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Research Article                                                                                                                                        Open Access

## Non-Suicidal Self-Injury and Indirect Self-Harm Among Danish High School Students

Bo Møhl 1 , Peter la Cour 2 , Annika Skandsen 3

1 Aalborg University and Psychiatric Center Copenhagen, Nannasgade 28, Copenhagen N, Denmark

2 Knowledgecenter for Functional Diseases, Psychiatric Center Copenhagen, Nannasgade 28, Copenhagen N, Denmark 3 Statens Barnehus, Stavanger, Norway

*Corresponding author: bo.moehl@regionh.dk

## Abstract

Background: Non-suicidal self-injury (NSSI) and indirect self-harm are prevalent among adolescents, but it is rare to see them described as related topics.

Objective: The purpose of this study was to investigate whether there is a correlation between the frequencies of NSSI and indirect self-harm (e.g., eating problems, alcohol and drug use) and how this may be influenced by gender.

Method: Questionnaires about NSSI (e.g., cutting, burning, scratching, hitting oneself) and indirect self-harm were distributed to high school students in the Copenhagen area (N = 5650; response rate 53%; females 60.8%).

Results: A total of 21.5% of the survey respondents had engaged in NSSI (lifetime prevalence), and 16.2% had practiced NSSI within the previous year. Gender differences in NSSI methods were identified. A total of 53.9% of the students had engaged in one or more types of indirect self-harm. The correlation between NSSI and indirect self-harm is twice as high for males (0.44; P < .001) as compared with females (0.20; P < .001).

Conclusions: Clinicians  must  be  aware  of  both  NSSI  and  indirect  self-harm.  A  positive  correlation  is  seen,  especially among young males. Males often perform other kinds of NSSI as compared with females, and clinicians  must look for gender-specific signs of NSSI. It is argued that NSSI can be perceived as a 'social pathology,' but it is also indicated that NSSI and indirect self-harm can be evaluated as an expression of ordinary behavior among modern high school students that must not be medicalized.

Keywords: Non-suicidal  self-injury  (NSSI),  methods  of  non-suicidal  self-injury,  gender-specific  NSSI,  indirect  self-harm, adolescents, social pathology

## Introduction

For  the  last  10  to  12  years,  the  incidence  of  selfharming  behavior  among  adolescents  in  Western countries has increased dramatically, but the prevalence  of  non-suicidal  self-injury  (NSSI)  has probably  reached  its  maximum  (1).  Self-harming behavior has reached a level that indicates that selfharm is no longer just a problem for the individual; rather, it has become a public health issue or a new 'social  pathology'  (2).  There  has  been  an  increase in NSSI that has an immediate effect on the body as well as on behavior, with possible long-term harmful  consequences  resulting  from  indirect  selfharm (e.g., alcohol and drug abuse) (3).

To  make  a  clear  distinction  between  NSSI  and indirect  self-harm,  we  will  apply  the  definition  of NSSI provided by the International Society for the Study of Self-Injury. Here, direct NSSI is  defined as 'the deliberate, direct, and self-inflicted destruction of body tissue resulting in immediate tissue damage, for  purposes  not  socially  sanctioned  and  without suicidal  intent'  (4).  This  definition  eliminates  selfinjurious  behavior  with  suicidal  intent  as  well  as both indirect self-harm and socially sanctioned behavior (e.g., piercing, tattooing, and plastic surgery).  Cutting,  burning,  scratching,  and  hitting oneself are examples of NSSI.

Indirect self-harm is defined as an activity that results in  damages  that  are  unintended  side  effects  of  the act.  The  damages  do  not  occur  immediately  but rather  are  deferred  or  are  long-term  consequences of accumulation. For the person engaged in indirect self-harming behavior, the negative impact is unknown and often a matter of risk or luck. There are varying  degrees  of  indirect self-harm; these include  less  severe  forms  (e.g.,  drinking  wine  with dinner, smoking, eating high-fat fast food) as well as more  severe  forms,  which  are  no  longer  just  bad habits but instead clear-cut risky behaviors.

For the purposes of this study, indirect self-harm is defined  as eating problems  (e.g., deliberately starving  oneself,  deliberately  vomiting  after  having eaten too much), consuming alcohol to the point of blackout, or taking illegal drugs (e.g., amphetamines, LSD, heroin).

