Journal of Psychosomatic Research 66 (2009) 477 – 493

Review article

Risk factors and correlates of deliberate self-harm behavior:

A systematic review
Herbert Fliege⁎, Jeong-Ran Lee, Anne Grimm, Burghard F. Klapp
Department of Psychosomatic Medicine and Psychotherapy, Charité Universitätsmedizin Berlin, Germany
Received 9 May 2008; received in revised form 20 October 2008; accepted 21 October 2008

Abstract

Objective: Deliberate self-harm behavior—without suicidal new incidence. Evidence of correlates encompasses distal/prox-
intent—is a serious health problem and may be studied as a imal, person/environment, and state/trait factors. Many studies
clinical phenomenon in its own right. Empirical studies of report associations between current self-harm behavior and a
sociodemographic and psychological correlates and risk factors history of childhood sexual abuse. Adolescent and adult self-
are systematically reviewed. Methods: We searched Medline, harmers experience more frequent and more negative emotions,
PsycINFO, PSYNDEX (German psychological literature), and such as anxiety, depression, and aggressiveness, than persons who
reference lists. We targeted self-induced bodily harm without do not self-harm. Two studies yield specific interactions between
conscious suicidal intent. Studies on suicidal behavior or self- childhood trauma and current traits and states such as low
poisoning were only included if they also assessed nonsuicidal self- emotional expressivity, low self-esteem, and dissociation with
harm. Results: Fifty-nine original studies met the criteria. respect to a vulnerability to self-harm. Conclusion: Evidence of
Deliberate self-harm may occur at all ages, yet adolescents and distal, biographical stressors is fairly strong. Proximal stressors
young adults are at a higher risk. Evidence on gender is complex. have rarely been investigated; protective factors, hardly at all.
Only 5 studies realize a prospective design (6 months to 10 years) Despite many findings of correlates, the data do not yet justify
and test predictors. The majority use cross-sectional and retro- terming them risk factors. Longitudinal studies are needed.
spective methods. No longitudinal study (separately) examines © 2009 Elsevier Inc. All rights reserved.
Keywords: Deliberate self-harm; Self-injurious behavior; Risk factors; Correlates; Systematic literature review

Introduction Definition of self-harm

Deliberate self-harm behavior is a significant health The most accepted term for auto-destructive acts in the
problem that is increasingly being studied as a clinical literature is self-harm [3] or, more specifically, deliberate
phenomenon in its own right [1–3]. It is detrimental to the self-harm behavior [11]. It is defined as the intentional
body and may impede social relations, medical treatment, self-induced harming of one's own body resulting in
and psychotherapy [4–9]. Some reports characterize aggres- relevant tissue damage [5,6,11,12]. The term encompasses
sive acts against one's own body as indicative of especially self-injurious behaviors and more indirect forms of bodily
severe psychopathological problems [6,10]. harm [13]. It is largely agreed upon to exclude the
following from the definition: (a) phenomena that are
explicit symptoms or classificatory criteria of other
disorders, such as eating disorders or substance abuse;
(b) everyday behaviors, such as unhealthy eating habits or
⁎ Corresponding author. Charité Universitätsmedizin Berlin, Depart- lack of exercise; and (c) psychological self-harm, such as
ment of Psychosomatic Medicine and Psychotherapy, Charitéplatz 1, D- deliberately engaging in an abasing partnership. The latter
10117 Berlin, Germany. Tel.: +49 30 450 553097; fax: +49 30 450 553989. is occasionally studied in the context of borderline
E-mail address: [email protected] (H. Fliege). personality disorder [14]. However, there is little consensus

