REVIEW

Deliberate Self-harm and Suicide in Adolescents
Donald E. Greydanus1, 2 and Daniel Shek3

Pediatrics & Human Development, Michigan State University College of Human Medicine, Michigan, USA
2
Kalamazoo Center for Medical Studies, Michigan, USA
3
Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China (PRC)

1(Received for publication on February 3, 2009)(Revised for publication on April 1, 2009)(Accepted for publication on April 16, 2009)

Abstract
Deliberate self-harm (DSH) is a widespread yet often hidden problem in adolescents and young
adults. Though most DSH can be classified as “non-suicidal self-cutting”, some do go on tocommit suicide. In this paper, deliberate self-harm is examined, including its prevalence, etiology, management, and future research directions using self-cutting and self-burning as examples. This article reviews recent literature to help understand what is known about self-cutting
behavior and its potential relationship to suicide as well as provide direction for research. Research shows that different ecological factors at the individual, family, peer, and societal levels
are related to deliberate self-harm. Although there is an association between some self-injurers
and drug abuse (including alcohol abuse) as well as eating disorders, there are various subgroups of self-cutters and most are not at high risk for suicide. However, all acts of self-injury
should be taken seriously by health care professionals and comprehensive therapy offered toany adolescent with a history of DSH. Future research directions on deliberate self-harm arealso discussed. (Keio J Med 58 (3) : 144－151, September 2009)

Keywords: self-injury, suicide, adolescents
Introduction
The tragedy of suicide in adolescents is a global phenomenon that deserves the attention of the world’s pediatricians.1-3 An estimated 2 million people die each year
as a result of homicide or suicide. In 2002, there were an
estimated 877,000 suicides in the world, of which approximately 200,000 were adolescents and young
adults.4-7 Even when controlling for global population
growth, suicide is among the leading causes of death foradolescents in the world and rates are rising faster inteens than in other age groups. Of 4 million worldwide
suicide attempts each year, at least 90,000 adolescents(up to age 19) successfully complete, with one successful suicide in every 5 minutes. Global suicide rates are
now at a crisis level and will require nothing short of acall to action to effect change in these rates.
Suicide rates vary from country to country dependingon local factors, including reporting methods (Table 1).

Among the major causes of death in youth around theworld, suicide ranks fifth or higher in all countries understudy (Table 2). Causes of suicide include depression,abuse (physical or sexual), loss of friends (including
boy- or girlfriend), academic failure, social isolation,
substance abuse, and others. Some youth who attempt orcomplete suicide have a history of self-cutting behavior.
This article aims to examine the current research on thenature of deliberate self-harm with specific focus on selfcutting behavior and its potential link to suicide.
Background
Deliberate self-harm (DSH) is not an illness but a behavior defined “as an act by an individual with the intent
of harming himself/herself physically.”8 Methods of selfharm are summarized in Table 39-14 with the most common methods being overdosing, self-poisoning and selfcutting in non-fatal injuries.1 5 In terms of background

Reprint requests to: Donald E. Greydanus, MD, FAAP, FSAM, FIAP (H), Pediatrics & Human Development, Michigan State University College of Human
Medicine; Kalamazoo Center for Medical Studies, 1000 Oakland Drive, Kalamazoo, Michigan 49008, USA, E-mail: Greydanus@kcms.msu.edu
144

Keio J Med 2009; 58 (3): 144－ 151

145

Table 1 1996 Global suicide rates (per 100,000) by gender andage group (i.e, 15 to 24 year olds*) of different countries

Table 2 Causes of death in adolescents/young adults in different
countries (decreasing order of frequency) 1,2,5

Country

Males

Females

Africa: AIDS, Other IFs*, Homicide/War, UIs**, Suicide

GreecePortugal
Italy
Spain
Netherlands
SwedenJapan
IsraelUnited Kingdom
Germany
Denmark
FranceBulgaria
Czech Republic
PolandUkraineHungary
Austria
IrelandUnited States
BelarusCanadaSwitzerland
Australia
NorwayEstonia
Finland
LatviaSlovenia
New ZealandRussian Federation
Lithuania