Shneidman (5) links indirect self-harm to suicide and emphasizes that drinking alcohol, using drugs, smoking, and even not eating a healthy diet can be seen as a kind of 'sub-intentional suicidal behavior,'  because  it  can  'clearly  jeopardize  one's health  and  longevity.'  Although  indirect  self-harm is not a conscious expression of a death wish, it can be fatal in the long run. The same can be said about direct  self-harm  or  NSSI.  The  line  between  selfharm and suicide attempts is easier to draw academically than clinically (5).

The prevalence of NSSI among non-clinical populations  is  reported  to  be  between  4%  and 41.5%, varying with the group being studied and the definition of self-harming behavior (1;6-8). Especially among high school and college students, the  prevalence  of  NSSI  is  high  (9;10).  A  Danish study  of  NSSI  in  high  schools  finds  a  lifetime prevalence  of  21.5%.  A  total  of  16.2%  of  the students  had  performed  NSSI  within  the  previous year (11).

Cutting is the most  frequent  form  of  NSSI (12;13); this is followed by scratching, burning, and hitting oneself (14). Males and females use different methods  of  NSSI.  Studies  find  that  more  females cut themselves and that more males hit themselves, but both genders exhibit a variety of NSSI methods (15-17).

Experimentation with alcohol and drugs as well as eating problems is common among Danish adolescents  (3).  Danish  youths  have  the  highest consumption of alcohol in Europe (18). A Danish study  of  quality  of  life  among  17-  to  24-year-old Danes  found  that  94.0%  of  males  and  90.7%  of females are alcohol consumers and that 32.6% and 16.6%  of  these  groups,  respectively,  are  drunk  at least  once  a  week  (3).  According  to  the  National Board  of  Health  (19),  44.5%  of  Danish  youths between  16  and  34  years  old  have  used  cannabis, and 14.4% have used other illicit drugs (e.g., amphetamines, LSD, heroin).

A survey of 15- to 19-year-old Danes found that 39.1% of females and 20.9% of males are often or always  thinking  about  their  weight  (3).  Another Danish study found that 25% of females and 3% of males between 14 and 21 years old have frequently been on a diet and that 30% of females and 24% of males  have  had  frequent  episodes  of  binge  eating. In addition, 25% of females are estimated to be at risk for the development of an eating disorder (20).

Despite the fact that many studies have documented that NSSI is prevalent among adolescents and that other studies have documented that  many  adolescents  have  indirect  self-harming behavior with the use of illicit drugs and alcohol or eating problems, it is rare to see NSSI and indirect self-harm  described  as  related  topics.  Most  of  the literature that addresses NSSI and indirect self-harm is  largely  non-overlapping  (21),  although  it  is  a common  clinical experience to find a positive correlation  between  NSSI  and  indirect  self-harm (22;23). If a patient cuts herself, the risk that she has an abnormal eating pattern or consumes too much alcohol is increased, and vice versa (24). A study by Favaro and colleagues (25) confirmed the significant correlation between NSSI and other forms of selfharming behavior, including alcohol and substance abuse, suicidal behavior, and eating disorders. These findings are confirmed by studies that demonstrate a  positive  correlation  between  NSSI  and  eating disorders (26), NSSI and substance abuse (27), and NSSI and alcohol consumption (28).

NSSI and indirect self-harm have some common features.  In  both  conditions,  the  body  is  used  as  a medium  to  regulate  the  state  of  mind,  the  social situation,  or  both.  NSSI  and  indirect  self-harm represent  attempts  to  modify  the  mental  or  social state of the individual (e.g., affect regulation, relaxing, coping with difficulties, altering consciousness) (29). NSSI and indirect self-harm are correlated with different forms of mental disorders (e.g., depression, anxiety, personality disorders) (21) and  the  risk  of  suicide  (30;31).  NSSI  and  severe types of indirect self-harm are indicators of distress and failure to succeed (3).

However, an important difference between NSSI and  indirect self-harm  is that the latter is  not necessarily  performed  with  the  intent  to  harm  the body; the behavior is therefore not considered selfharm by the person who is performing it. From an outside  perspective,  NSSI  and  indirect  self-harm seem  to  be  two  sides  of  the  same  coin,  but  it  is important to make a clear distinction, because NSSI and  indirect  self-harm  are  perceived  and  defined differently  by  the  individuals  who  are  performing the behavior.

The  purpose  of  this  article  is  to  examine  the possible correlations between  different  types of NSSI and indirect self-harm among male and female high school students in the Copenhagen  area. Suicidal  behavior  is  excluded  from  this  study,  and the  focus  is  on  some  of  the  common  but  harmful coping  strategies  that  are  seen  among  high  school students. This study is part of a larger study of selfharming behavior among Danish high school students in the Copenhagen area (11).