0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2008.10.013
478 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

as to how to classify different levels of frequency, severity Epidemiology

(e.g., delicate self-cutting vs. auto-mutilation), or specific
forms of deliberate self-harm, such as self-poisoning. In school and college student samples, lifetime prevalence
Another complex issue is how to distinguish between of nonsuicidal self-harm behavior ranges from 13% to 35%
deliberate self-harm and suicidal behavior. [11,45–48]. Several population-based samples from the
Prominent definitions of deliberate self-harm behavior United States and Canada yield a prevalence of 4% pertaining
exclude suicidal intention [5,12,15]. This understanding to the past 6 months and lifetime prevalence figures ranging
prevails in U.S. publications, whereas the term self-harm from 2.2% to 6% [49–51]. Deliberate self-harm behavior is
generally includes behaviors irrespective of a suicidal particularly prevalent in patients in psychosomatic medicine
intention in the UK, thus encompassing self-harm behaviors and psychiatric settings, including consultation–liaison
with and without suicidal intention. This discrepancy limits patients [29,52–54].
cross-national study comparability. There is some comorbid-
ity between suicidal and nonsuicidal self-harm, and deliber- Risk factors and protective factors
ate self-harm is prognostic for suicide attempts [14,16–21].
However, there appear to be some important differences Generally, the relation between a factor and an illness is
between self-harm with the intent to die and self-harm with no probabilistic, not deterministic. Therefore, the term risk
intent to die [22]. Studies have revealed a distinction between factors is more often preferred over the term causal factors.
the psychological functions of suicidal and nonsuicidal self- Kraemer et al. [55] define risk factor as a measurable
harm behavior [13]. This distinction is based on the criterion variable that must precede the outcome and be associated
of intention, which is difficult to operationalize. Suicidal with a higher risk of developing the outcome. They
intentions may be ambivalent, dissimulated, or concealed. distinguish between risk factors of first onset and those of
Thus, intention is more difficult to measure reliably than a relapse and—inversely—factors raising the probability of
observable behavior [16]. Skegg [3] proposes assessing self- a remission. Knowledge of these factors is relevant for the
harm behavior descriptively and many authors have adopted aims of primary, secondary, and tertiary prevention and for
the approach of assessing deliberate self-harm as an act of therapy. According to Kraemer et al. [55], a factor that has a
intentional self-injury or self-poisoning “irrespective of the correlation with an outcome, with both variables being
apparent purpose of the act” [23]. However, if we want to assessed at the same time, should merely be termed a cor-
expand our knowledge on differences between suicidal and relate. Kraemer argues that although a given factor may
nonsuicidal self-harm, further efforts to develop reliable indeed be a risk factor, it might also be an accompanying
assessments of intent are required. Some advances have condition or a consequence of the illness. To term a variable
recently been made in this area [24]. risk factor, it must be assessed before the outcome occurs.
Distal and proximal factors are distinguished depending
Diagnostic classification on the proximity between factors and outcome. This is often
operationalized along a time axis [56], with distal factors
Deliberate self-harm behavior may occur in clinical as arising earlier in the biography and proximal factors nearer to
well as in nonclinical samples [9,10,25–27]. DSM-IV and illness onset. The terms distal and proximal are merely
ICD-10 F list self-harm behavior as a diagnostic criterion of descriptive. Another aspect concerns the paths of effect. In a
borderline personality disorder. However, individuals who cause-and-effect chain, distal factors are supposed to have
self-harm are diagnostically heterogeneous and may suffer more indirect effects and proximal factors more direct effects
from a spectrum of other psychological disorders [28,29]. on the outcome [57]. More specifically, diathesis-stress
Frequently reported co-occurring diagnoses—other than models define distal as predisposing factors, which are those
borderline personality disorder—are alcohol and substance that make the individual vulnerable to stress, such as parental
abuse [29,30]; eating disorders [31–34]; dissociative, problems or childhood traumata. Thus, in predisposed
somatoform, or body dysmorphic disorders [35–37]; depres- individuals, proximal factors may trigger the onset of mental
sion and anxiety disorders [26,38,39]; posttraumatic stress or behavioral problems. Proximal factors are composed of
disorder [30,40]; and several personality disorders and daily hassles, conflicts, acute stress, life events, or traumata
schizophrenia [2,29]. In DSM-IV, self-harm behavior may closely prior to illness onset.
also be classified as a disorder of impulse control not Transactional models emphasize that risk factors can
otherwise specified and ICD-10 has an additional Z code for a transact with each other as well as with the behavior itself
personal history of self-harm. Concealed self-harm carried [58]. While some risk factors are largely considered static,
out with the aim of adopting the sick role is classified as like a history of childhood trauma or personality traits,
factitious disorder [13]. Within factitious disorders, indirect others are more often considered dynamic, like changing
forms of self-harm prevail [41]. Studies indicate certain mood states or the current course of events. More recent
overlaps between factitious disorder and open (or admitted) approaches underscore the variability of risk factors over
self-harm behaviors, making the diagnostic categories not time, rather than assume that the risk factors remain valid
absolutely distinct empirically [6,42–44]. indefinitely [58].
 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493 479

