What is the recommended treatment for a patient with recurrent Self-Injurious (SI) behaviors?

Management of Recurrent Self-Injurious Behaviors

For patients with recurrent self-injurious behaviors, a comprehensive treatment approach should include structured psychosocial interventions such as Dialectical Behavior Therapy (DBT) or Mentalization-Based Therapy (MBT), with MBT showing the strongest evidence for reducing repetition of self-harm (high-certainty evidence).

Initial Assessment

When evaluating a patient with recurrent self-injurious behaviors, focus on:

• Systematic assessment of thoughts or plans of self-harm in the last month and acts of self-harm in the last year 1
• Evaluation of impulsivity, covering both behavioral and cognitive aspects 2, 1
• Assessment of underlying psychiatric conditions, particularly depression, mania/hypomania, mixed states, substance abuse, and personality disorders 2
• Collateral information from caregivers or other individuals who may have knowledge about the patient's state of mind 2
• Evaluation for risk factors including previous attempts, methods other than ingestion or superficial cutting, and steps taken to avoid detection 2

Risk Stratification

Risk assessment should consider:

• Method of self-harm (minor self-cutting carries highest repetition risk with adjusted hazard ratio of 1.38) 3
• Timing of most recent self-harm episode (risk is highest when behavioral impulsivity assessment occurs within a month of attempt) 2
• Presence of continued desire to die, agitation, severe hopelessness, inability to engage in safety planning, inadequate support system, or high-lethality previous attempts 2
• Comorbid substance abuse and personality disorders, particularly borderline personality disorder 2

Evidence-Based Interventions

First-Line Treatments

1. Mentalization-Based Therapy (MBT)

   • Highest quality evidence for reducing repetition of self-harm (OR 0.35,95% CI 0.17 to 0.73) 4
   • High-certainty evidence from clinical trials 4

2. Dialectical Behavior Therapy (DBT)

   • May reduce frequency of self-harm episodes 4
   • Particularly effective for patients with borderline personality traits 5

3. Group-Based Emotion-Regulation Psychotherapy

   • Moderate-certainty evidence for reducing repetition of self-harm (OR 0.34,95% CI 0.13 to 0.88) 4

4. Cognitive Behavioral Therapy (CBT)

   • May reduce repetition of self-harm compared to treatment as usual (OR 0.35,95% CI 0.12 to 1.02) 4
   • More effective at longer follow-up time points (6-12 months) than immediately post-intervention 4

Additional Management Strategies

• Establish regular contact (telephone, home visits, letters) for persons with acts of self-harm in the last year 1
• Implement structured problem-solving approaches 1
• Restrict access to means for self-harm as long as the individual has thoughts, plans, or acts of self-harm 1
• Facilitate social support from available informal and formal community resources 1

Hospitalization Considerations

• Hospitalization in non-specialized services is not routinely recommended solely to prevent self-harm acts 1
• Consider hospitalization for patients who continue to endorse a desire to die, remain agitated or severely hopeless, cannot engage in safety planning, do not have an adequate support system, or had a high-lethality suicide attempt 2
• When specialized services are unavailable, mobilize family, friends, and other available resources for close monitoring 1

Pitfalls and Caveats

• Routine laboratory testing is generally low yield and unlikely to affect management of psychiatric patients without specific clinical indications 2
• Routine brain CT scans have unclear utility and raise concerns about radiation exposure in pediatric patients 2
• Hospitalization alone does not completely prevent suicide; it remains one of the most commonly reported sentinel events in inpatient settings 2
• Standard antidepressant treatments do not provide robust and rapid relief of suicidal ideation 2
• Treatment approaches should distinguish between non-suicidal self-injury and self-harm with suicidal intent, as they may require different management strategies 5

Follow-up Care

• Regular reassessment of self-harm thoughts, plans, and behaviors
• Ongoing psychotherapy with evidence-based approaches
• Monitoring for comorbid psychiatric conditions
• Evaluation of treatment response and adjustment as needed

By implementing these evidence-based interventions with careful attention to risk assessment, clinicians can effectively manage patients with recurrent self-injurious behaviors and reduce the risk of future self-harm and suicide.