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Attempted suicide v. non-suicidal self-injury: behaviour, syndrome or diagnosis?

  • Aine M. Butler (a1) and Kevin Malone (a2)
Summary

Nomenclature used to describe acts of self-harm without fatal consequences varies considerably. The term ‘non-suicidal self-injury’ (NSSI) offers an opportunity to clarify study in this field, dichotomising the presence or absence of suicidal intent. This may improve consistency in reporting suicide and self-injurious behaviour with implications for management and prognosis.

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Copyright
Corresponding author
Aine M. Butler, St John of God Hospital, Stillorgan, County Dublin, Ireland. Email: aine.butler@sjog.iex
Footnotes
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See pp. 326-328, this issue.

Declaration of interest

None.

Footnotes
References
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1 American Psychiatric Association. Non-suicidal self injury. In American Psychiatric Association DSM-5 Development. APA, 2012 (http://www.dsm5.org).
2 O'Connor, R, Platt, S, Gordon, J. International Handbook of Suicide Prevention. Research, Policy and Practice. Wiley-Blackwell, 2011.
3 Skegg, K. Self-harm. Lancet 2005; 366: 1471–83.
4 Nock, MK, Kessler, RC. Prevalence of and risk factors for suicide attempts versus suicide gestures: analysis of the National Comorbidity Survey. J Abnorm Psychol 2006; 115: 616–23.
5 Wilkinson, P, Goodyer, I. Non-suicidal self-injury. Eur Child Adolesc Psychiatry 2011; 20: 103–8.
6 Plener, PL, Libal, G, Keller, F, Ferget, JM, Muehlenkamp, JJ. An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA. Psychol Med 2009; 39: 1549–58.
7 Jacobson, CM, Muehlenkamp, JJ, Miller, AL, Turner, JB. Psychiatric impairment among adolescents engaging in different types of deliberate self-harm. J Clin Child Adolesc Psychol 2008; 37: 363–75.
8 Wilkinson, P, Kelvin, R, Roberts, C, Dubicka, B, Goodyer, I. Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry 2011; 168: 495501.
9 Brent, D. Nonsuicidal self-injury as a predictor of suicidal behavior in depressed adolescents. Am J Psychiatry 2011; 168: 452–4.
10 Muehlenkamp, JJ, Claes, L, Havertape, L, Plener, PL. International prevalence of adolescent non-suicidal self-injury and deliberate self-harm. Child Adolesc Psychiatry Ment Health 2012; 6: 10.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Attempted suicide v. non-suicidal self-injury: behaviour, syndrome or diagnosis?

  • Aine M. Butler (a1) and Kevin Malone (a2)
Submit a response

eLetters

Specific and effective suicide prevention measures for teens must be thoroughly and promptly explored from various aspects in Japan

Ken Inoue, Doctor
01 July 2013

The paper by Butler and Malone1 in the BJP focused on non-suicidal self-injury (NSSI) in the new category in the DSM-5, and the authors described the newest contents of the item. They also provided informationabout NSSI among young individuals. In Japan, the Japanese Cabinet decided to enhance suicide prevention measures for younger people given their increasing suicide rate and due to the prevalence of suicides among students due to 'bullying' in late August 2012.2 Thus, suicide preventionmeasures that are effective among younger age groups in Japan, and particularly among teens, must be designed promptly.

There were 58,509 suicides in Japan in 2011 and 2012 combined, according to the National Police Agency.3 This number included 1,209 suicides of youths under the age of 19 (2.1%). The causative factors were classified as "family problems", "health problems", "economic and life problems", "work problems", "problems of relations between the sexes", "problems in school", or "others". In 2011 and 2012, the most prevalent causative factor for suicide among youths under the age of 19 was "problems in school" (33.0%), followed by "health problems" (23.7%), and thus determining the detailed aspects of "problems in school" for teens will contribute to effective suicide prevention measures for that age group.

