Box 1

Five vignettes to illustrate the diversity of self-harm that falls within the remit of the guideline

  1. A 55-year-old bank manager, married for 30 years and a mother of three children. She has had no recent major adverse life events. At age 30 she suffered a severe depressive illness that responded to ECT. She had been well and on no treatment for 23 years until she became depressed again ‘out of the blue’. She became highly agitated and developed the depressive delusion that she was evil and would be responsible for the death of her children. To prevent this she drove to a secluded spot and took 100 tablets of her antidepressant.
  2. A 19-year-old student who has no previous history of mental health problems or of self-harm. Towards the end of a party the young man, who had drunk 8 cans of lager, had an argument with his partner, went into the bathroom and swallowed a handful of aspirin tablets. He almost immediately regretted his action and told a friend who phoned for an ambulance which took him to the local emergency department.
  3. A 22-year-old unemployed man who was raised in a series of children’s homes. He was subjected to repeated abuse as a child and has a history of substance misuse. He has cut his arms since the age of 14 at an average frequency of about once every three weeks. This gives him relief from intense feelings of emptiness and despair. He presents to an emergency department for the third time in a month with superficial cuts to his forearm. He does not describe persisting low mood.
  4. An 8-year-old boy, who was conceived when his mother was raped, was brought up by his mother and a stepfather whom the mother quickly married to avoid the shame of an illegitimate child. The boy was nevertheless called ‘the bastard’ by the stepfather, who also repeatedly sexually abused the boy from when he was about 4 years old. The mother was subject to frequent episodes of domestic violence at the hands of the pathologically jealous stepfather who attacked her for having a child by another man. The mother became depressed and began drinking heavily to ‘escape’ the beatings. When very drunk, the mother told the boy that her life was a misery and it was all because he had been born. In desperation the boy drank a bottle of bleach believing this would kill him and save his mother. He survived and was diagnosed as being depressed.
  5. A woman in her thirties who was sexually abused by her father from the age of 2 until the age of 16. She has taken an overdose on two occasions with suicidal intent, and received life-saving hospital treatment. She also self-harms by cutting her arms and body as a relief from the experience of excruciating emotional pain, and as an alternative to attempted suicide. She describes herself as compelled to do this, and regards it as an act done to herself by herself which inflicts physical wounds with the intention paradoxically of helping herself rather than killing herself.

From: 2, Introduction to self-harm

Cover of Self-Harm
Self-Harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care.
NICE Clinical Guidelines, No. 16.
National Collaborating Centre for Mental Health (UK).
Leicester (UK): British Psychological Society; 2004.
Copyright © 2004, The British Psychological Society & The Royal College of Psychiatrists.

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