Guidelines on Deliberate Self-Harm

Guideline Watch |
October 3, 2016

Guidelines on Deliberate Self-Harm

  1. Joel Yager, MD

Guidance from Australia and New Zealand applies to a broader population of patients who engage in self-harm, with or without lethal intent.

  1. Joel Yager, MD

Sponsoring Organization: Royal Australian and New Zealand College of Psychiatrists

Background and Objective

These guidelines use evidence plus expert clinical consensus to advise psychiatrists, other health professionals, and service organizations that care for patients who engage in deliberate self-harm (DSH), including nonsuicidal self-injury, “parasuicide,” and self-injurious behavior, as well as acts with lethal intent.

Key Points

  • Services intended to reduce repetitions of DSH should use psychological or psychosocial interventions, including cognitive-behavioral therapy (CBT), psychodynamic interpersonal therapy, and outreach combined with psychological therapy.

  • To address depressive symptoms in DSH patients, do not use CBT alone.

  • Do not initiate treatment with antidepressant medications, depot antipsychotic medications, or lithium specifically to reduce DSH risk — unless the medication would otherwise be indicated. Overall, evidence does not show that psychopharmacological interventions reduce the risk for DSH repetition.

  • Provide alcohol reduction–focused interventions if indicated on their own terms, but do not rely on them specifically to reduce the risk for DSH repetition.

  • DSH patients diagnosed with borderline personality disorder should receive CBT, mentalization-based therapy, or dialectical behavior therapy. Do not rely on group therapy alone to reduce the risk for DSH repetition.

  • Refer DSH patients to multidisciplinary team-based care.

  • Web-based CBT interventions may help patients who engage in DSH.

  • Do not rely solely on DSH risk-assessment scales and tools to determine the need for clinical services or follow-up.

  • Patients who engage in major self-mutilation should be considered to have a psychotic illness until proven otherwise.

  • Promising therapies for children and adolescents include CBT, mentalization-based therapy, and dialectical behavior therapy adapted for adolescents, but such approaches for this population still need research evaluation.


This guideline focuses on DSH with or without lethal intent. Given that people who initially self-injure with low lethal intention may evolve to suicidal intent, all patients who engage in DSH merit careful assessment, treatment suitable for suicidality and associated disorders, and monitoring for warning signs of escalating lethality. No other guidelines on this topic have been published since 2004.

Editor Disclosures at Time of Publication

  • Disclosures for Joel Yager, MD at time of publication Editorial boards Bulletin of the Menninger Clinic; Eating Disorders Review (Editor-in-Chief Emeritus); International Journal of Eating Disorders; UpToDate; FOCUS: The Journal of Lifelong Learning in Psychiatry


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