Percentage of deliberate self harm leading to suicide
Reading File
Searching PubMed
deliberate self harm suicide mortality risk
Finding Sources
Searching PubMed
self-harm suicide cohort follow-up mortality percentage
Reading File
Searching PubMed
self-harm repetition suicide death longitudinal cohort
Searching the Web
percentage deliberate self harm leading to suicide statistics epidemiology
Here is a comprehensive summary of what the evidence shows:
Percentage of Deliberate Self-Harm (DSH) Leading to Suicide
Key Figures by Follow-up Period
The risk of death by suicide after a DSH episode is time-dependent and rises progressively:
| Follow-up Period | Median Suicide Mortality |
|---|---|
| First year | 1.6 - 1.8% |
| 1 to 4 years | 3.0% |
| 5 to 10 years | 3.4% |
| 9+ years (long-term) | 6.7 - 8% |
These figures come from a widely-cited systematic review published in BMJ Clinical Evidence, available via PMC.
Relative Risk (How Much Higher vs. General Population)
The absolute percentages above understate just how dangerous DSH is as a risk factor:
- Adults who present with DSH have a 37 times higher one-year suicide rate compared to the general population (Columbia University/CUIMC study, n=61,297 Medicaid enrollees).
- Adolescents (age 12-24) after a nonfatal DSH episode are 46 times more likely to die by suicide in the 12 months afterward than matched controls.
- Overall, research from Columbia Psychiatry shows suicide risk is approximately 10 times greater in the first month after a violent-method self-harm event vs. the subsequent 11 months.
Pattern of Risk
- Risk is highest in the first year, and especially the first month, after a DSH episode.
- Repetition of DSH is common - median rates of ~16% within year 1, rising to ~23% over 4+ years - and each repeat episode compounds suicide risk.
- Method matters: Two-thirds of suicides occurring at the time of initial DSH used violent methods; firearm-related self-harm carried ~8x higher suicide completion risk.
- In Borderline Personality Disorder, where DSH is extremely prevalent, the textbook statistic is approximately 1 suicide per 23 attempts completed (Kaplan & Sadock's Comprehensive Textbook of Psychiatry).
- Males are twice as likely to complete suicide following DSH vs. females.
Risk Factors for Progression to Suicide After DSH
- Age 25-49 years
- Male sex
- Unemployment
- Divorce or social isolation
- History of prior attempts
- Comorbid depression, alcohol use disorder, or psychosis
- Use of violent methods (firearms, hanging)
- Recent psychiatric treatment (paradoxically a marker of higher severity)
Summary
In short: roughly 1 in 55 to 1 in 60 people who present with DSH will die by suicide within the first year, rising to approximately 1 in 15 to 1 in 12 over a decade. While the absolute percentage appears modest, the relative risk elevation (37-46x the general population) makes DSH the single strongest predictor of future completed suicide in clinical practice. The first year - and especially the first month - after a DSH episode is the highest-risk window for intervention.
What is deliberate self harm
Finding Sources
Searching the Web
deliberate self harm definition classification clinical features
Finding Sources
Finding Sources
Reading File
Reading File
Reading File
Here is a thorough explanation of deliberate self-harm:
Deliberate Self-Harm (DSH)
Definition
Deliberate self-harm (DSH) is the intentional, direct injury or destruction of one's own body tissue, regardless of whether or not the person intends to die. It is an umbrella term that covers a spectrum of self-injurious acts, from those with no suicidal intent whatsoever to genuine suicide attempts.
More precisely, the related term Non-Suicidal Self-Injury (NSSI) - increasingly preferred in modern psychiatry - refers specifically to "the direct, deliberate destruction of one's own body tissue in the absence of intent to die" (Rosen's Emergency Medicine). DSH is the broader term used in clinical and epidemiological settings that can include both NSSI and acts with suicidal intent.
Terminology Clarifications
The same behaviour has been called many names in the literature:
| Term | Meaning |
|---|---|
| Deliberate self-harm (DSH) | Broad umbrella - includes acts with and without suicidal intent |
| Non-suicidal self-injury (NSSI) | DSM-5 proposed diagnosis - self-harm specifically WITHOUT intent to die |
| Parasuicide | Older term for self-harm that resembles a suicide attempt but without clear intent to die |
| Self-mutilation | Often used for repetitive, non-suicidal self-injury (e.g. cutting) |
| Suicide attempt | Self-directed act specifically with the intent to die |
Terms considered inappropriate and to be avoided: "successful suicide," "suicidal gesture," "manipulative act."