"Problems in school" included "worrying about entrance exams", "worrying about one's academic progress", "poor academic performance", "poor relationships with teachers", "bullying", "discord with schoolmates", and "others". In 2011-12, "poor academic performance" (31.1%) was the most prevalent causative factor, followed by "worrying about one's academic progress" (25.6%). These two factors accounted for the majority of "problems in school". The incidence of "bullying" (which has been taken into account in currently used prevention strategies) and measures and responses to deal with "poor academic performance" and "worrying about one's academic progress" must be explored in conjunction with the results of the current study.

It is necessary to discuss specific and effective suicide prevention measures from various viewpoints.4,5 We therefore propose that understanding the criteria of NSSI in the DSM-5 is important, as noted by Butler and Malone.

1.Butler AM, Malone K. Attempted suicide v. non-suicidal self-injury: behaviour, syndrome or diagnosis?. Br J Psychiatry 2013; 202: 324-5.

2.Nihonkeizaisinbun. http://www.nikkei.com/article/DGXNASFS2800P_Y2A820C1MM0000/Last accessed 24 April 2013

3.National Police Agency. http://www.npa.go.jp/. Last accessed 15 March 2013.

4.Hirayasu Y, Kawanishi C, Yonemoto N, Ishizuka N, Okubo Y, Sakai A,Kishimoto T, Miyaoka H, Otsuka K, Kamijo Y, Matsuoka Y, Aruga T. A randomized controlled multicenter trial of post-suicide attempt case management for the prevention of further attempts in Japan (ACTION-J). BMCPublic Health 2009; 9: 364.

5.Tochigi M, Nishida A, Shimodera S, Oshima N, Inoue K, Okazaki Y, Sasaki T. Irregular bedtime and nocturnal cellular phone usage as risk factors for being involved in bullying: a cross-sectional survey of Japanese adolescents. PLoS One 2012; 7: e45736.

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Conflict of interest: None declared

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Re:Need for further clarity.

Heidi J. Hales, consultant psychiatrist
06 June 2013

Dear editorsI read with interest the editorials by Butler et al and Kapur et al about self harm and suicidal behaviour. An important thrust was the lack of clarity in definition of this behaviour and difficulties in making assumptions about other people's intentions. In completing research aboutsuicide and suicide-related behaviour in young offenders, I found the definitions suggested by O'Carroll and colleagues (1996)to be helpful, specifically that of Suicide-Related Behaviour which they defined as: Potentially self-injurious behaviour that either (a) the person intended at some level to kill him/herself or (b) the person wished to use the appearance of intending to kill him/herself in order to attain some other end. Thus the intention may be to kill oneself or to communicate a need, but the risk of death by either is high. O'Carroll, P.W., Berman, A.L., Maris, R.W., Moscicki, E.K., Tanney, B.L. & Silverman, M.M. (1996) Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life Threatening Behaviour 26: 237-252.

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Conflict of interest: None declared

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Need for further clarity.

William C Wilson, Social Worker
21 May 2013

I have many years experience is assessing and managing suicide risk, including a 16 year period of 'on call', dealing with crisis presentations.

We use language to communicate, and the clearer the terms used, the more effective and efficient is our communication. To imply in language that someone who is engaged in one of the forms of Deliberate Self Harm that this person is suicidal (as in fatal intent)simply clouds the issue. Wherein a major factor in helping the person is to definitively identify that persons needs and wants and to then take action to remedy their situation. It must always be recognized that 'misadventure', in the form of fatality without intent, can not be eliminated, but to then view and manage someonepracticing Deliberate Self Harm as if actually suicidal is misconstruing the facts and runs the risk of ignoring the often complex circumstance that has led the individual to these acts as a means of communication of their perception of abandonment or other distressing theme(s), and/or demonstrates maladaptive coping.

I hope that this discussion leads to a clearer definition and subsequent more productive interventions. As a caveat, I perhaps should have mentioned in the beginning how frustrating I've found people saying one thing, meaning another, and assuming everyone comes with the same terminology. This I have found particularly difficult when faced with deliberate self harmer's, who are presented as suicidal by others. It subverts communication by obscuring the reality of peoples behaviors and the psychopathology that drives them.How can you help someone if you can't see the problem?, and how does communicating a misrepresentation assist the transfer of knowledge?

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Conflict of interest: None declared

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