ITMHD - suicide & self-harm

definitions and conceptual challenges.

Concept	Definition	Exam-relevant Implication
Suicide	The act of deliberately killing oneself (WHO, 2014).	Used internationally but varies by culture & classification system.
Self-harm	Any behaviour where a person deliberately injures themselves, regardless of intent to die.	UK terminology; includes both suicidal and non-suicidal acts.
Non-suicidal self-injury (NSSI)	Intentional self-injury without intent to die (e.g. cutting, burning).	Preferred term in U.S.; proposed DSM-5 disorder (Zetterqvist, 2015).
Problem in field	No universal classification → difficult to measure risk, compare studies, or design interventions.	Expect MCQ on “Why suicide research is inconsistent” → answer: definitional variability.

• Key MCQ note: DSM-5 lists NSSI Disorder under “conditions for further study.”

classification systems.

Source	Inclusion Criteria	Age Cut-offs
WHO (2014)	“Act of deliberately killing oneself.”	Not specified.
ONS (UK)	(1) All deaths from intentional self-harm (≥10 yrs).(2) Deaths of undetermined intent (≥15 yrs).	≥10 / ≥15 years.

• exam hook: ONS includes undetermined intent to ensure under-reporting is minimised.

differences in terminology.

Region	Preferred Term	Coverage
UK/Europe	Self-harm	All deliberate self-injury (suicidal or not).
U.S.	Non-suicidal self-injury (NSSI)	Only acts without suicidal intent.

• debate: Kapur et al. (2013) question whether separating NSSI and suicidal behaviour is meaningful — overlap in motives and risk pathways.

motivations for self-harm (McManus et al., 2019; 987 pupils study).

Motivation Type	Example Motives	% Reporting
Intrapersonal (internal regulation)	Relief from distress (62.5%), wish to die (37.5%), self-punishment (34.1%).	79.5 % reported ≥1 intrapersonal motive.
Interpersonal (social influence)	Test if someone cares (20.5%), frighten someone (14.8%), get attention (12.5%).	40.9 % reported ≥1 interpersonal motive.

• exam inference: majority = cry of pain, not cry for help.

key takeaways — self-harm meaning.

Concept	Summary
Complexity	Multiple motives within/between people; not a single behaviour type.
Dynamic intent	Reasons for self-harm can shift over time/episodes.
Misconception correction	It is not primarily manipulative; often emotion-regulation.
Clinical implication	Staff assumptions affect engagement and treatment outcomes.

• phrase to recall: “cry of pain, not cry for help.”

epidemiology — the scale of the problem.

Feature	Notes
Under-reporting	Due to stigma and ambiguous classification.
Gender pattern	Females → higher self-harm rates; Males → higher suicide completion.
Age pattern	Adolescence = highest onset and recurrence period.
Scotland/UK trends	Consistent with global data: increasing adolescent self-harm, underestimation in official stats.

risk factors (Hawton, Saunders & O’Connor, 2012 — The Lancet).

Category	Specific Factors	Exam Markers
Sociodemographic / Educational	Female (self-harm), male (suicide), low SES, LGBTQ+, poor academic attainment.	“Gender pattern reversal” MCQ favourite.
Family / Adversity	Parental separation/death, abuse (physical/sexual), parental mental disorder, family suicide history, bullying, interpersonal conflict.	“Adverse childhood experiences → ↑ risk.”
Psychiatric / Psychological	Depression, anxiety, ADHD, substance misuse, impulsivity, low self-esteem, poor problem-solving, perfectionism, hopelessness.	Hopelessness = strongest psychological risk predictor.

suicide & self-harm — the interplay.

Influence Type	Examples	Mechanism
Biological/Genetic	Low serotonin, impulsivity traits.	↓ inhibition, ↑ mood dysregulation.
Psychiatric	Depression, anxiety, psychosis.	Psychological distress, hopelessness.
Social	Life stressors, exclusion, perfectionism.	External triggers for ideation.
Means availability	Access to lethal methods.	Determines lethality of outcome.
Exposure (“contagion”)	Seeing others self-harm/die by suicide.	Increases imitation risk.

• MCQ cue: Prior self-harm = strongest single predictor of future suicidal behaviour.

integrated motivational-volitional (IMV) model (O’Connor 2011; O’Connor & Kirtley 2018).

Phase	Description	Key Components
Pre-Motivational	Background vulnerabilities + stressors create potential.	Diathesis (e.g. impulsivity, low serotonin) × environment (e.g. trauma, bullying).
Motivational	Explains why suicidal thoughts form.	Defeat → Entrapment → Ideation. Threat-to-self moderators: rumination, poor coping. Motivational moderators: lack of belonging, burdensomeness, hopelessness.
Volitional	Explains why thoughts become acts.	Volitional moderators: access to means, exposure to suicide, impulsivity, past self-harm, fearlessness about death, suicidal planning/imagery, pain tolerance.

