Understanding Self-Harm: Function, Pattern, and Treatment Implications
This is Part 9 in our series on Past Psychiatric History.
Read Part 8: Suicide Attempt History: Getting It Right Without Losing the Relationship for the previous component.
With suicide risk assessed, we turn to a related but distinct phenomenon: self-harm as coping mechanism. Self-harm often functions as the body’s language for unspoken distress, a physical outlet for overwhelming emotional pain. Unlike suicide attempts, self-harm typically serves to relieve tension, express anguish, or punish oneself rather than to end life.
Understanding self-harm requires careful assessment of intent, function, and pattern. Non-suicidal self-injury (NSSI) reveals critical information about emotion regulation capacity, distress tolerance, and underlying psychopathology. While the intent differs from suicide attempts, self-harm significantly increases future suicide risk and requires targeted therapeutic intervention.
Learning Objectives
After reading this section, you should be able to:
- Distinguish non-suicidal self-injury from suicide attempts based on intent and function
- Identify common self-harm methods and their clinical significance
- Assess the psychological functions self-harm serves for individual patients
- Recognize patterns that increase risk or indicate severity
- Document self-harm history accurately with attention to function and treatment implications
Start With Chart Review
Before interviewing the patient, review available documentation for self-harm history:
Emergency department records – Look for chief complaints involving lacerations, burns, or wounds described as “self-inflicted” or “intentional.” Note wound patterns, locations, and whether suicidal intent was documented.
Prior psychiatric evaluations – Search for terms like “cutting,” “self-injury,” “self-harm,” “superficial wounds,” or “non-suicidal self-injury.” Note whether function was assessed.
Inpatient psychiatric records – Often document self-harm behaviors observed during admission or restrictions placed due to self-harm risk.
School or college counseling records – May contain early documentation of self-harm, particularly in adolescents and young adults.
Medical records from primary care or dermatology – Sometimes document unexplained scars, burns, or wounds that raise concern for self-harm.
Collateral documentation – Family reports, therapist notes, or case manager observations may describe visible injuries or self-harm disclosures.
💡 Clinical Pearl: Even brief mentions of “scratching,” “minor cuts,” or “superficial wounds” in medical records may signal significant emotional dysregulation. The medical severity of injuries doesn’t always correlate with psychological severity. Always verify the context and intent behind any documented injuries.
Interview the Patient
After chart review, explore self-harm history directly with the patient. This requires creating safety for disclosure, as many patients feel shame about self-harm or fear judgment.
Opening Questions
Begin with direct but nonjudgmental screening:
- “Have you ever hurt yourself on purpose – like cutting, burning, or hitting yourself – but not to end your life?”
- “Some people hurt themselves when they’re overwhelmed as a way to cope. Has that been true for you?”
- “Have you ever engaged in self-harm or self-injury?”
Follow-Up Questions
If the patient endorses self-harm, explore systematically:
Methods Used
- “What ways have you hurt yourself?”
- “Have you tried different methods at different times?”
Timing and Frequency
- “When did you first start hurting yourself?”
- “How often does it happen now?”
- “When was the most recent time?”
- “Was there a period when it was more frequent?”
Function and Motivation
- “What does self-harm do for you?”
- “What are you feeling right before you hurt yourself?”
- “How do you feel afterward?”
- “What would happen if you didn’t do it?”
Severity and Medical Care
- “How severe are the injuries typically?”
- “Have you ever needed medical attention – stitches, wound care, burn treatment?”
- “Has self-harm ever been more dangerous than you intended?”
Context and Triggers
- “Are there specific situations or feelings that lead to self-harm?”
- “Does it happen more at certain times or places?”
- “Is anyone else usually aware when it happens?”
💡 Clinical Pearl: How patients describe the function of self-harm guides treatment selection. “I cut to release tension” suggests emotion regulation deficits requiring DBT skills. “I do it to punish myself” points to self-critical cognitions requiring cognitive therapy. “It helps me feel something when I’m numb” may indicate dissociation requiring trauma-focused treatment. Understanding function transforms self-harm from a behavior to be eliminated into a communication about underlying needs.
