Singapore Med J 2015; 56(6): 306-309

Practice Integration & Lifelong Learning

doi: 10.11622/smedj.2015087

CMEArticle
Deliberate self-harm in adolescents
Michelle Lauw1, BSc(Hons), MPsych, Choon How How2, MMed, FCFP, Cheryl Loh1, MBBS, MMed

Lyn, a 17-year-old student, came to see you for frequent headaches. She was quiet and avoided
eye contact while her mother was telling you about her increasing withdrawal at home. You
noticed that Lyn’s left wrist had multiple slash scars that were recent and healing. You asked
Lyn’s mother to wait outside so that you could speak with her alone. Lyn then shared that she
had been cutting herself with a penknife whenever she felt stressed. You initially considered
dismissing this as a case of teenage angst but decided to ask a few more questions to ensure
the patient’s safety and to exclude a more serious condition.

WHAT IS DELIBERATE SELF-HARM? Table I. Risk factors associated with deliberate self‑harm
in adolescents.(4)
Deliberate self-harm refers to an intentional act of causing
physical injury to oneself without wanting to die. Deliberate • Perfectionistic personality traits

self-harm behaviours most commonly include cutting (with a • Low self‑esteem

knife or razor), scratching or hitting oneself, and intentional drug • Impulsivity

overdose. They may also include limiting of food intake and • Difficulties expressing emotions verbally

other ‘risk-taking’ behaviours such as driving at high speeds and • Low distress tolerance

having unsafe sex.(1,2) Many individuals who self-harm use more • Non‑heterosexual orientation

than one method of self-injury. These acts are often gratifying • History of violence or forensic problems

and cause minor to moderate harm. Some individuals self-harm • Early invalidating environments

on a regular basis, while others do it only once or a few times. • Self‑harm behaviours among family members and friends

Although deliberate self-harm is done without lethal intent, it • Family history of psychiatric disorders

could lead to fatality. • Dysfunctional family backgrounds

• Social isolation

WHO IS AT RISK?
Deliberate self-harm is a significant clinical problem, especially
Table II. Models of deliberate self‑harm.
among younger people in Singapore. It has been found to be
positively associated with the female gender, mood disorders, Model Description

adjustment disorders and regular alcohol use.(3) Table I lists other Affect An attempt to alleviate intense emotional pain
regulation that cannot be expressed verbally or through
risk factors of deliberate self-harm.(4) Adolescents who self-harm
other means
tend to experience some common stressful precipitating events,
Anti‑ An attempt to avoid suicide by channeling
including peer friendship or relationship problems, academic suicide destructive impulses into self‑harm
stress, physical or psychological abuse and bereavement. behaviours
Anti‑ An attempt to stop feeling numb and to
WHY DO ADOLESCENTS SELF-HARM? dissociation escape the effects of dissociation that results
from intense emotions
In the current literature, several models have been proposed
Interpersonal An attempt to affirm one’s boundaries and
to outline why individuals engage in deliberate self-harm.(2,5,6)
boundaries protect against the loss of identity by creating
These models are not mutually exclusive, and each describes a distinction between self and others
deliberate self-harm as an attempt to cope with intense Interpersonal An attempt to communicate a need for help or
emotional states (Table II). Most patients have reported feeling influence to manipulate others to get needs met
extremely tense, anxious, angry or fearful prior to the act of Self‑ An attempt to relieve feelings of shame,
self-harm, and the self-harm behaviour is positively reinforced punishment self‑hatred or guilt

through feelings of relief, satisfaction and decreased tension.(2) Sensation‑ An attempt to generate excitement or
seeking stimulation
Adolescents may also engage in deliberate self-harm behaviours

Department of Psychological Medicine, 2Care and Health Integration, Changi General Hospital, Singapore
1

Correspondence: Dr Cheryl Loh, Consultant, Department of Psychological Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889. Cheryl_loh@cgh.com.sg

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in the process of social learning among their peers, out of Table III. Ways to elicit and respond to disclosure of deliberate
curiosity or in order to ‘fit in’. self‑harm.

Ways to elicit disclosure

WHAT CAN I DO IN MY PRACTICE? • “How have you been feeling recently?”
Assess for self-harm behaviours and associated • “Have you ever felt so low that you thought of harming yourself?”
psychiatric conditions • “ Could you tell me more?”
If you suspect an adolescent patient is engaging in deliberate (Assess for precipitants, frequency and lethality)

self-harm, it is important to assess for the presence of self-harm • “Have you ever felt that life is not worth living?”

as well as other salient features of the act, including precipitating • “Have you done anything about these thoughts and plans?”

factors, frequency and lethality of the method. Primary care Empathic responses

physicians are also urged to familiarise themselves with common • “Sounds like things have been quite rough for you.”

psychiatric conditions that tend to accompany deliberate self- • “Seems like you have been feeling hopeless and stressed lately.”

harm behaviours in order to rule out the presence of these • “You are trying your very best to cope with a very tough time.”
• “ Thank you for sharing this with me. Let’s think of how we can
conditions. They include (a) acute stress disorder or adjustment
help you feel better.”
disorder; (b) depression, in particular, the presence of suicidal
ideation; (c) anxiety disorders; (d) post-traumatic stress disorder;
(e) psychosis; and (f) learning difficulties.(7) Table IV. List of local helplines.