• exam mnemonic:

  • D → E → I → B

  • (Defeat → Entrapment → Ideation → Behaviour)

volitional moderators — turning thought into act.

Moderator	Explanation
Access to means	Availability of lethal method increases risk.
Planning	“If–then” cognitive scripts predict attempt likelihood.
Exposure	Suicide in family/peers/media normalises behaviour.
Impulsivity	Rapid progression from thought to action.
Fearlessness about death	Reduced inhibition; desensitisation.
Pain endurance	Higher tolerance correlates with attempt likelihood.
Past behaviour	Strongest predictor of future attempts (May et al., 2013).

predicting suicide risk.

Limitation	Evidence
Risk scales unreliable	Franklin et al. (2017): no scale shows strong sensitivity/specificity.
Past attempts matter most	May et al. (2013): prior attempt = best single predictor.
Implication	Use psychosocial + compassionate assessment, not checklist-based prediction.

• MCQ warning: “which single factor best predicts future suicide attempts?” → previous self-harm/suicide attempt.

managing self-harm and suicide risk.

Level	Evidence-Based Actions
Assessment	Comprehensive psychosocial assessment (not scale alone).
Crisis/Safety Planning	Identify triggers, coping strategies, emergency contacts.
Follow-up Contact	Post-discharge calls, texts, postcards → ↓ repeat attempts (Hawton et al., 2016).
Therapeutic Interventions	CBT, DBT → ↓ repetition and distress (Hawton et al., 2016a,b).
Youth interventions	Evidence weaker; need more longitudinal trials (Townsend, 2014).

• common therapeutic elements: assessment + safety plan + follow-up = reduced risk.

warning signs — talking about suicide.

Verbal/Behavioural Clues	Interpretation
Expressing hopelessness or feeling trapped.	Possible ideation.
Giving away possessions, making arrangements.	Indicates planning.
Major life losses, not coping.	Triggers.
Sudden calmness after agitation.	May reflect resolved intent.
Previous attempt.	Highest risk indicator.

• exam cue: sudden lift in mood after prolonged distress → potential red flag for final decision.

psychological theories recap.

Theory	Key Idea	Authors
IMV Model	Defeat → Entrapment → Ideation → Behaviour; 3-phase process.	O’Connor (2011); O’Connor & Kirtley (2018).
Diathesis–Stress	Vulnerability × environmental stress → suicidal risk.	General framework; supports IMV.
Cry of Pain Model	Suicidal behaviour = response to defeat/entrapment without rescue.	Williams & Pollock (2001) – precursor to IMV.

numerical and research anchors (mcq target).

Finding	Value / Reference
Intrapersonal motives	62.5 % “relief,” 37.5 % “to die,” 34.1 % “punish self.”
Interpersonal motives	20.5 % “to see if loved,” 14.8 % “to frighten,” 12.5 % “to get attention.”
At least one motive	79.5 % intrapersonal vs 40.9 % interpersonal.
Past attempt predictor	May et al. (2013).
Therapy reduces repetition	Hawton et al. (2016a,b).
Risk factor review	Hawton, Saunders & O’Connor (2012).

mcq recap quick notes.

Question Theme	Correct Answer / Concept
“Main difficulty in suicide research?”	Lack of standardised definitions.
“UK vs US terminology?”	UK = self-harm (any intent); US = NSSI (no intent).
“DSM-5 status of NSSI?”	“Condition for further study.”
“Most common motive for self-harm?”	Relief from negative emotion (intrapersonal).
“Strongest single predictor of suicide?”	Past self-harm behaviour.
“Hopelessness as a factor belongs to which model?”	Motivational phase of IMV.
“Phase turning thoughts into action?”	Volitional phase.
“What moderates entrapment → intent?”	Belongingness, burdensomeness, hopelessness.
“Which therapy reduces self-harm repetition?”	CBT/DBT.
“What does sudden calmness indicate?”	Possible decision to act (increased risk).

suicide and self harm — summary.

Domain	Key Facts
Definitions	Suicide = deliberate self-killing; Self-harm = injury regardless of intent; NSSI = non-suicidal.
Measurement Issue	Lack of standard definitions → data unreliability.
Motives	Primarily intrapersonal (emotion regulation, punishment).
Risk Factors	Psychological (hopelessness, impulsivity), Psychiatric (depression, anxiety), Social (abuse, bullying), Biological (serotonin).
Model	IMV = Pre-motivational (vulnerability) → Motivational (defeat/entrapment) → Volitional (means + impulsivity).
Predictors	Past attempts > any other factor.
Prevention	Psychosocial assessment + safety plan + follow-up + CBT/DBT.
Warning Signs	Hopeless talk, giving possessions, sudden calmness, previous attempt.
Epidemiology	Women = ↑ self-harm; Men = ↑ completed suicide.
Exam Keyword Pairs	Cry of pain, Defeat → Entrapment, Volitional moderators, Past attempt predictor.