Adolescents are particularly vulnerable to mental health disorders. Depression, anxiety, and behavioural disorders are among the leading causes of illness and disability globally.
Sometimes, mental health disorders involve self-harm and suicide attempts. Some data suggest that self-harm is becoming increasingly common among adolescents, with prevalence rates now falling between 15% and 40%. Suicide is the third leading cause of death among young people aged 15-29.
Non-suicidal self-injury (NSSI) and suicide attempts are distinct phenomena. Some adolescents engage in NSSI without suicide attempts, while others attempt suicide without a history of non-suicidal self-injury. However, NSSI and suicide attempts also often co-occur. Understanding how these behaviours are related is important to help clinicians identify those at risk for different kinds of self-harm, including suicidal behaviours.
What Is Non-Suicidal Self-Injury?
Self-injurious behaviour (SIB) refers to a broad range of behaviours where someone deliberately harms themselves. Non-suicidal self-injury (NSSI) is a type of SIB. Young people who engage in NSSI deliberately harm their bodies but without any intention to end their lives.
Suicide attempts are another form of SIB. Suicide attempts are defined as direct attempts to end one’s own life.
Correlation Between NSSI and Suicide Attempts
Research suggests that NSSI and suicide attempts often co-occur. A 2006 study among adolescents in a psychiatric inpatient program found that 70% of adolescents who had recently engaged in NSSI had a history of at least one suicide attempt. A 2007 study among 540 high school students found that around 30% of those who self-harmed had also attempted suicide.
While many adolescents engage in NSSI without suicide attempts, the number of young people with a history of suicide attempts but not NSSI is very low. Among the 540 high school students, only 1.9% fell into this category.
Why Are Adolescents Who Engage in NSSI at an Increased Risk of Suicide Attempts?
It’s still not clear exactly why adolescents who engage in NSSI are at an elevated risk of suicide. One idea is that through repeated self-injury, young people normalise (or become adjusted to) experiences of fear and pain. This may make it more likely that they will attempt a frightening behaviour such as suicide.
Some experts also link suicide attempts and NSSI with de-sensitisation to pain. Studies show that adolescents who repeatedly self-harm sometimes experience minimal or no pain when they self-harm despite serious damage to their physical bodies. Other research has found that adolescents who have attempted suicide have a higher pain tolerance than those without a history of suicide attempts. It’s possible that repeated NSSI de-sensitises young people to pain, making suicide attempts (often a painful concept) more likely: in one analysis, adolescents who reported no pain during NSSI made almost twice as many suicide attempts.
On the other hand, the elevated risk of suicide attempts among young people who engage in NSSI may also be explained by common risk factors. That is, experiences and predispositions that make a young person more likely to engage in NSSI also make them more likely to make suicide attempts. Some experts conceptualise self-injurious behaviours (such as NSSI) as a continuum, where suicide attempts constitute one of the most severe types of behaviour.
What Are the Risk Factors for NSSI During Adolescence?
Research has uncovered several features and experiences that are more common among adolescents who engage in non-suicidal self-harm than among those who don’t. These include:
- Depressive symptoms
- Hopelessness
- Suicidal ideation
- Low self-esteem
- Body dissatisfaction
- Disordered eating behaviours
There are also several protective factors that make self-harm among young people less likely, such as high self-esteem and support from families and peers.
Among adolescents in an inpatient mental health treatment program who engaged in NSSI, 87.6% experienced a mental health disorder, including externalising, internalising, and substance use disorders. About ⅔ of adolescent females also met the criteria for a personality disorder. These findings emphasise the high prevalence of mental health disorders among young people engaging in any form of self-harm.
What Are the Risk Factors for Suicide Attempts Among Adolescents Who Engage in NSSI?
Young people who engage in NSSI and suicide attempts show higher levels of certain traits and experiences than those who only engage in NSSI. Recognising these traits can help clinicians identify adolescents who are at a particular risk of suicide attempts and provide interventions and support.
A study among 370 high school students found that among adolescents engaging in NSSI, those who also made suicide attempts tended to:
- have lower self-esteem
- experience more suicidal ideation
- have less support from parents
- experience more anhedonia (an inability to find things pleasurable)
- have more negative self-evaluations
Other community-based research has connected NSSI with suicide attempts to more suicidal ideation, as well as:
- fewer reasons for living
- less future-orientated thinking
Young people who engaged in NSSI without suicide attempts were able to identify more reasons to be alive than those who made suicide attempts. Many young people who self-harm maintain a motivation to live despite ongoing self-harm behaviours. This supports the understanding of non-suicidal self-harm as an unhelpful and harmful coping mechanism for emotional distress that is motivated by different thought processes to suicide attempts.
While it may seem obvious, suicidal ideation is also a clear predictor of suicide attempts among adolescents who self-harm. Suicidal ideation among young people engaging in NSSI is often overlooked because NSSI is defined as self-harming behaviours without an intention to attempt suicide. However, screening for suicidal ideation (as well as reasons for living, self-esteem, and other factors) is important in order to identify a higher risk of suicide and prevent suicide attempts among young people.
Young people who engage in NSSI and make suicide attempts also tend to experience more anhedonia (the inability to experience pleasure) and think less about the future. These adolescents may express a lack of motivation for the future and struggle to identify future goals to work towards. Such thought patterns and feelings may signify an elevated risk of suicide attempts.
Conceptualising NSSI and Suicide Attempts as a Continuum
Some researchers conceptualise self-harming behaviours as a continuum. Within this theory, NSSI exists somewhere along this continuum, and suicide attempts are the final endpoint. Although NSSI and suicide attempts have different motivations, they are both conceptualised as types of self-harm.
This theory is supported by the shared risk factors for NSSI with and without suicide attempts, where young people who also make suicide attempts experience certain risk factors more severely. That is, young people who engage in NSSI and suicide attempts experience more suicidal ideation, fewer reasons for living, and possibly more depressive symptoms than those who only engage in NSSI. In turn, those who engage in NSSI report significantly greater suicidal ideation and depressive symptoms – and fewer reasons for living – than those who don’t self-harm.
Preventing Self-Harm and Suicide
There are many different approaches to preventing self-harm and suicide. Some involve changes at a societal level that address social risk factors like isolation, lack of community support, and instability and uncertainty. Other approaches relate to education about mental health, helping both young people and adults to identify the signs of mental illness and know where to seek help.
One important approach that’s especially relevant to this research is identifying those at risk of self-harm and suicide so that individuals can access the support they need. This might involve evaluating the risk of self-harm among young people receiving treatment for other mental health disorders. It may also include identifying traits that are risk factors for suicide attempts among young people who self-harm.
These processes are not perfect, and some young people may self-harm and make suicide attempts without experiencing common risk factors for these behaviours. However, looking out for risk factors can go some way to identifying, intervening, and preventing self-harm and suicide attempts among teenagers and young adults.
Suicide Prevention
If you are feeling suicidal, there are people who would like to help. You could talk to a friend, family member, or someone else you trust about your feelings. You can also call a phone line for confidential support:
- Samaritans – call 116 123
- Papyrus (for people under 35) – call 0800 068 4141
While seeing a doctor can feel stressful, it’s a step towards caring for yourself. Doctors may be able to help you to feel better about parts of your life that feel bad right now.