3.8
4.3
5.7
7.1
9.1
10.0
10.1
11.7
12.2
12.7
13.4
14.0
15.4
16.4
16.6
17.2
19.1
21.1
21.5
21.9
24.2
24.7
25.0
27.3
28.2
29.7
33.0
35.0
37.0
39.9
41.7
44.9

0.8
2.0
1.6
2.2
3.8
6.7
4.4
2.5
2.3
3.4
2.3
4.3
5.6
4.3
2.5
5.3
5.5
6.5
2.0
3.8
5.2
6.0
4.8
5.6
5.2
10.6
3.2
9.3
8.4
6.2
7.9
6.7

SE ASIA: UIs, Other IFs, AIDS, Suicide, Homicide/War*World Health Organization: http://www.unicef.org/pon96/insuicid.htm

factor, females usually outnumber males.1 6 In Westerncountries, 5-8% of adolescents report self-harm eachyear because of risk factors such as depression, drug
abuse, anxiety disorders, and poverty.14 High risk factors
for overt suicide in DSH include a strong suicidal intent,concomitant psychiatric disorders, using a method ofhigh lethality (e.g., gun), and taking measures against
being discovered.1 4 Thus, self-injurious behavior is an
important issue which will be considered in great detailin this paper.
Prevalence of Deliberate Self-harmMany studies around the world have verified the existence of DSH such as self-cutting behavior as an established phenomenon in youth (Table 4). For example, a
study of 1,036 9th to 12th graders in the Western part of
the United States by Yates and colleagues identified rates
of self-cutting that ranged from 26% to 37%; 51.2%
were females and major underling factors included criticism by and alienation from parents.1 7 Li reviewed
medical records in eastern Taiwan and identified 1% ofSouth America/Caribbean: Homicide/War, UIs, Suicide, Other IFs,
AIDS
Western Pacific†: UIs, Suicide, Other IFs, Homicide/War, AIDS
†Australia, New Zealand, China, Japan, Korea, Malaysia,
Micronesia, Philippines, Singapore, Vietnam, and others inthis area.
Europe: UIs, Suicide, Homicide/War, Other IFs, AIDS
Eastern Mediterranean†: UIs, Other IFs, Homicide/War, AIDS,
Suicide†Afgahanistan, Egypt, Iraq, Jordan, Saudi Arabia, Israel, andother Middle East Countries.
North America: UIs, Suicide, Homicide, Cancer, Other IFs, AIDS
*IFs = infections **UIs = Unintended Injuries

all injuries were for deliberate self-harm; 80% of this
DSH involved stabbing or cutting injuries and alcohol
use was a major risk factor for the reported deliberate
self-harm.18
Nixon and colleagues conducted a population-based
study that examined the prevalence of self-cutting andrelated behaviors among community-based youth aged
14-21 year olds in Canada.1 9 They noted that 17% reported self-harming behavior with a mean age of onsetof 15.2 years of age and 83% of self-destructive behavior
involved cutting, scratching, or self-hitting. Help wassought in 56% of these individuals and self-harm was related to depression and attention-related problems.19
Morey et al. did a cross-sectional survey of 3,881 Irish
teens (with 85% response rate) and noted that 9.1% had
a lifetime history of deliberate self-harm in which females outnumbered males (13.9% to 4.3%) and self-cutting was more common than drug overdose (66% to35%).2 0 Another study in Great Britain by O’Loughlin
and Sherwood identified 4,474 episodes of deliberate
self-harm in one British town from 1981 to 2000; rates
were highest in females who tended to use overdose as
their method of self-harm versus males who were more
likely to use self-cutting.2 1 The cohort with the highest
rate of self-harming behavior was the 15 to 24 year age
group and there was less repetitive DSH if the first episode was followed by psychiatric management.21
De Leo and Heller carried out a cross-sectional study
on 3,757 adolescent students in Australia in which 6.2%
reported deliberate self-harm in the 12 months prior to
the study with self-cutting found in 59% and drug overdose in 30%.22 Underlying factors that were identified inthese adolescent self-harmers included having ineffective coping skills such as self-blame and similar self-injurious behavior in family or friends. Most of these self-

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Table 3 Methods of self-harm 9-14