Risk factors may be inherent in the person or in the Methods

environment. Accordingly, protective factors can be personal
resources (resilience) or social resources [59]. Research strategies

Protective factors We searched Medline, PsycINFO, and PSYNDEX (Ger-

According to the salutogenic approach, when a person man psychological literature) for the keywords [“self-harm”
faces stress, protective factors diminish the risk of deve; OR “self-injur⁎” OR “self-cut⁎” OR “self-destruct⁎” OR
loping a disease [60]. Identifying protective factors is “auto-mutilat⁎” OR “auto-destruct⁎”] combined with [“risk
relevant, provided they can be modified and enhanced facto⁎” OR “correlate⁎” OR “precurs⁎” OR “predict⁎” OR
by interventions. “causal facto⁎”]. We also searched reference lists. We
included studies that adopt the definition of deliberate self-
Interaction between risk factors and protective factors harm as self-induced bodily harm without conscious suicidal
Well-known models of the interaction between risk and intent [1]. Studies on suicidal behavior or self-poisoning
protective factors are the compensation model, which claims alone were generally excluded. However, in order not to omit
that a protective factor simply has an additive positive effect relevant evidence, we included a small number of studies on
on health and thereby compensates the negative effect of risk suicidal behavior, provided that they also assessed non-
factors [59], and the protective factors model, which claims suicidal self-harm. We considered original papers that report
that a protective factor must moderate the association at least one correlate, risk factor, or protective factor. Case
between risk factor and outcome [61,62]. studies and studies without any group comparisons were
not included.
Literature review Up to the end of 2007, a total of 59 original papers that
met inclusion criteria emerged (Table 1). Table 1 gives an
Although there are some excellent reviews on deliberate overview of included studies, sample characteristics, and
self-harm behavior [1–3], we believe that we have added assessment methods of deliberate self-harm. Assessment
to this knowledge in several ways. In contrast to earlier methods are described briefly and are then assigned to one of
reviews that give a comprehensive overview [3] or focus the following eight categories: (a) there is no information on
on the functions of self-harm [1,2], our review elucidates how deliberate self-harm was assessed; (b) deliberate self-
on the possible factors in the etiology of deliberate self- harm was established by an (unspecified) diagnostic case
harm that have been empirically investigated. Since ascertainment at hospital admission or by inspecting medical
Gratz's 2003 review on risk factors and functions of records, chart reviews, or other; (c) deliberate self-harm was
deliberate self-harm [1], a considerable number of self- assessed by a standardized clinician rating based on clinical
harm studies have been published, thus making an updated interview and medical documentation; (d) deliberate self-
review expedient. Moreover, other than Gratz's 2003 harm was established on the basis of interviews that were
review, which focused on childhood traumatic experiences constructed ad hoc for the study; (e) deliberate self-harm was
and emotion regulation as possible factors [1], our review established on the basis of interviews for which validation
focuses on a broader range of empirically investigated data are available; (f) deliberate self-harm was assessed by
sociodemographic and psychological factors. Additionally, single self-report (or interview) items; (g) deliberate self-
we evaluate each risk factor or correlate in terms of the harm was assessed by a self-report questionnaire constructed
methodological strength of the available evidence and infer ad hoc for the study; (h) deliberate self-harm was assessed by
open research issues that need to be addressed. a self-report questionnaire for which psychometrical valida-
Our review focuses on sociodemographic and psycholo- tion data are available.
gical factors. Although several studies also yield associations
between deliberate self-harm and alcohol or other substance Taxonomy of correlates and risk factors
abuse, binge eating, or restricted eating, we will not include
this information. One reason for this is that substance abuse We included sociodemographic factors, distal and
and disturbed eating may indicate co-occurring disorders. As proximal correlates, and risk factors. We distinguished
a result, the question of correlates or risk factors would be correlates and risk factors from protective factors. A factor
strongly linked with the question of diagnostic comorbidity such as “self-esteem” may be reported as a protective factor
proper. A second reason is that substance abuse and disturbed or—inversely, as low self-esteem—as a risk factor. We
eating are in themselves behavior with a strong inherent presented factors according to the way they were treated in
element of self-harm. This makes it a much more complex the studies.
issue than just treating substance abuse and disturbed eating Empirical evidence is summarized and presented in
as correlates or risk factors. In our view, the relation between Table 2. For each factor, we listed all relevant studies by
deliberate self-harm with alcohol or substance abuse and authors and indicated whether the study design was cross-
disturbed eating behaviors, in particular, deserves investigat- sectional (CS), including retrospective assessment, or long-
ing in more detail than this review would allow. itudinal (LT). We rated the strength of the evidence for each
 480
Table 1
Samples and self-harm assessment of the 59 studies
Study Sample Deliberate self-harm assessment
Authors (year Psychometric
of publication) Reference Kind/Setting N n/n Age Assessment instruments Category validation data
Akyuz et al. (2005) [63] Population-based 628 14 with DSH 18–65 (34.5±11.5) Ad hoc self-report 7 None reported
random sample of 614 without DSH questionnaire (frequency,
the city of Sivas, duration, types)
Central Turkey; females
Boudewyn and [64,65] College psychology 438 46 with DSH 392 16–65 (mean=24.9) Questions about acts of (6) None reported
Liem (1995a, 1995b) students without DSH deliberate self-harm, not
described