## Methods

## Participants

The  participation  of  fourteen  high  schools  in  the Copenhagen  area was requested, and the high schools  were  selected  for  being  a  representative cross-section of Danish urban society. Seven schools agreed to participate. There were no significant  differences  in  size  or  sociodemographic position between the participating and nonparticipating schools.

Among the students from the seven schools (N = 5650),  the  response  rate  was  53%  (range,  41%  to 62%). Because the prevalence of NSSI and indirect self-harm  per  school  varied  little  with  the  school's response rate, we do not believe that non-response bias is a major issue.

Some  of  the  questionnaires  were  ambiguous,  or suggested suicidal thinking, 135 were excluded from the  study,  and  we  were  left  with  a  sample  size  of 2864.  This  group  consisted  of  1123  males  (39.2%) and  1741  females  (60.8%)  between  the  ages  of  16 and  19  years.  Gender  data  were  missing  in  some cases.

## Data and design

Data were collected from a one-page questionnaire handed out by the teachers. The questionnaire was constructed by the authors to obtain basic information about NSSI and indirect self-harm. It is reproduced in a translated version as an appendix to this paper. Students had 1 week to complete the questionnaire and could return it anonymously by putting it into specially designed mailboxes at the high schools.

The  questionnaire  focuses  on  different  types  of NSSI  and  starts  with  a  yes-or-no  question  asking whether  the  respondent  has ever engaged  in  NSSI ('Have  you  ever  in  your  life  deliberately  harmed yourself [for example cut, burned, scratched, or hit yourself] without the intention of killing yourself?'). If the student answered yes to that question, he or she was asked to go on to the next question, which asked  how  he  or  she  had  performed  NSSI  ('How did  you  harm  yourself?'),  with  the  possibility  of answering yes or no to the following types of NSSI: cutting,  burning,  scratching,  hitting,  or  other  types of  NSSI.  To  reveal  indirect  self-harming  behavior, we asked the respondent to answer yes or no to the following  questions:  'Have  you  ever  deliberately starved  yourself  and/or  deliberately  vomited  when having eaten too much?' 'Have you ever drunk so much  alcohol  that  you  blacked  out?'  and  'Have you  ever  taken  drugs  (amphetamine,  LSD,  heroin, or the like)?'

Data were analyzed with the use of SPSS software version 18, with standard settings used for all tests involved.  A  principal  component  analysis  (PCA) was  performed  with  varimax  rotation  and  Kaiser normalization.

## Ethics

The Ethics Board of Science in Copenhagen received  a  copy  of  the  questionnaire  and  protocol for their review. They had no annotations, and the study was approved.

## Results

## Non-suicidal self-injury

The  21.5%  of  the  students  who  filled  out  the questionnaire  (N  =  2864)  had  performed  NSSI  at some  point in their lives (lifetime prevalence). Minor gender differences were seen (females, 22.3%;  males,  18.9%),  but  the  difference  was  not significant ( P = .3 [chi-squared test]).

An  average  of  16.2%  (15.9%  females,  16.6% males)  performed  NSSI  during  the  year  preceding their answering of the questionnaire. Further details are described by Møhl and Skandsen (11).

The variety of NSSI methods used by those who had performed NSSI is summarized in Table 1. As seen, a total of 643 (21.5%) of the full sample had performed  NSSI  at  least  once  during  their  lives. Large gender differences are found with two types of self-harm, which may thus be considered genderspecific methods. Of the 50.0% of respondents who had cut themselves, the females held the dominant position  at  63.1%,  with  males  having  a  rate  of 25.9% ( P <  .001  for  gender  difference  chi-squared test).  The  opposite  was  the  case  among  the  47.0% of  respondents  who  hit  themselves.  This  specific form  was  dominated  by  males  at  63.8%,  with females  having  a  rate  of  38.8%  ( P <  .001).  For  a graphical overview, see Figure 1.

Of the students who performed NSSI, 53.2% had used  only  one  of  the  listed  methods;  27.8%  used two  methods,  10.6%  used  three  methods,  6.2% used four methods, and 1.9% used all of the listed methods.