Table 4 Prevalence of deliberate self-harm (DSH) behavior fromvarious studies

1. Drug Overdose
2. Self-Poisoning
3. Self-Cutting
4. Other forms of self-mutilationa. Self-hitting (battery)b. Pinchingc. Scratchingd. Bitinge. Burning
5. Self-shooting
6. Hanging
7. Jumping from high places
8. Jumping into wells

AuthorPopulation

Prevalence

1. Yates17

9th to 12 grade(USA)
Teens & Adults(Taiwan)
14-21 year olds
(Canada)3,881 Irish
Teenagers
3,754 Teens(Australia)
4.060 Teens(Norway)
Teenagers(Japan)26-37% (self-cutting)

2. Li 18
3. Nixon 19
4. Morey 20
5. De Leo 22
6. Ystgaard 23
7. Matsumoto 27

harmers did not seek help before resorting to self-injurious behavior and thus, preventive programs for such behavior were recommended.22
Ystgaard et al. conducted a self-report survey of 4,060
11 t h graders in Norway who were 15 to 16 years ofage.2 3 One or more acts of self-harm were reported in
6.6% of these youth in which self-cutting was seen in
74% of the DSH versus 17% for drug overdose. Only
6.1% of the self-cutters had contact with hospital personnel versus 47% of those having a drug overdose. General
identified underlying factors included low self-esteem,
drug abuse, similar behavior in friends, and major conflicts with parents; similar behavior in family members
was particularly significant in males who committed actsof self-harm.23 Specific factors in females with DSH included a history of sexual abuse, anxiety, impulsivity,
parental divorce, and alcohol abuse.2 3 Self-cutting andself-scratching behavior is increased in adult women diagnosed with drug-dependence disorders and also posttraumatic stress disorder (PTSD). 24
In a clinical study by Hawton et al., 14,892 self-harmpatients were identified in a United Kingdom general
hospital gathered over a period of 23 years with 428 selfcutters versus 11,065 self-poisoners.2 5 The self-cutterswere more often male, single, unemployed, had a historyof deliberate self-harm, lived alone, and misused alcohol.25 One study of adolescents (11-18 years of age witha mean age of 15) who were self-cutters and were seen
in intensive psychiatric programs revealed a range ofself-cutting behavior.26 Those who are frequent self-cutters (i.e., over three times) were typically females who
engage in high-risk behavior, such as sexual activity
without consistent condom use and who had a history of
sexual abuse.2 6 Matsumoto and colleagues showed thatthe prevalence for self-cutting and suicidal ideation injunior and senior high school students in Japan were
9.9% and 40% respectively.27
Setting fire to oneself is an unusual means of self-harmand suicide attempt that is seen more often in adults thanin adolescents. 2 8, 2 9 Over an 11 year period (1994 to

1% of all injuries; 80%
self-cutting
17% DSH; 83%: cutting,scratch, self-hitting
9.1% DSH; 66%:
self-cutting
6.2% DSH past 12 monthsof survey
6.6% DSH; 74%:
self-cutting
9.8% DSH with
self-cutting2005), 1,745 patients were admitted to a tertiary careburn unit in the United Kingdom; this included 41 patients with a mean age of 29 ± 12 years who had a burnfollowing an assault and 86 patients (mean age of 37 ±12) who had self-induced burns.30 Gasoline, accelerants,
and other flammable liquids were the means used for theburns and the rate of mortality was 29% in the self-burnpatients.
In summary, deliberate self-harm is a widespread yet
often hidden problem in adolescents, especially females,
which shows both similarities and differences internationally.31
Etiology of Deliberate Self-harm
Ecological models have been commonly used to understand suicide and related behavior, where an individual’s behavior is seen as a result of the interaction of different ecological systems (Table 5). For example, Shagle
and Barber used a social-ecological framework to analyze adolescent suicidal ideation where family, school,
peers and religion were proposed to influence adolescentsuicidal ideation via self-derogation.32 Jackson and Nuttall33 and Perkins and Hartless 34 similarly supported theuse of an ecological risk-factor model for examining suicidal behavior in children and adolescents.
With reference to the personal system, research findings show that hopelessness was related to suicide andrelated behavior.35, 36 Previous research also showed thatadolescents with affect dysregulation,37 problem solving
deficits,38 and low self-esteem39 had increased chance ofsuicide. With specific reference to the role of emotions
in deliberate self-harm, adolescents engage in non-suicidal self-injury to influence behaviors of others and todeal with internal emotions.4 0 Two pathways to selfwounding have been identified: cutting may result when