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

Briere and Gil (1998) [49] Population-based 1410 927 population based 18–90 (46±17) Single item from Trauma 6 None reported
sample, clinical sample 390 clinical 18–58 (36±10) Symptom Inventory [66]
(inpatients, outpatients), 93 self-harmers ./. (35±9) [“Intentionally hurting
and self-harmers via yourself (e.g., by
advertisement scratching, cutting, or
burning) even though
you weren't trying to
commit suicide”]
Brown et al. (2007) [67] College psychology 223 23 with recent DSH 19.4±2.1 Standardized self-report 8 Available
students 39 with past DSH questionnaire: DSHI [11]
161 without DSH (type, frequency,
severity, duration)
Brunner et al. (2007) [45] Students, 9th grade 5759 630 with occasional 14.9±0.73 Single item from 6 None reported
DSH Schedule for Affective
229 with repetitive DSH Disorders
4900 without DSH
Carroll et al. (1980) [68] Psychiatric patients, 28 14 patients with DSH 21–41 (mean=28.1) Interview, not specified (4) None reported
subgroup of patients 14 controls
with DSH and age-/
sex-matched sample
without DSH
Colman et al. (2004) [69] Patients presenting to 1 369 92 with recurrence 16–55 Case ascertainment at 2 None reported
of 5 emergency within 1–2 years hospital admission; risk 8 for the diagnostic
departments of factors by European code; available
Edmonton, Alberta, Parasuicide Study for interview and
Canada, for Interview Schedule, intent scale
“parasuicide” Suicide Intent Scale
Crowell et al. (2005) [70] “Parasuicidal” 46 23 with DSH 14–18 (15.3±1.1) Semistructured/ (5) None reported
adolescents and age- 23 without DSH structured interview;
matched controls; Lifetime Parasuicide
females Count Interview
[71] self-/parent report,
DSH group only
Darche (1990) [72] Adolescent psychiatric 96 48 patients 13–17 (mean=15.4) Review of medical 2 None reported
inpatients and age-/sex- 48 controls records
matched controls
De Leo and [73] Students from 14 high 3757 233 with DSH 10–11 Single-item from 6 None reported
Heller (2004) schools on the 3524 without DSH the Lifestyle and Coping
Gold Coast, Questionnaire
Queensland, Australia [“Have you ever
deliberately taken an
overdose (…) or
tried to harm
yourself in some
other way (such as
cut yourself)?”] and
further questions on
most recent episode
Demitrack et al. [74] Inpatients of an eating 60 30 patients 16–39 (23.3±4.4) Initial clinical interview 2 None reported