Forms / Methods
DSH takes many forms:
- Cutting or scratching the skin (most common)
- Burning (with cigarettes, lighters, hot objects)
- Self-poisoning / overdose (most common method requiring emergency care)
- Hitting or bruising oneself
- Hair pulling (trichotillomania)
- Wound interference - picking at wounds to prevent healing
- Head banging
- Bone fracturing (less common, more severe)
Why Do People Self-Harm? (Functions)
DSH is primarily a coping mechanism for unbearable emotional states, not an attention-seeking behaviour. The main psychological functions include:
- Emotion regulation - releasing overwhelming anger, anxiety, or distress ("taking the lid off a pressure cooker")
- Relief from numbness - physical pain creates a sense of feeling "real" in dissociative or depersonalised states
- Neurobiological reinforcement - self-injury can trigger endorphin or dopamine release, temporarily relieving dysphoria (Kaplan & Sadock's Synopsis of Psychiatry)
- Communication - expressing distress that cannot be verbalised
- Self-punishment - in response to shame, guilt, or low self-worth
- Social learning - particularly in adolescents, may spread through peer groups
Who is Affected?
- Lifetime prevalence: approximately 3-5% of the general population in Europe and the US
- Most common in adolescents and young adults (peak 15-24 years)
- More common in females, though males tend to use more lethal methods
- Strongly associated with Borderline Personality Disorder (BPD) - 4 in 5 BPD patients have a history of suicidal or self-harm behaviour
- Also associated with: depression, PTSD, eating disorders, anxiety disorders, substance use, and childhood trauma/sexual abuse
DSH vs. Suicide Attempt - Key Distinctions
| Feature | DSH / NSSI | Suicide Attempt |
|---|---|---|
| Intent | To relieve distress, NOT to die | To end one's life |
| Frequency | Often repetitive | Usually less frequent |
| Lethality | Usually low | Can be high |
| Medical severity | Typically mild-moderate | Can be severe |
| Emotional state before | Extreme tension, anxiety | Hopelessness, despair |
| Emotional state after | Relief, calm | Variable |
Note: the boundary is not always clean - the same person may have mixed or unclear intent, and NSSI is a strong risk factor for future actual suicide attempts. As noted in Rosen's Emergency Medicine, "there are cases where NSSI may have potentially lethal consequences, even if the intent was not suicide, so it is critical to consider both lethality and intent when performing a safety assessment."
Clinical Importance
- DSH is one of the strongest predictors of future suicide - those with a DSH history are 37-46x more likely to die by suicide than the general population
- It is often the first point of contact with the healthcare system for people in severe psychiatric distress
- In BPD, the statistic is approximately 1 completed suicide per 23 attempts
- Repetition is common: ~16% repeat within the first year, ~23% over 4 years
- Treatment focus should be on addressing underlying emotional dysregulation, not simply stopping the behaviour
DBT
Finding Sources
Searching the Web
dialectical behaviour therapy DBT components skills evidence
Finding Sources
Reading File
Reading File
Reading File
Reading File
Here is a thorough breakdown of DBT drawn from the textbooks:
Dialectical Behaviour Therapy (DBT)
Origin and Theoretical Basis
DBT was developed by Marsha Linehan, Ph.D. originally as a treatment for chronically suicidal patients with Borderline Personality Disorder (BPD). The term "dialectical" reflects the core tension in therapy: the simultaneous acceptance of the patient as they are AND the need to change maladaptive behaviour.
The therapy is rooted in the biosocial model of BPD - which holds that BPD arises from a biological predisposition to emotional vulnerability combined with a chronically invalidating environment during development. The result is pervasive emotion dysregulation, which drives virtually all BPD symptoms: self-injury, impulsivity, unstable relationships, identity disturbance, and rage.