70

60

50

40

30

20

10

0

Cutting I Female

TABLE 1. Non-suicidal self-injury methods within the group that harmed themselves (N=643) Overall

|            | Female      | Male        | Overall     |
|------------|-------------|-------------|-------------|
| Cutting    | 243 (63.1%) | 55 (25.9%)  | 322 (50.0%) |
| Burning    | 48 (12.3%)  | 68 (31.2%)  | 124 (19.3%) |
| Scratching | 188 (48.3%) | 68 (31.2%)  | 273 (42.5%) |
| Hitting    | 151 (38.8%) | 139 (63.8%) | 302 (47.0%) |
| Other      | 42 (10.8%)  | 44 (20.2%)  | 91 (14.2%)  |

FIGURE 1. Types of self-harm. Percentage of type within the group of selfharmers

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## Indirect self-harm

A total of 53.9% of the students indicated that they have  experiences  with  one  type  of  indirect  selfharming behavior: either eating problems (deliberately starving or deliberately vomiting when having eaten too much), consuming alcohol to the point of blackout, or taking illegal drugs  (e.g., amphetamines, LSD, heroin). More specifically, 12.6%  indicated experiences with two  different types  of  indirect  self-harm,  and  2.7%  indicated experiences  with  all  three  types  of  indirect  selfharm. As shown in Table 2, alcohol blackout seems to be especially common among Danish high school students.

TABLE 2. Indirect self-harming behavior in the full sample (N=2622)

|                  | Female      | Male        | Overall      |
|------------------|-------------|-------------|--------------|
| Eating Problems  | 438 (28.2%) | 73 (7.6%)   | 536 (20.4%)  |
| Alcohol blackout | 625 (40.4%) | 482 (48.5%) | 1174 (43.9%) |
| Drug use         | 105 (6.8%)  | 140 (14.4%) | 262 (10.0%)  |

## Correlations between non-suicidal self-injury and indirect selfharm

Variables  that  contained  information  about  how many  types  of  NSSI  and  indirect  self-harm  the individual had been practicing were correlated (Pearson).  Correlations  between  NSSI  and  indirect self-harm in the full sample were 0.3 (Pearson; P < .001). When the sample was divided into gender, the correlation  was  twice  as  high  for  males  (0.44; P < .001) as compared with females (0.20; P < .001).

TABLE 3. Gender-specific correlations between sums of nonsuicidal self-injury and sums of indirect self-harm

| Females   | Indirect type sum Non-suicidal self-injury sum   | 378 389 (Pearson correlation = 0.20; P < .001)   |
|-----------|--------------------------------------------------|--------------------------------------------------|
| Males     | Indirect type sum Non-suicidal self-injury sum   | 211 442 (Pearson correlation = 0.44; P < .001)   |

## Factor analysis of self-harm

After  combining  all  of  the  types  of  self-harm,  we did a factor analysis to investigate eventually underlying  patterns.  Considering  the  eigenvalues and  the  scree plot, a  three-factor  solution  was chosen as presented in Table 4.

The  different  types  of  NSSI  and  indirect  selfharm  are  intercorrelated  in  such  a  way  that  three groups can be described separately:

1. Outward active self-harm. The first group consisted of individuals who  had performed outward active self-harm methods: students taking drugs, drinking  themselves  to  the  point  of  blackout, and burning themselves. The category of 'other' also  belongs  with  this  factor,  but  the  nature  of self-harm types in this category is widely unknown. The group of 379 persons (63.9% of the  self-harmers)  who  had  performed  one  of these  types  of  self-harm  was  characterized  by being  mainly  male  (77.5%  [versus  females  at 56.3%]), and the gender difference grows when more than one type of self-harm is involved.
2. Less-invasive self-harm. The second group consisted of  students  who  had  performed  less-invasive types of self-injury, such as eating problems and scratching. This group consisted of 360 individuals (60%) and was predominantly female.
3. Gender-specific  self-harm. The  third  group  included the two gender-specific NSSIs (cutting and hitting  oneself),  which  are  highly  but  inversely correlated  as  a  result  of  the  gender  issue.  The persons who perform the one type of self-harm are not performing the other type. The group of students who had performed one of these types of self-harm included 480 individuals (79.0%).