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

(1990) disorder unit and 30 controls at hospital admission
age-matched controls;
females
Dubo et al. (1997) [75] Psychiatric inpatient with 59 33 with DSH 18–60 (mean=31.7) Ad hoc self-report 7 None reported
borderline or other 26 without DSH questionnaire (duration,
personality disorder number of
episodes, severity)
Dulit et al. (1994) [76] Psychiatric inpatients 124 62 without DSH 32.8±9.2 Ad hoc self-report 7 None reported
with borderline 23 with infrequent DSH questionnaire 8 for DSH items;
personality disorder, with 39 with frequent DSH (frequency); Suicide available for
or without DSH Intent Scale [77] intent scale
Evren and Evren [78] Substance dependents 136 47 with DSH Mean=36.4 Single-item from the 6 None reported
(2005) after inpatient 89 without DSH Childhood Abuse and
detoxification; males Neglect Questionnaire
Fliege et al. (2003) [79] Psychosomatic 354 32 with DSH 18–65 (30.1±10.1) Standardized clinician- 3 Available
inpatients, consultation– 322 without DSH administered rating form,
liaison patients based on clinical
and outpatients interview and
medical records
Fliege et al. (2004) [80] Psychosomatic medicine 854 63 with DSH 17–65 (32.5±11.6) Standardized clinician- 3 Available
consultation–liaison 63 matched controls out administered rating form,
patients and outpatients, of 791 without DSH based on clinical
general hospital interview and medical
records
Fliege et al. (2006) [52] Psychosomatic inpatients 361 109 with DSH 17–77 (41.9±14.9) Standardized self-report 8 Available
252 without DSH questionnaires: DSHI
[11]; Self-Harm
Behavior Questionnaire
DSHQ [46]
Gladstone et al. [81] Inpatients and 269 26 with current DSH 18–77 Ad hoc semistructured/ 4 None reported
(1999) outpatients with 29 with history of DSH structured interview
depressive disorder containing questions
on self-harm
Gladstone et al. [82] Outpatients with 125 33 with current DSH 17–68 (37.8±12.1) Ad hoc semistructured/ 4 None reported
(2004) depressive disorder; 34 with history of DSH structured interview
females containing unspecified

481
questions of self-harm
(continued on next page)
(continued on next page)
 482
Table 1 (continued)
Study Sample Deliberate self-harm assessment
Authors (year Psychometric
of publication) Reference Kind/Setting N n/n Age Assessment instruments Category validation data
Gratz (2001) [11] Undergraduate students 150 53 with DSH 18–64 (23.2±7.1) Standardized self-report 8 Available
of psychology 97 without DSH questionnaire: DSHI [11]
Gratz (2006) [83] Undergraduate students 249 91 with DSH 18–55 (23.3±6.0) Standardized self-report 8 Available
of psychology; females 158 without DSH questionnaire: DSHI [11]
Gratz et al. (2002) [84] Undergraduate students 133 51 with DSH 18–49 (22.7±6.2) Standardized self-report 8 Available
of psychology 82 without DSH questionnaire: DSHI [11]
Haavisto et al. (2005) [85] Representative birth 2307 51 with DSH (at age 18) 8/18 Ad hoc single item 6 None reported
cohort sample at 2256 without DSH (“I deliberately tried

