Comprehensive Assessment of Self-Harm Cutting Risk
All individuals over 10 years of age with mental health conditions, chronic pain, or acute emotional distress should be systematically assessed for thoughts or plans of self-harm in the last month and acts of self-harm in the last year at initial assessment and periodically thereafter. 1
Key Components of Self-Harm Risk Assessment
1. Direct Questioning About Self-Harm
- Ask explicitly about:
- Thoughts or plans of self-harm in the past month
- Acts of self-harm in the past year
- Frequency and severity of cutting behaviors
- Location of cuts (concealed vs. visible) - concealed cuts are associated with higher risk of repetition 2
- Methods used (severity of cutting, multiple methods)
2. Assess Specific Risk Factors
- Previous self-harm history - one of the strongest predictors of future self-harm 3
- Mental health conditions, particularly:
- Depression
- Anxiety disorders
- Substance use disorders
- Eating disorders (particularly bulimia symptoms, which are significant predictors of near-fatal self-harm) 4
- Impulsivity assessment - both behavioral and cognitive aspects 1
- Recent traumatic events or interpersonal conflicts
- Social support availability
- Access to means for self-harm (e.g., sharp objects)
3. Evaluate Characteristics of Self-Cutting
- Method specifics - minor vs. severe cutting (severity increases risk) 3
- Location of cuts - concealed cuts are associated with:
- Previous self-harm
- Current psychiatric treatment
- Premeditation
- Greater risk of repetition 2
- Frequency - increased frequency indicates higher risk
4. Assess Psychological State
- Suicidal intent - distinguish between non-suicidal self-injury and suicidal behavior
- Emotional distress levels
- Coping mechanisms
- Problem-solving abilities
- Dissociative symptoms
Comprehensive Assessment Tools
- Structured psychosocial assessment - recommended for all individuals presenting with self-harm 1
- Validated screening tools when appropriate:
- Bulimia Investigatory Test, Edinburgh (BITE) - particularly useful for predicting near-fatal self-harm in females who cut 4
- Alcohol Use Disorders Identification Test (AUDIT) - to assess alcohol misuse
- Impulsivity measures (e.g., Barratt Impulsiveness Scale)
Risk Management Following Assessment
- Restrict access to means for self-harm as long as the individual has thoughts, plans, or acts of self-harm 1
- Establish regular contact (telephone, home visits, letters) for persons with acts of self-harm in the last year 1
- Implement structured problem-solving approaches for persons with acts of self-harm in the last year 1
- Facilitate social support from available informal and formal community resources 1
- Consider appropriate psychosocial interventions based on risk level:
- Cognitive Behavioral Therapy (CBT)
- Dialectical Behavior Therapy (DBT)
- Mentalization-Based Therapy (MBT)
- Group-based emotion regulation therapy 5
Important Considerations
- Hospitalization in non-specialized services is not routinely recommended solely to prevent self-harm acts 1
- If imminent risk exists, urgent referral to mental health services should be considered
- When specialized services are unavailable, mobilize family, friends, and other available resources for close monitoring 1
- All young people presenting to hospital following self-harm should receive a psychosocial assessment 2
By systematically addressing these components in the assessment of self-harm cutting risk, clinicians can better identify individuals at higher risk and implement appropriate interventions to reduce morbidity and mortality.