TABLE 4. Principal component analysis of non-suicidal self-injury and indirect self-harm

| Factor         |    1 |    2 |     3 |
|----------------|------|------|-------|
| Drug use       | .753 |      |       |
| Blackout       | .658 |      |       |
| Burning        | .643 |      |       |
| Other          | .427 |      |       |
| Scratching     |      | .741 |       |
| Eating problem |      | .689 |  .332 |
| Hitting        |      |      | -.788 |
| Cutting        |      | .361 |  .724 |

For all values, the following factors were used:

Varimax rotation with Kaiser normalization; eigenvalue >1; cutoff, <0.3

## Discussion

The  purpose  of  this  study  was  to  investigate  the connection between NSSI and indirect self-harming behavior in a gender context. The findings indicate that  about  three  to  four  students  in  each  grade  of high school have had at least one incidence of NSSI within the previous year. This corresponds with the results of other studies of NSSI among high school students (9). More than half of the students in the study had engaged in one or more types of indirect self-harm (e.g., eating problems, consuming alcohol to the point of blackout, taking illicit drugs). To our knowledge, no other Danish studies have investigated the prevalence of alcohol blackout among  high  school  students,  but  the  incidence  of eating  problems  of  either  a  restrictive  or  bulimic type found in our study corresponds with what has been found in other Danish studies (32).

When  it  comes  to  experiences  with  illicit  drugs (e.g., amphetamines, LSD, heroin), the figures obtained by this study are below the national average, according  to  a  study  by  the  National  Board  of Health (19). This study found that 10% of students (14.4% of males, 6.8% of females) had tried one or more  of  the  above-mentioned  drugs  at  least  once, whereas  the  National  Board  of  Health  (19)  found that  14.4%  of  the  population  between  the  ages  of 16  and  34  years  had  tried  illicit  drugs  (except  for marijuana)  at  least  once  in  their  lives.  The  lower figures in this study could be explained by the fact that  the  students  are  younger  (i.e.,  16  to  19  years old) than the participants in the National Board of Health study.

This study confirms a connection between NSSI and  indirect  self-harm,  which  has  been  found  in other surveys as well (25). The correlation between NSSI  and  indirect  self-harm  is  twice  as  high  for males (0.442) as for females (0.200), and more males have  engaged  in  the  more  severe  forms  of  NSSI (e.g.,  burning)  as  well  as  indirect  self-harm  (e.g., drug use, alcohol blackout). The higher correlation between NSSI and indirect self-harm may indicate a more smooth transition between NSSI and indirect self-harm among males. An explanation may be that excessive  drinking  and the  intake  of  drugs  reduces self-control, thereby increasing the risk of acting out with NSSI. Further studies are required to confirm this.

In accordance with other studies (17;33), significant gender differences with regard to methods of NSSI and indirect self-harm were found in  this  study.  The  majority  of  females  who  have engaged in NSSI have cut themselves, whereas the most frequent form of NSSI among males is hitting themselves.  It  seems  that  males  in  this  study  are generally  more  self-harming  and  self-destructive  in their  lifestyles  than  females  are.  Males  dominate  in the outward self-harming group, with members who drink  themselves  to  the  point  of  blackout,  take drugs, and burn themselves. This pattern was confirmed  in  a  previous  part  of  the  study,  which showed that males are involved in a more persistent and  intense  form  of  self-injurious  behavior  than females, who tend to stop NSSI or to practice it less during the last years in high school (11). This is in line  with  the  study  by  Claes  and  colleagues  (34), who found that males who performed NSSI reported a greater number of NSSI episodes per day than females did.

This  study  does  not  address  the  reasons  behind the gender differences in NSSI methods and indirect self-harming behavior, but the patterns found here seem to reflect the gender stereotypes of Western culture. Several studies indicate that females  under  emotional  stress  tend  to  internalize their emotional reactions, with the risk of developing depression and other psychopathological  symptoms  (35),  whereas  males are more likely to externalize their emotional reactions  (e.g.,  to  get  into  a  fight  or  hit  another person). Beating the fist against something or someone seems to be a masculine response, and this behavior constitutes a transition between aggression against the outside world and aggression against the self (36).

The high rates of NSSI and indirect self-harming behavior indicate that NSSI and indirect selfharming behavior can no longer be understood just as symptoms of individual distress or psychopathology. When NSSI and self-harm appear as  frequently  as  documented  in  this  and  several other  studies,  they  constitute  a  so-called  'social pathology'  (2).  The  term social  pathology refers  to  a condition that is so common in the culture during a certain  period  of  time  that  it  becomes  a  public health problem. This is the case when three to four students in each grade have had at least one incidence  of  NSSI  and  when  more  than  half  of them have engaged in one or more types of indirect self-harm.