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

age 8 and again to hurt or kill myself”)
at age 18, males
Haines and Williams [86] Prison inmates and 50 19 prisoners with DSH (22.3±6.17) Not reported 1 None reported
(1997) students of psychology; 13 prisoners and 18
males students without DSH
Hawton et al. (2002) [87] Pupils from England, 6020 398 with DSH 15–16 Ad hoc self-report 7 None reported
survey 5622 without DSH questionnaire (type,
consequences, functions,
intent); a posteriori
classification of open
response categories
Herpertz et al. (1997) [88] Inpatients with any 165 54 patients with DSH Mean=24 Ad hoc structured 4 None reported
personality disorder and 66 patients without DSH Mean=24.3 interview questions, in
nonclinical controls 45 nonclinical controls addition to the SCID
Interview for DSM-III-R
Howat and Davidson [89] Elderly psychiatric 77 34 parasuicidal patients N65 Ad hoc structured 4 None reported
(2002) patients treated for 21 depressive patients interview questions on
“parasuicidal” behavior 22 controls self-harm, method
or depression, and and intent
controls
Johnston et al. (2006) [90] Patients from an 4743 516 with history of N16 Medical records on 2 None reported
emergency department recurrent DSH occurrence (Manchester
and psychiatric self-harm monitoring
inpatients, treated system MASH)
for self-injury
Joyce et al. (2006) [91] Psychiatric patients in a 195 46 with DSH N18 Ad hoc structured 4 None reported
long-term treatment 149 without DSH interview questions, in
program for depression addition to the SCID
Interview for DSM-IV
Kapur et al. (2006) [23] Patients presenting to an 7723 1054 with recurrence 15–98 Medical records on 2 None reported
emergency department within 12 months (median=30) occurrence (Manchester
with episodes of and Salford self-harm
self-harm including project MASSH)
self-injury
Kirkcaldy et al. (2006) [92] Patients from a hospital 3649 2153 with DSH 3–24 (13.4±3.3) Ad hoc self-report 7 None reported
for child and adolescent 1496 without DSH questionnaire
psychiatry and
psychosomatic medicine
Klonsky et al. (2003) [26] Military recruits, 1986 79 with DSH 20±5 Two items from 6 Available for
U.S. Air Force 1907 without DSH Schedule of Nonadaptive the total
and Adaptive Personality questionnaire
(“When I get very tense,
hurting myself physically
somehow calms me
down”; “I have hurt
myself on purpose
several times”)
(exclusion when item
“I have tried to commit
suicide” endorsed)
Lipschitz et al. (1999) [93] Adolescent psychiatric 71 28 with DSH 12–18 (14.8±1.6) Ad hoc self-report 7 None reported

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

inpatients 43 without DSH questionnaire (type,
frequency, age at onset,
precipitants)
Low et al. (2000) [35] Mentally disordered 50 37 with DSH (15 Medical examination 2 None reported
patients in high-security infrequent, 22 frequent) records on occurrence
detention; females 13 without DSH and frequency
Lundh et al. (2007) [94] Age-group cohort from 123 84 with DSH 15 Standardized self-report 8 Available for
three schools in Southern 44 without DSH questionnaire: DSHI original version
Sweden [11], modifiedàsuicidal
intent was asked for each
endorsed self-harm
behavior
Marchetto (2006) [27] Patients presenting to an 516 16–60 (28.8±8.74) Medical examination 2 None reported
emergency department records on occurrence
with five or more and frequency
episodes of self-cutting
Matsumoto et al. [95] Adolescent inmates of a 201 33 with DSH 14–19 (16.8±1.6) Ad hoc self-report 7 None reported
(2004) juvenile detention center 168 without DSH questionnaire [“Have
you cut your wrist and/or
your arm more than
once?”; “Have you ever
attempted suicide with
any ways (including
self-cutting)?”]
(plus items on burning,
frequency, precipitants,
functions)
McAuliffe et al. [96] Patients treated for 836 Mean=36 Self-harm assessment 1 None reported
(2005) “parasuicide”, several not described; 4
treatment centers (WHO semistructured/
multicenter study in 12 structured interview,
European regions) European Parasuicide
Study Interview
Schedule
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page)

483
 484
Table 1 (continued)