• IMH Mental Health Helpline: 6389 2222 (24‑hr)

Provide empathic listening • Family Service Centre: 1800 838 0100
Empathic listening is the process of listening so that others are • Counselling and Care Centre: 6536 6366
encouraged to talk; this is especially crucial for adolescents, who • Fei Yue Counselling Centre: 6536 1106
often feel unheard and misunderstood.(8) Primary care physicians • Care Corner (Mandarin): 1800 774 5935 (Daily: 1000–2200 hr)
can facilitate engagement with adolescent patients by creating a safe • Samaritans of Singapore: 1800 221 4444 (24‑hr)
space for them to freely discuss their problems without interruption. •S
 ingapore Association for Mental Health:
(Mon–Fri: 0900–1300 hr, 1400–1800 hr)
Adolescents may be more willing to disclose their struggles when
they are interviewed alone or given time to open up and when they
know that their right to patient confidentiality is respected. Provide parental education
As deliberate self-harm is a coping method, focusing solely Primary care physicians also play an important role in educating
on condemning or stopping the act can be detrimental. Advice family members about deliberate self-harm and modelling
on harm minimisation (such as keeping cutting objects sterile a compassionate approach to talking about self-harm to
and having first aid supplies at home) is more helpful when adolescents. Many parents tend to seek a quick fix for the self-
the adolescent has learnt alternative self-soothing methods. In harm act, but it is important for them to adjust their expectations
addition, a majority of adolescent patients feel ashamed of or about recovery. Advice for parents or caregivers of adolescents
disgusted with the act of self-harm and often worry about the who self-harm:
negative judgement of others. Therefore, primary care physicians • Remain calm and validate the emotional experiences;
should demonstrate an empathic stance. They can help their • Do not punish them for the self-harm act, as this may deepen
adolescent patients feel understood by using simple reflections to guilt or shame;
validate their emotional experiences and by withholding negative • Do not push them to talk if they do not feel comfortable to;
judgements of their self-harm acts. Table III shows some examples • Focus on the underlying struggles rather than the act of
of ways to elicit and respond empathically to a disclosure of self-harm;
deliberate self-harm. • Encourage and model healthy ways of coping with stress;
• Praise them for their strengths and resourcefulness;
Provide brief problem-solving advice • Allow them time to learn alternative self-soothing methods
Primary care physicians can also provide their adolescent patients to replace the self-harm behaviours;
with brief problem-solving advice after they have identified the • Seek assistance and support from school counsellors, child
stressors. This may include: (a) suggesting alternative self-soothing and adolescent psychiatrists or psychologists, or social
ways to improve their moods (such as exercising, engaging workers at family service or counselling centres.
in hobbies or listening to calming music); (b) helping them to
identify solutions to their prevailing predicament, as well as listing Refer to specialist care
down the advantages and disadvantages of each solution; and For adolescent patients presenting with more severe psychiatric
(c) identifying supportive individuals whom they can reach out conditions or who have poor responses to initial treatment
to for support during times of distress (such as family members, within the primary care setting, referral to a specialist or other
classmates or friends). Primary care physicians should also allied healthcare colleagues can be considered. A referral for
provide adolescent patients with details of local helplines and psychiatric hospitalisation is indicated for high-risk patients
resources that are available in the community (Table IV). presenting with the following: (a) strong suicidal intent or plan, or

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6. Primary care physicians play an important role in educating

Lyn explained to you that her stress had been caused family members about deliberate self-harm and modelling
by longstanding difficulties communicating with her a compassionate approach to recovery.
parents, who were opposed to her relationship with 7. Referral to specialist care is indicated for adolescent patients
her boyfriend. Lyn denied suicidal thoughts and with more severe psychiatric conditions or poor responses
maintained that she was still interested in her social to initial treatment.
and academic pursuits. You validated Lyn’s emotional
experiences and helped her to recognise that self-harm
was not a long-term solution to her problems. You ABSTRACT Deliberate self-harm refers to an intentional
encouraged her to explore ways to cheer herself up and act of causing physical injury to oneself without wanting
to die. It is frequently encountered in adolescents who
to communicate her feelings of distress to her parents.
have mental health problems. Primary care physicians
You reassured her that if her initial attempt at talking
play an important role in the early detection and timely
to her parents did not go well, you could arrange a intervention of deliberate self-harm in adolescents.
session to meet them together. You also offered to refer This article aims to outline the associated risk factors
her to a psychologist to learn more effective emotion and possible aetiologies of deliberate self-harm in
regulation and assertiveness skills. Lyn appreciated you adolescents, as well as provide suggestions for clinical
for taking time to listen to her problems and felt that assessment and appropriate management within the
your compassionate responses had given her motivation primary care setting.
to work on some of the suggested ways to better cope Keywords: adolescent mental health, deliberate self-harm, primary care
with her stressors.

