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Josh, age 16, gets poor grades in school and occasionally smokes marijuana and abuses inhalants. After his girlfriend breaks up with him, he cuts his wrist with a hunting knife. While bleeding profusely, Josh calls his mother at work, who calls 911. The cut is deep and requires sutures. Josh says he did not try to kill himself; he only wanted to carve his girlfriend’s initials into his wrist to show his love for her.
When treating teenagers with self-harming thoughts and behavior, it may be difficult to distinguish suicide attempts from self-injury without intent to die. Understanding adolescent self-harm, suicide risk assessment, and treatment options guides clinicians to appropriate interventions. Recognizing the need for aggressive treatment—including psychiatric hospitalization—is essential to keeping self-harming teenagers safe.
Suicidal vs nonsuicidal self-harm
Suicidal behavior involves intent to end one’s life and includes ideation (thoughts) and actions (non fatal or fatal attempts).1 Nonsuicidal self-injury (NSSI) involves socially unacceptable, self-inflicted harm to one’s body without intent to die.2
Suicide is the third leading cause of death among youths age 12 to 19, claiming almost 2,000 lives each year.3 Nearly 1 in 5 (17%) U.S. high school students has suicidal thoughts each year, and almost 1 in 10 (8%) attempts suicide.4
Studies report a 13% to 23% lifetime prevalence of NSSI.5 These behaviors often begin between age 13 to 15.6 Cutting and hitting are the most common forms of NSSI; other methods include burning, scratching, and interfering with wound healing. Most teens who harm themselves without suicidal intent report that they feel little or no pain during the act.5 Unlike suicide attempts, NSSI can be viewed as a means to stay alive. Many adolescents injure themselves to cope with overwhelming feelings that can produce suicidal thoughts. Self-injury may distract the adolescent from painful emotions, reduce tensions, or penetrate numbness.7
Teenagers who hurt themselves but do not intend to die are at high risk for suicide and suicide attempts. Adolescents who engage in NSSI are more likely to experience suicidal behaviors, and vice versa.8 In a large study, 70% of adolescents who engaged in NSSI had made at least 1 suicide attempt and 55% made multiple suicide attempts.2 Current suicidal ideation is a risk factor for suicide, and a past suicide attempt is the strongest predictor of future suicidal behavior.9
Risk factors for suicidal behavior and NSSI overlap (Table 1)2,5,6,10,11 and include:
- depression
- substance use
- anxiety
- impulsive aggression
- history of childhood trauma.
Many teens who engage in NSSI report depression.2 A history of psychiatric illness—especially depression—increases the likelihood of adolescent suicide.8 A study comparing adolescents who engaged in NSSI with those who attempted suicide found that both groups reported similar levels of suicidal ideation and depressive symptoms.6 However, adolescents with a history of NSSI and attempted suicide reported higher levels of suicidal ideation and fewer reasons for living than those who attempted suicide but have no history of NSSI.12
Factors that protect against suicidal behavior include:
- a good parent-child relationship
- strong cultural or religious values
- an intact family
- a sense of connection with peer group and community.13
No studies have determined protective factors for NSSI.
Table 1
Characteristics of teens who harm themselves
| Factor | Comments |
|---|---|
| Older age | Both suicide attempts and NSSI are more common in mid-adolescence (age 13 to 15) |
| Sex | Males complete suicide more often (4:1) but more females make attempts. Sex differences have not been consistently identified for NSSI |
| Psychiatric illness | Diagnoses associated with adolescent suicide include major depression, substance abuse, and conduct disorder |
| Psychosocial and situational risks (usually combined with psychiatric illness) | Recent loss or rejection, living alone (eg, running away or homeless), poor social supports, family conflicts, family suicidal behavior, poor communication with parents, availability of firearms, exposure to suicide in the community or media, academic difficulties, legal problems, gender identity conflicts, history of maltreatment, being bullied, and risky behaviors |
| NSSI: nonsuicidal self-injury | |
| Source: References 2,5,6,10,11 | |
CASE CONTINUED: ‘No point in living’
As Josh becomes less guarded, he says that he sees “no point in living” without his girlfriend. He thought the only way to feel better was to “get high,” but this left him feeling even more despondent and anxious. He wrote a suicide note, but after cutting himself he was unsure he wanted to die. Josh says that when he feels depressed he can’t talk to his parents because “they wouldn’t understand and don’t care.”
Assessing self-harming adolescents
Distinguishing between suicidal behaviors and NSSI can be challenging (Table 2). Identifying risk factors for adolescent suicidal behavior must be coupled with a thorough psychiatric evaluation. If possible, interview the adolescent alone and obtain collateral information from parents, family members, teachers, caseworkers, probation officers, and others as needed. Also examine family interactions because conflicts and communication problems could undermine the teenager’s safety.