Evidence-Based Reviews

Adolescents who self-harm: How to protect them from themselves

Current Psychiatry. 2010 August;9(8):15-A

References

1. O’Carroll PW, Berman AL, Maris RW, et al. Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav. 1996;26:237-252.

2. Nock MK, Joiner TE, Jr, Gordon KH, et al. Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts. Psychiatry Res. 2006;144(1):65-72.

3. Centers for Disease Control and Prevention. Injury prevention and control: data and statistics (WISQARS). Available at: http://www.cdc.gov/injury/wisqars. Accessed June 22, 2010.

4. National Center for Health Statistics. Health, United States, 2006. Available at: http://www.cdc.gov/nchs/data/hus/hus06.pdf#062. Accessed May 28, 2010.

5. Jacobson CM, Gould M. The epidemiology and phenomenology of non-suicidal self-injurious behavior among adolescents: a critical review of the literature. Arch Suicide Res. 2007;11(2):129-147.

6. Muehlenkamp JJ, Gutierrez PM. An investigation of differences between self-injurious behavior and suicide attempts in a sample of adolescents. Suicide Life Threat Behav. 2004;34:12-23.

7. Nixon MK, Cloutier PF, Aggarwal S. Affect regulation and addictive aspects of repetitive self-injury in hospitalized adolescents. J Am Acad Child Adolesc Psychiatry. 2002;41:1333-1341.

8. Whitlock J, Knox KL. The relationship between self-injurious behavior and suicide in a young adult population. Arch Pediatr Adolesc Med. 2007;161:634-640.

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CASE CONTINUED: Inpatient treatment

After the interview Josh says he still feels that “there is no point in living” and he cannot develop an adequate safety plan with his family. He is hospitalized to maintain safety, improve his coping skills and communication with his family, and mobilize safety plans, social supports, and follow-up care.

Maintaining safety

Psychosocial treatments for suicidal behaviors and NSSI are similar because with both, the priority is to help the patient maintain safety. This may include:

developing a collaborative safety plan with family
increasing monitoring
removing access to firearms or other lethal means
helping the adolescent to develop alternate, safer coping methods.

Clinical Point

Many clinicians rely on no-harm contracts or agreements; however, there is no evidence that they are effective

Many clinicians rely on no-harm contracts or agreements; however, there is no evidence that they are effective.²⁰ The American Psychiatric Association recommends against using no-harm contracts with patients who are new, in an emergency setting, using substances, agitated, psychotic, or impulsive.²¹ Instead, clinicians, adolescents, and families can discuss specific steps the patient can take to remain safe. This collaborative plan should identify situations likely to trigger self-harming impulses; adaptive ways the teenager can cope, such as taking a nap or jogging; methods for communicating distress to family members and other helpers; and places to go for help, such as an emergency room. These safety plans should draw on the patient’s internal and external resources.

CASE CONTINUED: Strengthening relationships

While in the hospital, Josh finds it helpful to use a 0-to-10 scale to measure his distress and let his family know the intensity of his feelings. He identifies situations when he felt like hurting himself, such as being humiliated in math class. Josh learns about cognitive distortions—such as “they don’t care” and “there is no point in living”—and discusses methods for managing his feelings if he encounters further disappointments. His parents become more attentive when Josh explains his feelings, which allows the family to develop a collaborative safety plan. Josh decides to strengthen friendships he had been neglecting and agrees to attend a substance abuse treatment program.

Psychosocial treatment

In addition to maintaining safety, treatment goals for self-harming adolescents include:

managing underlying psychiatric disorders
identifying triggers for self-injurious acts
improving family relationships
developing better communication and coping skills.

Improving affective language skills, acquiring frustration tolerance, and learning alternatives to self-injury are key to strengthening coping abilities. Address problem-solving skills because self-harming adolescents often lack these abilities.²²

Treatment of self-harming adolescents often consists of cognitive-behavioral therapy (CBT)²³ or dialectical behavior therapy (DBT).²⁴ CBT involves examining cognitive distortions or otherwise unhealthy beliefs about oneself, others, and life in general, focusing specifically on thoughts the patient has immediately before engaging in self-harm. DBT also integrates emotion regulation training and mindfulness. A review of 28 studies found these therapies effectively reduced self-harm behaviors in adults.²⁵ However, few studies have examined these therapies’ efficacy in self-harming adolescents.

Pharmacotherapy

Psychopharmacology should focus on treating underlying psychiatric disorders. No medications are specifically effective for treating suicidal thoughts, suicidal behaviors, or NSSI. Some evidence suggests that antidepressants may trigger suicidal thoughts in a small proportion of youth,²⁶ but the benefits of antidepressants outweigh the risk of suicidal thoughts.²⁷ When prescribing antidepressants, inform patients and their parents of possible adverse reactions and monitor the patient regularly.²⁸

Clinical Point

No medications are specifically effective for treating suicidal thoughts, suicidal behaviors, or nonsuicidal self-injury

Take precautions when prescribing medication for self-harming adolescents. For example, benzodiazepines may cause disinhibition, and larger quantities of medication could be lethal in an overdose. If possible, arrange for parents or guardians to monitor medication use.

What to document

Good documentation is especially helpful when an adolescent requires involuntary commitment or is discharged home. Involuntary commitment is based on legal interpretation of 3 circumstances—danger to self, danger to others, or gravely disabled—in which safety concerns may override an individual’s civil rights. If involuntary commitment is needed, a physician must clarify how the youth meets ≥1 of these criteria. If the adolescent is discharged, document that the patient is not an imminent danger to self or others and why you made this determination. Also note that follow-up services and a safety plan are in place, a parent will monitor safety issues and remove firearms and other lethal means from the home, and acute conflicts have been resolved. Other details, such as using the patient’s words to describe reasons for living, can be helpful.

Related Resources

National Alliance for the Mentally Ill. National Helpline. 800-950-6264.
American Foundation for Suicide Prevention. www.afsp.org.
American Association of Suicidology. www.suicidology.org.
National Suicide Prevention Lifeline. 800-273-TALK (8255).