Keio J Med 2009; 58 (3): 144－ 151

Table 5 Etiology of deliberate self-harm
1. Suicidal ideation
2. Feelings of hopelessness
3. Low self-esteem
4. Depression
5. Impulsivity
6. Family dysfunction and conflict
7. Bullying and intimidation in school
8. Poverty
9. Others (See text)

there is a steady increase of tension until a threshold isreached (the “spring” path), or as a result of the “switching on” of the impulse (the “switch-path”). Dissociation
during cutting and a craving for cutting were more often
associated with switching to this impulse.1 7, 4 1 Furthermore, two main personal characteristics in adolescentself-harmers are having overwhelmingly negative emotion and self-derogation. Reasons noted for the non-suicidal self-injury include efforts to resist thoughts of suicide, expression of self-anger or disgust, resolve times ofdissociation, influence others, or seek help from others.42, 43
Research findings also showed that deliberate selfharm was related to individual psychological well-being.
A study of 201 adolescents in a juvenile detention centerin Japan noted that 16.4% had cut themselves at least
once and 35% had burned themselves at least once.4 4Those who had both self-cutting and self-burning behaviors had increased rates of depression and dissociation
while those who had self-burning without cutting had
less psychopathology. Studies also demonstrated thatfactors underlying deliberate self-harm included different forms of psychopathologies,45 such as schizophrenia,
major depression, and substance abuse disorders;2 8, 4 6, 4 7
there is an association of drug abuse (including alcoholabuse) and eating disorders with some self-injurers.4 8
Deliberate self-harm is also associated with personality
disorders.4 9,50 However, self-cutting can also arise denovo without any overt history of trauma or borderline
personality disorder.51
Nevertheless, the type of self-harm does not necessarily identify the seriousness of the underlying psychopathology. Cryole, for example, studied 280 college undergraduates and noted that 31% had “minor” self-harming
behavior characterized by skin picking or fingernail biting over the previous three years; 20% had “major” selfinjurious behavior with self-cutting and self-burning.5 2
Both groups were associated with underlying psychopathology, including disordered eating patterns (with negative self-esteem),5 3 negative thinking,5 3 impulsivity, somatic issues, and obsessive-compulsive issues.31
From the family perspective, different family processes
are postulated to be related to adolescent suicidal behavior. Richman54 proposed that communication disturbanc-147

es and excessive secretiveness were family factors thatmight lead to heightened suicidal behavior. Researchfindings demonstrated that parent-adolescent communication was associated with adolescent suicidal ideation
and adolescent deliberate self-harm.55, 56 Syed and Khan
showed that family conflict was the main factor contributing to deliberate self-harm in young people in Pakistan.57 Besides, a major factor often found in many selfcutting youth is severe family dysfunction that induces
variable states of depersonalization and an altered stateof mind or dissociation.58, 59 Finally, self-cutting may be
noted in youth who suffer from sexual or physicalabuse,4 9, 6 0, 6 1 severe family neglect,6 2 early separationfrom parents, being homeless, and running from home.63
Other research notes the importance of parental alienation (with intense parental criticism) in adolescents with
non-suicidal self-injury (NSSI such as self-cutting, selfhitting, self-burning).17
Studies have indicated that peer factors are related toadolescent suicide and related behavior. Research studies
showed that number of friends and relationship problems
with peers (e.g. conflict, bully-victim problem, intimidation) were significantly related to the degree of suicidal
ideation.6 4 Intense conflicts with peers can induce DSH
especially being a victim of bullying.6 5 Such internal
conflicts can result in attention-seeking behavior and impulsivity that leads to DSH.11 Self-cutting may occur inattempts to relieve “a terrible state of mind” in those engaged in such behavior. 3 1 The self-cutting behavior,though confusing to others, often serves as a way of releasing intense and unbearable pain from suppressed
negative feelings driven by underlying depression andanxiety from conflicts with family and/or peers.12, 19, 66-68
On the other hand, social support was found to be an important protective factor against suicidal ideation.69
There are studies showing that macro socio-cultural
factors are related to deliberate self-harm in adolescents.
Social integration and social regulation were found to be
negatively related to suicide in the United States from1930 to 2000.70 Hawton et al. found that socioeconomic
deprivation was related to deliberate self-harm.7 1 In an
attempt to examine the relationship between area characteristics, individual characteristics and self-harm repetition, Johnston and colleagues showed that four individual factors (i.e., previous self-harm attempts, history ofpsychiatric treatment, employment status, and marital
status) and proportion of Caucasian people in an area
were related to deliberate self-harm. 7 2 Added to this,Wenz also reported that low economic status was related
to self-injury rates.73 Self-burning may occur as a resultof war-induced post-traumatic stress disorder and may
also be encouraged by media accounts of such incidents.74

