Deliberate self-harm among adolescents : course, outcome and treatment

Abstract

Background: Self-harm among adolescents is prevalent, and is a risk factor for suicide, which is one of the leading causes of death among youth worldwide. There is a need to better understand the role and impact of self-harm within clinical samples, and the subsequent risks associated with self-harm with and without suicidal intent. Dialectical behavior therapy (DBT) has the strongest empirical support for treatment of self-harm among adolescents, and extended knowledge on important treatment components is critical for the development of brief, efficacious interventions that are easily accessible for adolescents.

Aim: The aims were to study clinical and psychosocial correlates as well as long-term outcome among clinical samples with self-harm and explore experiences of care among young adults who have participated in specialist-level interventions targeting self-harm (i.e. DBT).

Methods: The clinical and psychosocial correlations was studied in a case-control study (N = 25,161) comparing three subgroups of patients; 1) self-harm only, 2) self-harm and suicidality, and 3) neither self-harm nor suicidality (controls). Linear regression and logistic regression were used to calculate associations. Outcomes were studied in three different longitudinal cohort studies: 1) outcomes after self-harm with and without suicidal ideation/behavior (N = 6,120), 2) outcomes for boys or girls with self-harm (N = 110,072), and 3) outcomes after nonsuicidal self-injury (NSSI) or suicide attempt (SA) using NSSI and SA as time-varying covariates (N = 2,219). By using Cox regression, Hazard Ratios with 95% Confidence Intervals were estimated for each outcome. Salient treatment components were studied with a qualitative analysis of 19 semi-structured interviews with former DBT patients.

Results: Self-harm within clinical populations was associated with higher clinical and psychosocial burden and higher risk of adverse outcomes, e.g. alcohol/substance misuse, violent and nonviolent criminality, as compared with patients with no self-harm. Patients with both self-harm and suicidality are the most vulnerable group. The young self-harming patient valued a therapist who showed explicit concern and trust in the patient’s competence to change destructive behaviors, but also meeting and learning from peers.

Conclusion: Help-seeking boys and girls with self-harm need appropriate care and assessment, including prevention and treatment of alcohol and substance use. Self-harm might serve as a risk marker for emotion dysregulation and impulsivity within both sexes. Suicidality in addition to self-harm need to be regularly assessed and signals highly increased risks for future adverse outcomes. Interventions that lower the risks are necessary. Young patients with self-harm, can be strongly motivated, and work hard, to improve their well- being and pursue a life worth living. Teaching and learning from peers might be of particular value and importance among adolescents.