REFERENCES
a recent suicide attempt; (b) severe psychiatric conditions such as 1. Pattison EM, Kahan J. The deliberate self-harm syndrome. Am J Psychiatry
1983; 140:867-72.
psychosis; and (c) high frequency, intensity and lethality of self- 2. Klonsky ED. The functions of deliberate self-injury: a review of the
harm acts. A referral for formal psychotherapy may be helpful for evidence. Clin Psychol Rev 2007; 27:226-39.
adolescent patients to address underlying psychological issues 3. Loh C, Teo YW, Lim L. Deliberate self-harm in adolescent psychiatric
outpatients in Singapore: prevalence and associated risk factors. Singapore
and to develop more effective coping skills in regulating emotions
Med J 2013; 54:491-5.
and tolerating distress. 4. Ougrin D, Tranah T, Leigh E, Taylor L, Asarnow JR. Practitioner review:
self-harm in adolescents. J Child Psychol Psychiatry 2012; 53:337-50.
TAKE HOME MESSAGES 5. Suyemoto KL. The functions of self-mutilation. Clin Psychol Rev
1998;18: 531-54.
1. Primary care physicians play an important role in the early 6. Nock MK. Why do people hurt themselves? New insights into the nature
detection and timely intervention of deliberate self-harm in and functions of self-injury. Curr Dir Psychol Sci 2009; 18:78-83.
adolescents. 7. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders: DSM-5. 5th ed. Washington: American Psychiatric
2. Deliberate self-harm can be dangerous and should be taken Association, 2013.
seriously. 8. Decety J, ed. Empathy: From bench to bedside. Cambridge: MIT
3. Primary care physicians should be familiar with the Press, 2012.
associated risk factors and common psychiatric conditions
that increase the risk of deliberate self-harm in adolescents. RECOMMENDED READING
4. Deliberate self-harm may serve one or more different • American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders: DSM-5. 5th ed. Washington: American Psychiatric
functions. Association, 2013.
5. Non-judgmental empathic responses to a disclosure of • Claes L, Vandereycken W. Self-injurious behavior: differential diagnosis
self-harm help adolescent patients feel that they are heard and functional differentiation. Compr Psychiatry 2007; 48:137-44.
• National Institute for Clinical Excellence. (2004). Self-harm: The short‑term
and may lead to a greater willingness to talk about their physical and psychological management and secondary prevention of
problems. self-harm in primary and secondary care. NICE Guidelines, July 2004.

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SINGAPORE MEDICAL COUNCIL CATEGORY 3B CME PROGRAMME

(Code SMJ 201506A)
True   False
1. Deliberate self-harm specifically refers to teenagers slashing their wrists. □ □
2. Only female teenagers engage in deliberate self-harm. □ □
3. There are a variety of different reasons why adolescents engage in deliberate self-harm. □ □
4. Adolescents who self-harm may feel embarrassed or ashamed about their self-harm act and tend to □ □
hide it from others.
5. Primary care physicians play an important role in educating family members about deliberate self-harm □ □
in adolescents.
6. Most teenagers who self-harm have other high-risk behaviours, which need to be elicited by the □ □
physician.
7. Teenagers who self-harm engage in such acts daily even if they say otherwise. □ □
8. Teenagers who have difficulties expressing emotions have a higher risk of self-harm. □ □
9. Teenagers who come from families with constant conflicts are at a higher risk of self-harm. □ □
10. Perfectionistic, high-performing teens are at a lower risk of self-harm. □ □
11. Adjustment disorders are commonly found in teenagers who self-harm. □ □
12. Teenagers who say they self-harm to punish themselves are simply trying to make themselves look □ □
good to the doctor.
13. Self-harm does not help teenagers to feel better in acute situations. □ □
14. Teenagers who self-harm will not commit suicide. □ □
15. If self-harm marks are noticed in a clinic, it would be best to avoid bringing up the subject of self-harm, □ □
unless the patient does so.
16. If parents are anxious on discovering their teenager’s self-harm behaviour, advise them that it is a □ □
normal teenage behaviour that is not worrisome.
17. Being non-critical in approach to adolescent deliberate self-harm sends the message that it is an □ □
acceptable behaviour.
18. Teenagers who self-harm due to auditory hallucinations need urgent psychiatric care. □ □
19. Teenagers who self-harm in response to life stressors may benefit from practical problem-solving □ □
advice.
20. Advising parents to keep penknives, medications and other dangerous objects away from a teenager □ □
who self-harms is good initial advice.

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