Distinguishing Self-Harm from Suicide Attempts
The fundamental distinction lies in intent, though this boundary can sometimes blur:
Non-Suicidal Self-Injury (NSSI)
Intent: Relieve emotional pain, regulate affect, express distress – not to die
Function:
- Affect regulation: Release tension, interrupt numbness
- Self-punishment: Express self-hatred or guilt
- Communication: Show others the depth of distress
- Sensation-seeking: Feel real or alive
Lethality: Usually low-lethality methods (superficial cutting, minor burns)
Patient’s Description: “I did it to feel better,” “It helps me cope,” “I needed to release the pressure”
Typical Pattern: Repeated episodes over time, relatively consistent severity
Suicide Attempt
Intent: End one’s life, escape existence
Function: Permanent solution to unbearable suffering
Lethality: Can range from low to very high
Patient’s Description: “I wanted to die,” “I thought it would kill me,” “I hoped I wouldn’t wake up”
Typical Pattern: May be single catastrophic event or escalating attempts
The Blurred Boundary
This distinction is not always clear-cut:
- Some self-harm carries unintended lethal risk (deep cuts near arteries, severe burns)
- Patients may engage in both NSSI and suicide attempts at different times
- Chronic self-harm can transition to suicidal behavior
- Ambivalence exists: “I didn’t want to die, but I didn’t care if I did”
- Impulsive escalation during self-harm episodes can become life-threatening
🚩 Important Note: Never assume that self-described “non-suicidal” self-injury carries no suicide risk. History of NSSI is itself a significant risk factor for future suicide attempts. The presence of self-harm always warrants careful suicide risk assessment, regardless of stated intent.
Common Self-Harm Methods
Document all forms of self-injury, as method diversity correlates with severity:
Cutting – Most common method; usually forearms, thighs, abdomen. Depth varies from superficial scratches to deep lacerations requiring sutures.
Burning – Using cigarettes, lighters, hot objects, or chemicals. Can cause significant scarring and infection risk.
Hitting or Bruising – Punching walls, hitting oneself, head-banging. May cause fractures, concussions, or internal injuries.
Scratching or Picking – Compulsive skin-picking, scratching until bleeding. Can become chronic and disfiguring.
Interfering with Wound Healing – Picking at scabs, reopening cuts. Maintains visible evidence of distress.
Hair-Pulling (Trichotillomania) – May serve self-harm function in some patients, though diagnostically distinct.
Other Methods – Swallowing dangerous objects, self-poisoning with non-lethal intent, excessive risk-taking.
💡 Clinical Pearl: Use of multiple methods is associated with more severe psychopathology and increased suicide attempt risk. A patient who engages in cutting, burning, and hitting represents higher clinical acuity than someone using a single method. Method escalation over time (superficial scratches progressing to deep cuts) suggests worsening emotion dysregulation.
Functions of Self-Harm
Understanding why patients self-harm is essential for treatment planning. Different functions require different interventions:
Affect Regulation
Description: “I do it to release tension,” “It helps calm me down,” “The pain distracts from emotional pain”
Psychological Mechanism: Self-harm provides temporary relief from overwhelming negative emotions through physiological mechanisms (endorphin release, arousal reduction) or psychological distraction.
Treatment Implications: Requires emotion regulation skills (DBT), alternative coping strategies, distress tolerance training.
Managing Numbness or Dissociation
Description: “I need to feel something,” “It makes me feel real,” “Cutting brings me back”
Psychological Mechanism: Self-harm generates sensation during dissociative states, providing grounding through physical pain.
Treatment Implications: Trauma-focused therapy, grounding techniques, treatment of dissociative symptoms.
Self-Punishment
Description: “I deserve it,” “I need to punish myself,” “I’m so bad I should suffer”
Psychological Mechanism: Physical pain expresses self-hatred, guilt, or shame. May provide sense of justice or atonement.
Treatment Implications: Cognitive therapy targeting self-critical beliefs, compassion-focused therapy, trauma processing if self-blame relates to abuse.
Communication and Validation
Description: “It shows people how much I’m hurting,” “Words aren’t enough,” “People take me seriously when they see it”
Psychological Mechanism: Visible wounds communicate internal distress. May elicit care, concern, or validation from others.
Treatment Implications: Communication skills training, assertiveness, identifying and expressing needs verbally, examining relationship patterns.
Sensation-Seeking or Experimentation
Description: “I was curious what it would feel like,” “I like watching myself bleed,” “It’s fascinating”
Psychological Mechanism: Novelty-seeking, fascination with injury, or reduced pain sensitivity.
