing deliberate self-harm as an act of intentional self-injury or self-poisoning “irrespective of the apparent purpose of the act” [23].

However, if we want to expand our knowledge on differences between suicidal and nonsuicidal self-harm, further efforts to develop reliable assessments of intent are required. Some advances have recently been made in this area [24].

Diagnostic classification

Deliberate self-harm behavior may occur in clinical as well as in nonclinical samples [9,10,25–27]. DSM-IV and ICD-10 F list self-harm behavior as a diagnostic criterion of borderline personality disorder. However, individuals who self-harm are diagnostically heterogeneous and may suffer from a spectrum of other psychological disorders [28,29]. Risk factors and correlates of deliberate self-harm behavior

Frequently reported co-occurring diagnoses—other than borderline personality disorder—are alcohol and substance abuse [29,30]; eating disorders [31–34]; dissociative, somatoform, or body dysmorphic disorders [35–37]; depres- sion and anxiety disorders [26,38,39]; posttraumatic stress disorder [30,40]; and several personality disorders and schizophrenia [2,29]. In DSM-IV, self-harm behavior may also be classified as a disorder of impulse control not otherwise specified and ICD-10 has an additional Z code for a personal history of self-harm.

Concealed self-harm carried out with the aim of adopting the sick role is classified as factitious disorder [13]. Within factitious disorders, indirect forms of self-harm prevail [41]. Studies indicate certain overlaps between factitious disorder and open (or admitted) self-harm behaviors, making the diagnostic categories not absolutely distinct empirically [6,42–44]. Risk factors and correlates of deliberate self-harm behavior

Epidemiology

In school and college student samples, lifetime prevalence of nonsuicidal self-harm behavior ranges from 13% to 35% [11,45–48]. Several population-based samples from the United States and Canada yield a prevalence of 4% pertaining to the past 6 months and lifetime prevalence figures ranging from 2.2% to 6% [49–51]. Deliberate self-harm behavior is particularly prevalent in patients in psychosomatic medicine and psychiatric settings, including consultation–liaison patients [29,52–54]. Risk factors and correlates of deliberate self-harm behavior