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148

DSH and Risk for Suicide
Though youth with evidence of deliberate self-harmsuch as self-cutting vary widely in the underlying causes,
all youth with evidence of DSH must be taken seriously
and carefully evaluated for risk of eventual or completedsuicide.75 If underlying factors are not corrected (such as
psychiatric problems as well as chronic conflicts withpeers or parents), these acts of DSH can become repetitive, involve severe self-mutilation and multiple methodsof DSH,65,75 increased depression with suicidal ideation,
and also suicide attempts stemming from very negative
attitudes towards life.6 8 Suicide is usually the result ofchronic problems in those who are self-cutters; however,acute reactions can also lead to suicide in infrequent situations.68
The overall risk of suicide increases after a self-harm
episode over time, with a 1.7% increase after 5 years,
2.4% at 10 years, and 3.0% at 15 years.76 Approximately
5% of self-harm patients seen at an emergency department or hospital commit suicide within 9 years of theself-harm incident.14 Males with bulimia and males who
experience analgesia during self-cutting are especially atrisk for suicide.5 9, 7 7 Youth who cut their wrists havehigher suicide risks than arm-cutters, though the latter isassociated with more dissociation.78 Children who sufferfrom sexual abuse later developed increased risks for selfcutting behavior with increased association with eating
disorders and suicidal ideation.6 0 In a study of 11,583
patients with deliberate self-harm in Oxford, Englandfrom 1978 to 1997, 39% had repeated DSH and the highest risk for suicide was found in females with multiple
DSH episodes.79
Management
It is important not to assume that the youth’s self-cutting behavior is “harmless” and only reflects “harmless”
attention-seeking behavior.11 Self-cutters are not a homogenous group and all should be considered at highrisk of suicide that requires careful evaluation and management in this regard.8 0 For example, adults may be
wrongfully accused of inducing burns in children unless
a careful forensic examination takes place to identify
self-induced burns versus assault with burns.8 1 The Internet may encourage self-harming behavior by normalizing and encouraging such behavior among adolescents.8 2 Thus, it is important for clinicians to ask about
DSH and correct any misconception of normalcy withregard to any DSH behavior. An evaluation by the clinician may reveal skin trauma consistent with previously
undiagnosed self-cutting.8 3 Youth who engage in selfcutting behaviors have increased risk for various highrisk behaviors and should be asked about sexual activity,
condom use if sexually active, history of sexually transmitted diseases, and illicit drug use.84

Unfortunately, most self-cutters do not come to the attention of healthcare providers.2 0 In a study of young
adults with DSH, only half sought help from professionals and those who did rated the care they received in a
hospital emergency department as poor.8 5 The risk forsuicide increases with time after this behavior, as noted
before, and it is best to provide thorough protection andintensive monitoring rather than ignore the DSH, potentially ending up with a later suicide.11 Multiple intervention modalities can be used to manage DSH, includinggroup therapy, school-based interventions, hospitalization, art therapy, and anti-depressant medication for depression.1 7 Therapy needs to build skills for improved
communication skills, management of stress, and development of positive coping mechanisms.40 Those engaged
in repetitive self-wounding need intensive therapy.4 0
Monitoring deliberate self-harm presentations to general
hospitals is also important.86
In a meta-analysis of suicide data from 18 studies,
there was no evidence that intervention after self-harm
actually reduced later suicide.87 Thus, more research on
successful intervention strategies is clearly needed. Factors leading to successful intervention include having atrusting relationship with a health care professional, theavailability of support during times of crisis, intensive
management of concurrent psychiatric illness, and continuing support of family and friends.14
Preventive programs should be developed that will allow methods of managing stress and problem-solving.68
Mitchell and Ybarra also suggested that chat room andinstant messaging should be added to telephone hotlines
to prevent deliberate self-harm.88 However, Fortune andcolleagues pointed out that “little is known about young
peoples’ views on prevention of DSH.”89
Existing Research Gaps and Future Research
Directions
Although much work has been done to examine thephenomenon of deliberate self-harm in young people, asurvey of the literature shows that existing studies on deliberate self-harm, particularly on self-cutting, are notadequate. For example, a computer search of PsycINFO
using the key word “self-cutting” in November 2008
showed that there were only 103 citations. Obviously,
more research in this area should be conducted.
Regarding future research in this area, there are several
major possible directions. In the first place, although thepresent review shows that ecological factors at the individual, interpersonal and family contexts are related todeliberate self-harm, there are at least two areas thatshould be further researched. First, systematic studies on
the role of spirituality in deliberate self-harm are few. A
computer search of PsycINFO using the key word “selfharm” and “spirituality” in October 2008 showed that
there was no related citation. As deliberate self-harm is a