DBT draws on:
- Cognitive-behavioural therapy (CBT) - change-focused behavioural principles
- Acceptance-based strategies - radical acceptance, validation
- Eastern philosophy (Zen) - mindfulness, present-moment awareness
- Dialectical reasoning - moving the patient from "either-or" to "both-and" thinking
(Kaplan & Sadock's Comprehensive Textbook of Psychiatry)
The 5 Core Functions of DBT (per Linehan)
- Enhance the patient's repertoire of skillful behaviours - teach what they lack
- Improve motivation to change - reduce reinforcement of maladaptive behaviours
- Ensure generalisation - new skills must transfer from therapy to real life
- Structure the environment - reinforce effective behaviours outside therapy
- Enhance therapist motivation and capability - prevent burnout and maintain treatment fidelity
The 4 Modes of Treatment
| Mode | Description |
|---|---|
| 1. Group Skills Training | Weekly didactic sessions where patients learn the four skill modules from a manual. Unlike traditional group therapy - observations about other group members are discouraged |
| 2. Individual Therapy | Weekly 50-60 min sessions. Therapist and patient review diary cards, examine the past week's events, and identify where skills could have been applied. Follows a strict treatment hierarchy |
| 3. Telephone Consultation | Therapist available 24 hours/day for brief crisis calls (~10 min). Patient is encouraged to call before reaching crisis - not after self-injury. The 24-hour rule applies: no phone coaching for 24 hours after a self-injurious episode (to avoid inadvertently reinforcing self-harm with therapist warmth) |
| 4. Consultation Team | Therapists meet weekly to review each other's cases, provide validation and support, maintain adherence to the DBT model, and prevent burnout |
The 4 Skill Modules
1. Core Mindfulness
- The foundation of all DBT skills
- Cultivates non-judgmental awareness of present-moment experience - thoughts, feelings, and sensations
- Drawn from Zen tradition
- Teaches "wise mind" - the balance between "emotion mind" and "rational mind"
2. Distress Tolerance
- Skills for tolerating emotional crises without making them worse
- Crisis survival strategies: distraction (activities, opposite emotions), self-soothing (using the five senses), "TIPP" (Temperature, Intense exercise, Paced breathing, Progressive relaxation)
- Radical acceptance: fully accepting reality as it is without fighting it
- Designed to break the cycle of using self-harm or other maladaptive behaviours to escape distress
3. Emotion Regulation
- Skills to understand, label, and modify intense emotions
- Includes the opposite-action skill: when an emotion is unjustified or unhelpful, deliberately act opposite to the emotion's action urge (e.g., approach what you fear; engage when depressed and withdrawn)
- Reduces emotional vulnerability by improving sleep, nutrition, exercise, and substance avoidance (the PLEASE skill)
- Aims to reduce the frequency and intensity of painful emotional episodes
4. Interpersonal Effectiveness
- Teaches how to ask for what you need, say no, and manage conflict - while maintaining relationships and self-respect
- Uses structured acronyms:
- DEAR MAN (Describe, Express, Assert, Reinforce, Mindful, Appear confident, Negotiate) - for achieving goals
- GIVE (Gentle, Interested, Validate, Easy manner) - for maintaining relationships
- FAST (Fair, Apologies minimal, Stick to values, Truthful) - for self-respect
- Particularly important because interpersonal stressors are a common trigger for suicidal crises in BPD
Treatment Hierarchy in Individual Therapy
DBT prioritises problems in this strict order during each individual session:
- Life-threatening behaviours (suicidality, self-harm) - always addressed first
- Therapy-interfering behaviours (missing sessions, non-compliance)
- Quality-of-life-interfering behaviours (substance use, job loss, relationship chaos)
- Skill acquisition - building a life worth living
Dialectical Strategies
The therapist uses dialectical reasoning to help the patient move from polarised "all-or-nothing" thinking to a synthesis. Common strategies include:
- Validation - acknowledging that the patient's responses make sense given their history and context
- Irreverence - using unexpected, sometimes humorous responses to shift entrenched patterns
- Devil's advocate - presenting the opposite extreme to provoke a more balanced position
- Entering the paradox - accepting apparent contradictions rather than resolving them artificially
Who is DBT Used For?
Originally developed for BPD with chronic suicidality; now evidence-based for:
- Borderline Personality Disorder (strongest evidence)
- Deliberate self-harm / NSSI
- Chronic suicidality
- Substance use disorders
- Eating disorders (especially binge-eating and bulimia)
- PTSD
- Major Depressive Disorder
- Bipolar Disorder
- Adolescent emotional and behavioural problems
Evidence and Outcomes
From Kaplan & Sadock's Synopsis of Psychiatry:
- Low dropout rate compared to other therapies for BPD
- Significant reduction in parasuicidal (self-harming) behaviours
- Decreased angry affect on self-report
- Improved social adjustment and work performance
- Multiple RCTs have confirmed DBT's superiority over treatment-as-usual for BPD, and in some studies over "therapy by experts" for suicidal and self-harming patients
DBT is considered the gold-standard psychotherapy for BPD and chronic self-harm and is recommended by NICE guidelines for this population.
This is a shared conversation. Sign in to Orris to start your own chat.