11 - Suicide and deliberate self-harm

Summary

Introduction

The aims of this chapter are threefold. First, to give an overview of the multi-faceted context in which the management of those presenting following an episode of self-harm needs to be considered. Second, to consider the link between the spectrum of suicidal behaviours and completed suicide. Finally, to consider assessment and management procedures and review the evidence for effectiveness of current practices.

Throughout this chapter the term ‘deliberate self-harm’ will be used to denote ‘an act of intentional self-poisoning or injury, irrespective of the apparent purpose of the act’. It describes a spectrum of behaviours from impulsive, superficial, self-cutting, which rarely presents to medical attention, through to premeditated and carefully planned suicide attempts which, for some reason, have not resulted in death. Whilst there is controversy concerning this definition (Van Heeringen 2001), it allows for the inclusion of the full range of self-harming behaviours, without drawing arbitrary distinctions based on perceived intent, which is often far from clear.

Suicide, as a term, appears easier to define, namely as ‘a self-destructive behaviour with a fatal outcome’. It is classified within the International Classification of Diseases (ICD) as codes E950–959. However, major differences exist in the process of determining death, both within and between countries (Neeleman et al. 1997) and therefore cross-cultural epidemiological findings need to be considered with caution.

Epidemiology

Suicide

Despite the variations in the categorization of suicide, these can only in part explain the wide variations in suicide rates across countries and over time.