Risk factors and correlates of deliberate self-harm behavior

Risk factors and correlates of deliberate self-harm behavior

Risk factors and correlates of deliberate self-harm behavior

Journal of Psychosomatic Research 66 (2009) 477–493

Review article

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


Objective: Deliberate self-harm behavior—without suicidal intent—is a serious health problem and may be studied as a clinical phenomenon in its own right. Empirical studies of sociodemographic and psychological correlates and risk factors are systematically reviewed. Methods: We searched Medline, PsycINFO, PSYNDEX (German psychological literature), and reference lists. We targeted self-induced bodily harm without conscious suicidal intent. Studies on suicidal behavior or self- poisoning were only included if they also assessed nonsuicidal self- harm. Results: Fifty-nine original studies met the criteria. Deliberate self-harm may occur at all ages, yet adolescents and young adults are at a higher risk. Evidence on gender is complex. Only 5 studies realize a prospective design (6 months to 10 years) and test predictors. The majority use cross-sectional and retro- spective methods. No longitudinal study (separately) examines

⁎ 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

new incidence. Evidence of correlates encompasses distal/prox- imal, person/environment, and state/trait factors. Many studies report associations between current self-harm behavior and a history of childhood sexual abuse. Adolescent and adult self- harmers experience more frequent and more negative emotions, such as anxiety, depression, and aggressiveness, than persons who do not self-harm. Two studies yield specific interactions between childhood trauma and current traits and states such as low emotional expressivity, low self-esteem, and dissociation with respect to a vulnerability to self-harm. Conclusion: Evidence of distal, biographical stressors is fairly strong. Proximal stressors have rarely been investigated; protective factors, hardly at all. Despite many findings of correlates, the data do not yet justify terming them risk factors. Longitudinal studies are needed. © 2009 Elsevier Inc. All rights reserved.

Keywords: Deliberate self-harm; Self-injurious behavior; Risk factors; Correlates; Systematic literature review


Deliberate self-harm behavior is a significant health problem that is increasingly being studied as a clinical phenomenon in its own right [1–3]. It is detrimental to the body and may impede social relations, medical treatment, and psychotherapy [4–9]. Some reports characterize aggres- sive acts against one’s own body as indicative of especially severe psychopathological problems [6,10].

Definition of self-harm

The most accepted term for auto-destructive acts in the literature is self-harm [3] or, more specifically, deliberate self-harm behavior [11]. It is defined as the intentional self-induced harming of one’s own body resulting in relevant tissue damage [5,6,11,12]. The term encompasses self-injurious behaviors and more indirect forms of bodily harm [13]. It is largely agreed upon to exclude the following from the definition: (a) phenomena that are explicit symptoms or classificatory criteria of other disorders, such as eating disorders or substance abuse; (b) everyday behaviors, such as unhealthy eating habits or lack of exercise; and (c) psychological self-harm, such as deliberately engaging in an abasing partnership. The latter is occasionally studied in the context of borderline personality disorder [14]. However, there is little consensus



478 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

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. 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]. 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]. 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].


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].