In contrast with the point of view that NSSI is a serious  problem,  Adler  and  Adler  (37)  consider NSSI as a non-pathological act, which they describe as  a  'voluntarily  chosen  deviant  behavior.'  They stress  that  NSSI  represents  a  kind  of  symbolic interaction  rather  than  purely  a  medical  problem, and  thus  they  understand  NSSI  to  be  a  normal behavior among young people as a product of 'their active choice and free will.'

This  point  of  view  corresponds  with  the  selfperception  of  some  of  the  students  who  perform NSSI and indirect forms of self-harming behaviors.

During the interviews for the current study, some of the  students  stated  that,  in  their  opinion,  alcohol blackout is not a  self-harming behavior but rather a result of a certain kind of lifestyle.

Many  young  people  reach  the  point  of  blackout (i.e., amnesia for the drinking episode) once or twice before  they  actually  learn  how  much  alcohol  they can  tolerate  without  becoming  ill.  A  male  student told us that 'everybody has tried to have too much to  drink.  This  is  part  of  the  ordinary  high  school culture.'

As the results of this study are assessed, we must be careful to not medicalize a behavior that may be 'a part of the ordinary high school culture.' Further research is needed to judge the qualitative aspects of the findings of this study.

## Limitations of the study

This  study  is  based  on  self-report  questionnaires. Self-reporting comes with the possibility of a retrospective bias, and the impact of this is impossible to determine. This is a common limitation of psychological research.

It  is  also  a  limitation  of  this  study  that  it  has  no quantification  of  the  amount  of  indirect  self-harm. Students only indicated whether they had deliberately starved themselves or deliberately vomited when having eaten too much, whether they had consumed alcohol to the point of blackout, and whether they had taken drugs (e.g., amphetamines, LSD, heroin). If it happened only once, it does not constitute a problem  for the person who  has performed the indirect self-harming behavior. Young  people  experiment  with  lifestyle  choices, including alcohol, drugs, and food.

Another limitation of the study is the list of NSSI opportunities  (i.e.,  cutting,  burning,  scratching,  or hitting  oneself).  Studies  indicate  that  the  use  of  a checklist will yield higher figures for NSSI. However,  in  this  study,  it  is  a  limitation  as  well, because  some NSSI opportunities  that  seem  to  be common in other studies (e.g.,  biting,  hair  pulling, sticking  pins  into  the  skin)  have  been  omitted.  It was not possible to track all students who engage in NSSI, so this study provides a conservative estimate of the prevalence of NSSI.

Finally, the gender bias must be mentioned. Only 39%  of  the  respondents  were  males,  but  this  is roughly equivalent to what has been seen in similar studies (38). Gender bias may influence the outcome  of the study, especially because it is focused  on  gender  differences.  Further  research must be conducted to confirm our findings.

## Clinical significance

Among young people in the Western world, NSSI and indirect self-harm seem to be big issues, and the main findings of this study confirm this. Teachers, school counselors, educators, and clinicians must be aware of the connection between NSSI and indirect self-harm,  especially  among  young  males,  and  they must  look  for  other  signs  of  NSSI  in  addition  to scars  and  other marks of cutting. Males often beat themselves, which can leave signs that may easily be mistaken  for  sports  injuries  or  consequences  of  a wild and careless lifestyle (e.g., a black eye).

## Acknowledgements

This study was made possible by a research grant from Tryg Fonden, Denmark, which was awarded to BM. We are indebted to headmaster Marianne Zibrandtsen, MA, for helping us to get in contact with the schools involved in the study.

## Declaration of interest

The authors have declared that there is no conflict of interest.

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## Appendix

## Self-Harm Questionnaire

Sex

Male

Female

(put a mark)

Grade

1.g

2.g

3.g

Have you ever in your life deliberately harmed yourself (for example cut, burned, scratched, or hit yourself) without the intention of killing yourself?

Yes

No

If you answered yes to the question above, please go on to the next questions:

## How did you harm yourself?

Cut yourself (cutting)

Yes

No

Burned yourself

Yes

No

Scratched yourself

Yes

No

Hit yourself

Yes

No

Other

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How many times have you deliberately harmed yourself within the last year?

Once

1-5 times

6-20 times

>20 times

Have you ever deliberately starved yourself and/or deliberately vomited when having eaten too much?

Yes

No

Have you ever drunk so much alcohol that you blacked out?

Yes

No

Have you ever taken drugs (amphetamine, LSD, heroin, or the like)?

Yes

No

If you have any questions or remarks about self-injury or the questionnaire, please send an e-mail to bo.moehl@regionh.dk

Many thanks for your help!

Bo Møhl, Chief Psychologist