Treatment Implications: Behavioral interventions, redirection to safer sensation-seeking activities, assessment for conduct disorder or psychopathy traits in severe cases.
Anti-Suicide Function
Description: “When I cut, I don’t feel like I need to kill myself,” “It prevents me from doing something worse”
Psychological Mechanism: Self-harm serves as alternative to suicide, providing relief that prevents escalation to lethal behavior.
Treatment Implications: Complex clinical picture requiring careful risk assessment. Treatment must provide alternative coping without removing the “safety valve” before other skills are in place.
Patterns That Increase Concern
Certain patterns in self-harm history warrant heightened clinical attention:
Multiple Methods – Associated with more severe psychopathology and higher suicide risk
Increasing Frequency – Suggests worsening emotion dysregulation or inadequate coping alternatives
Escalating Severity – Progression from superficial to deeper injuries indicates treatment urgency
Transition to Higher-Lethality Methods – Moving toward methods closer to suicide attempt methods (cutting near major vessels, more dangerous burns)
Impaired Judgment During Episodes – Self-harm while intoxicated or dissociated increases risk of unintended serious injury
Lack of Pain During Self-Harm – Suggests severe dissociation or emotional numbing
Self-Harm in Response to Specific Triggers – Identifies high-risk situations requiring targeted safety planning
Combination of NSSI and Suicide Attempts – Particularly concerning pattern indicating both chronic emotion dysregulation and acute suicide risk
Beyond these risk patterns, several contextual variables further shape assessment and treatment.
Special Considerations
Self-Harm in Adolescents
Self-harm often begins in adolescence, with prevalence peaking in mid-to-late teens:
- May be influenced by peer modeling or social contagion
- Often begins experimentally but can become entrenched coping pattern
- Family response (support vs. punishment) shapes help-seeking and disclosure
- Early intervention can prevent chronic self-harm patterns
Self-Harm in Context of Personality Disorders
Self-harm is particularly associated with borderline personality disorder but occurs across diagnoses:
- In BPD: Often serves multiple functions, linked to identity disturbance and relationship crises
- Pattern may be chronic and treatment-resistant without specialized intervention (DBT, MBT)
- Requires comprehensive treatment approach, not just symptom management
Self-Harm and Trauma History
Strong association between trauma exposure and self-harm:
- May serve to manage trauma-related dissociation, flashbacks, or emotional dysregulation
- Self-punishment function often linked to trauma-related shame or self-blame
- Trauma processing may reduce self-harm urges by addressing root cause
Digital and Social Media Influences
Contemporary considerations in self-harm assessment:
- Online communities may normalize self-harm or provide detailed methods
- Social media posting of injuries may serve communication or validation functions
- “Challenges” or social contagion effects in peer groups
- Can both increase risk (modeling, normalization) and provide support (recovery communities)
What to Document
Your documentation should capture methods, frequency, function, and clinical implications of self-harm.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Method, frequency, last occurrence | “Reports history of superficial forearm cutting; last episode 3 months ago. Currently denies self-harm urges.” | Routine follow-up; remote history; patient stable in treatment; no current concerns |
| Standard | Minimal + Function, severity, medical care required, current status | “History of self-harm by cutting (forearms and thighs) beginning age 15, now age 22. Reports cutting 2 to 3 times weekly at peak (ages 17 to 19), primarily for affect regulation and tension release. Required emergency department suturing on two occasions for deeper lacerations. Engaged in DBT 2 years ago with significant reduction in frequency. Last episode 3 months ago during relationship conflict. Has safety plan and alternative coping skills. No current self-harm urges. Scars visible on bilateral forearms.” | Initial evaluations; active or recent self-harm; need to guide treatment planning; moderate clinical complexity |
| Detailed | Standard + Detailed function analysis, pattern recognition, triggers, relationship to other symptoms, treatment response | “Patient has chronic self-harm history beginning age 14 (now age 26) in context of childhood sexual abuse. Primary method is cutting (forearms, abdomen, thighs), with occasional burning using cigarettes. Reports multiple functions: (1) affect regulation during overwhelming emotions, particularly shame and anger; (2) managing dissociation and ‘feeling real’; (3) self-punishment related to trauma-related guilt. At peak severity (ages 16 to 20), cut daily, requiring multiple ER visits for sutures. History includes one serious episode at age 19 cutting femoral area requiring surgical repair – patient reports was self-harm that ‘went too far,’ not suicide attempt, though acknowledges ambivalence about survival at that time. Significant improvement following 18 months of trauma-focused therapy and DBT. Current frequency approximately once monthly, typically triggered by interpersonal conflict or trauma anniversary reactions. Severity has decreased – now superficial scratches rather than cuts requiring medical care. Patient demonstrates good insight into triggers and functions, uses DBT skills (ice, exercise, calling friend) with partial success. Reports self-harm urges remain strong during dissociative states. Extensive scarring present, which patient reports triggers shame and limits clothing choices. “ | Complex presentations; chronic self-harm; multiple functions; treatment planning for high-risk patients; consultation or referral documentation; forensic evaluations; teaching cases |
Why This Information Matters
Self-harm history provides essential information that shapes diagnosis, risk assessment, and treatment planning in ways distinct from other psychiatric history components.