Keio J Med 2009; 58 (3): 144－ 151

precursor to actual suicidal attempts which might lead totermination of life, it is both theoretically and practicallyimportant to explore the possible role of spirituality suchas life meaning in self-harmers. As spirituality is a growing concern in the mental health contexts,9 0, 9 1 morework along this line should be carried out. Second, although the present review highlights the importance offamily processes in deliberate self-harm, further work isneeded to examine how specific family processes suchas different types of parental control and parental marital
qualities and related experiences are related to deliberate
self-harm.9 2 As deliberate self-harm is commonly regarded as a signal to seek help, how family processes
may inhibit the healthy help-seeking processes among
adolescents should be explored.
Third, most of the existing studies investigating the antecedents and consequences of deliberate self-harm arecross-sectional studies. Although cross-sectional studies
can help to identify the correlates of deliberate self-harm,causal relationships involved cannot be clearly established. Fourth, this literature review reveals that with afew exceptions, quantitative methods have been primarily used to study deliberate self-harm. While a post-positivistic approach represents the dominant research paradigm in medical and social science research, its limitations should be duly acknowledged. Methodologically, it
would be illuminating if qualitative research adopting
constructionist orientations could be carried out in future. Fifth, comparative studies should be conducted to
examine deliberate self-harm in different communities.
As commented by Madge et. al., “there is little reliable
comparative international information on its extent orcharacteristics” (p.667).9 3 In view of the rising suicide
figures in different non-Western communities such as
Hong Kong,9 4 comparisons regarding deliberate selfharm among different communities would be important.
Finally, research on intervention programs for deliberate self-harm should be carried out. For tertiary prevention, relative efficacy of different intervention approaches should be examined. For secondary prevention, identification of adolescents with self-harming behavior thatdeserves professional attention at an earlier stage is important. This requires the development of screening instruments with good psychometric properties. Similarly,
primary prevention programs that reduce young people’s
likelihood of engaging in deliberate self-harm is of paramount importance. Based on the perspective of positive
youth development, it is argued that strengthening young
people’s psychosocial competence and developmental
assets in young people would reduce their likelihood toengage in deliberate self-harm behavior.95, 96
Summary
Deliberate self-harm is a widespread yet often hidden
problem in adolescents, especially females, which shows

149

both similarities and differences internationally.3 1 Twomain characteristics of DSH noted are negative emotion
and self-derogation. Reasons for non-suicidal self-injury
include efforts to resist suicidal thoughts, expression ofself-anger or disgust, resolve times of dissociation, influence others, or seek help from others.42, 43 There is an association of drug abuse (including alcohol abuse) andeating disorders with self-injurious behavior.48 There arevarious subgroups of self-cutters and most are not athigh risk for suicide.9 7 However, all acts of self-injury
should be taken seriously by healthcare professionals
and comprehensive therapy offered to any adolescentwith a history of self-injury or DSH. Programs for suicide prevention should be implemented for youth whoare at risk for suicide, including those who self-injure
themselves.2, 3, 22, 98-100 More research on deliberate selfharm should be carried out with reference to the researchgaps identified in this paper.
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