Psych · Emergency psychiatry — self-harm and crisis
Self-harm and crisis intervention
Also known as Deliberate self-harm · Non-suicidal self-injury · NSSI · Self-injury · Crisis intervention psychiatry · Psychosocial assessment after self-harm · Safety planning self-harm · Hospital-treated self-harm
Exam-exhaustive fellowship reference on self-harm presentations and crisis response — NSSI vs suicide attempt on the intent continuum; epidemiology and repetition/suicide risk after hospital-treated self-harm; affect-regulation functions; NICE-style medical-then-psychosocial assessment; Stanley-Brown safety planning; brief contact and psychological interventions; disposition; youth vs adult; cultural safety and non-stigmatising language. Distinct from suicide-risk-assessment (focus here is self-harm care pathway). FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Self-harm with clear intent to die, high expected lethality, or disappointment at survival — treat as elevated near-term suicide risk; do not discharge to an empty plan
- Medical toxicity or injury not yet stabilised — medical care first; do not delay antidotes or resuscitation for a mental-health interview
- Escalating NSSI frequency or intensity with emerging suicidal intent or new means access — reformulate risk and escalate care intensity
- Adolescent self-harm with family conflict, bullying, or safeguarding concerns — involve carers/school pathways and do not discharge without a safety net
- Older adult self-harm — higher suicide-to-self-harm ratio; assume serious risk until a full formulation shows otherwise
- Stigmatising dismissal as 'attention-seeking' or reliance on a no-suicide contract — both are exam and clinical failures
Meet the patient
A 19-year-old university student is brought to the ED at 2 a.m. after taking twelve paracetamol tablets during an argument with her boyfriend. She is medically stable, tearful, and tells the nurse she "just wanted him to notice". Two hours later, alone and quieter, she whispers that she does not really want to be here any more.[6][9]
The trap in that sentence is the word "just". The first statement tempts a dismissive label; the second is a different clinical picture entirely. Your job tonight is to resist the shortcut, treat the medical need first, and then read the intent continuum carefully — because the long tail of suicide risk after hospital-treated self-harm runs for years, not hours.[7][8]
References24ShowHide
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- [2]Swannell SV, Martin GE, Page A, et al. Prevalence of nonsuicidal self-injury in nonclinical samples: systematic review, meta-analysis and meta-regression Suicide Life Threat Behav, 2014.PMID 24422986
- [3]Fox KR, Franklin JC, Ribeiro JD, et al. Meta-analysis of risk factors for nonsuicidal self-injury Clin Psychol Rev, 2015.PMID 26416295
- [4]Klonsky ED The functions of deliberate self-injury: a review of the evidence Clin Psychol Rev, 2007.PMID 17014942
- [5]McManus S, Gunnell D, Cooper C, et al. Prevalence of non-suicidal self-harm and service contact in England, 2000-14: repeated cross-sectional surveys of the general population Lancet Psychiatry, 2019.PMID 31175059
- [6]Owens D, Horrocks J, House A Fatal and non-fatal repetition of self-harm. Systematic review Br J Psychiatry, 2002.PMID 12204922
- [7]Hawton K, Bergen H, Cooper J, et al. Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000-2012 J Affect Disord, 2015.PMID 25617686
- [8]Geulayov G, Casey D, Bale L, et al. Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study Lancet Psychiatry, 2019.PMID 31706930
- [9]Hawton K, Bale L, Brand F, et al. Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study Lancet Child Adolesc Health, 2020.PMID 31926769
- [10]Kapur N, Steeg S, Turnbull P, et al. Hospital management of suicidal behaviour and subsequent mortality: a prospective cohort study Lancet Psychiatry, 2015.PMID 26254717
- [11]Kapur N, Murphy E, Cooper J, et al. Psychosocial assessment following self-harm: results from the multi-centre monitoring of self-harm project J Affect Disord, 2008.PMID 17761308
- [12]Steeg S, Emsley R, Carr M, et al. Routine hospital management of self-harm and risk of further self-harm: propensity score analysis using record-based cohort data Psychol Med, 2018.PMID 28637535
- [13]Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department JAMA Psychiatry, 2018.PMID 29998307
- [14]Fleischmann A, Bertolote JM, Wasserman D, et al. Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries Bull World Health Organ, 2008.PMID 18797646
- [15]Carter GL, Clover K, Whyte IM, et al. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning BMJ, 2005.PMID 16183654
- [16]Witt KG, Hetrick SE, Rajaram G, et al. Psychosocial interventions for self-harm in adults Cochrane Database Syst Rev, 2021.PMID 33884617
- [17]Witt KG, Hetrick SE, Rajaram G, et al. Interventions for self-harm in children and adolescents Cochrane Database Syst Rev, 2021.PMID 33677832
- [18]Ougrin D, Tranah T, Stahl D, et al. Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis J Am Acad Child Adolesc Psychiatry, 2015.PMID 25617250
- [19]Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder Arch Gen Psychiatry, 2006.PMID 16818865
- [20]Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial JAMA, 2005.PMID 16077050
- [21]Posner K, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults Am J Psychiatry, 2011.PMID 22193671
- [22]Large MM, Ryan CJ, Carter G, et al. Can we usefully stratify patients according to suicide risk? BMJ, 2017.PMID 29042363
- [23]Muehlenkamp JJ, Ertelt TW, Miller AL, et al. Borderline personality symptoms differentiate non-suicidal and suicidal self-injury in ethnically diverse adolescent outpatients J Child Psychol Psychiatry, 2011.PMID 20735511
- [24]Nock MK, Borges G, Bromet EJ, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts Br J Psychiatry, 2008.PMID 18245022