Risk Stratification: While self-harm is typically non-suicidal in intent, it significantly increases future suicide risk. Patients with NSSI history are 5 to 10 times more likely to attempt suicide than those without such history. Understanding self-harm patterns helps identify patients at elevated long-term suicide risk even when current suicidal ideation is absent. Additionally, some self-harm episodes carry unintended lethality – deep cuts near major vessels, severe burns, or self-harm during dissociation may result in death despite non-suicidal intent. Comprehensive risk assessment must account for both the direct risk of self-harm escalation and the statistical elevation in suicide attempt risk.
Diagnostic Clarification: Self-harm patterns inform diagnostic formulation. Chronic self-harm beginning in adolescence with emotion regulation function strongly suggests borderline personality disorder, particularly when combined with relationship instability and identity disturbance. Self-harm linked to dissociation and trauma triggers points toward PTSD or complex trauma presentations. Self-harm occurring exclusively during mood episodes may indicate bipolar disorder. The pattern, function, and context of self-harm provide diagnostic clues that supplement other clinical data.
Understanding Emotion Regulation: The presence and pattern of self-harm reveal critical information about distress tolerance and emotion regulation capacity. A patient who self-harms multiple times daily demonstrates severe emotion dysregulation requiring intensive intervention. One who self-harms only during specific triggers has more targeted skill deficits. The function self-harm serves – affect regulation, managing dissociation, self-punishment, communication – directly guides treatment selection. DBT targets affect regulation and distress tolerance. Trauma therapy addresses dissociation and self-blame. Communication skills training helps those using self-harm to express distress.
Treatment Planning: Self-harm history determines appropriate interventions. Patients with chronic self-harm typically require specialized treatments like DBT, which directly targets self-harm through skills training, behavior chain analysis, and crisis management. Standard supportive therapy often fails with chronic self-harm, while evidence-based interventions show strong efficacy. Understanding what has helped reduce self-harm previously (medications, therapy modalities, environmental changes) guides current treatment recommendations. If self-harm persists despite multiple interventions, this suggests need for intensive treatment like residential DBT or day treatment programs.
Safety Planning: Knowing self-harm methods, triggers, and patterns allows concrete safety planning. A patient who cuts when alone at night needs specific plans for evening hours. One who self-harms in the bathroom may benefit from supervised bathroom use during high-risk periods in inpatient settings. Understanding preferred methods allows means restriction – removing razors, locking up lighters, limiting access to medications. Identifying warning signs (specific emotions, thoughts, situations) enables earlier intervention before self-harm occurs.
Monitoring Treatment Progress: Self-harm frequency and severity serve as measurable treatment outcomes. Reduction from daily to weekly self-harm indicates treatment progress. Transition from deep cuts requiring medical care to superficial scratches shows improved control. Documentation of patterns over time allows objective assessment of whether treatment is working. Persistent high-frequency self-harm despite treatment suggests need for intervention adjustment, medication optimization, or higher level of care.
Understanding self-harm transforms it from a behavior to be eliminated into a communication about suffering, a marker of emotion dysregulation, and a guide for therapeutic intervention. Self-harm assessment reveals not just what patients do, but why they do it – and that understanding becomes the foundation for effective treatment.
Next in this series: Part 10 – Trauma History: Creating Safety for Disclosure
Previous post: Part 8 – Suicide Attempt History: Getting It Right Without Losing the Relationship