Study Sample Deliberate self-harm assessment

Authors (year Psychometric
of publication) Reference Kind/Setting N n/n Age Assessment instruments Category validation data
McKay et al. (2004) [97] Psychiatric inpatients 48 30 with DSH 30.0±9.3 (with DSH) Semistructured/ 4 Available
with borderline 18 without DSH 29.11±6.4 structured interview:
personality disorder with (without DSH) Self-Injury Interview
or without DSH (methods, location, pain
perception, precipitants,
urge, relief)
Milnes et al. (2002) [98] Patients admitted to 150 N15 Ad hoc clinical interview 4 None reported
hospital following with questions on

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

self-harm self-harm (occurrence,
type, frequency); Beck
interview scale for
suicidal intent
Newman and [99] Patients with 707 507 with DSH 16 to over 45 Medical examination 2 None reported
Bland (2007) “parasuicidal” behavior 200 without DSH records on occurrence,
and age-/sex-matched frequency, method
controls treated at an
emergency department
Nijman et al. (1999) [100] Psychiatric inpatients 54 24 with DSH 37.5±12.4 Ad hoc interview on 4 None reported
with or without DSH 30 without DSH self-harm (type,
frequency, age of
onset, severity)
Paivio and McCulloch [101] Undergraduate students 100 41 with DSH 21±1.7 Ad hoc self-report 7 None reported
(2004) of psychology; females 59 without DSH questionnaire
(type, frequency)
Portzky et al. (2007) [102] Students from Belgium 4431 and 4643 Belgium: 460 with DSH, 15–16 Ad hoc self-report 7 None reported
and the Netherlands 3969 without DSH questionnaire [“Have
The Netherlands: you ever deliberately
183 with DSH, taken an overdose (…) or
4460 without DSH other medication or tried
to harm yourself in some
other way (such as cut
yourself)?”], with open
description and a
posteriori classification
Rodriguez-Srednicki [103] College students; 441 18 with DSH 18–23 (20.6±1.2) Ad hoc self-report 6 None reported
(2001) females 423 without DSH questionnaire items
(occurrence, frequency)
Romans et al. (1995) [104] Random community 477 23 with DSH 18–65 Ad hoc interview, 4 None reported
sample; females 454 without DSH self-harm section not
described
Schaffer et al. (1982) [105] Psychiatric inpatients 28 14 with DSH 21–41 (28.1) Ad hoc interview on 4 None reported for
and outpatients with 14 without DSH self-harm; Diagnostic 5 self-harm interview,
DSH, patients without Interview for Borderline available for
DSH matched for age, Patients [106] borderline interview
sex, and setting
Schmidtke et al. (1996) [107] Multicenter-study on 3.968.125 6.310 with DSH 15 to over 55 Medical examination 2 None reported
“parasuicide” at 16 3.961.815 without DSH records on occurrence
treatment centers in
13 European regions;
self-harm included
self-cutting behavior
Simeon et al. (1992) [108] Patients with any 52 26 with DSH 31.0±9. Semistructured/ 5 Available
personality disorder with 26 without DSH 31.4±9.4 structured interview:
or without DSH, Schedule for
age-matched groups Interviewing Borderlines
(occurrence, frequency)
Sourander et al. (2006) [109] Representative birth 839 52 with DSH (at age 15) 12/15 Ad hoc single item 6 None reported
cohort assessed at age 787 without DSH (“I deliberately try to hurt

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

12 and again at age 15 or kill myself” response
categories: not true,
sometimes/somewhat,
often/very true)
Tuisku et al. (2006) [110] Adolescent psychiatric 218 29 with DSH 13–19 Ad hoc structured 4 None reported
outpatients treated for 189 without DSH interview questions on
depression suicide attempts and
deliberate self-harm
without intent to die
(none, occasional,
frequent)
Tulloch et al. (1997) [111] Adolescent patients 104 52 with DSH 14–19 (16.4±1.4) Medical examination 2 None reported
presenting to an 52 matched controls records on self-harm 4
emergency department occurrence and severity
with self-harm and and ad hoc interview
nonpsychiatric hospital questions on suicide
controls, matched for history
age, sex and
socioeconomic status
van der Kolk et al. [112] Patients with any 74 28 with DSH/not suicide 18–39 Ad hoc self-report 7 None reported
(1991) personality disorder and/ attempt questionnaire
or bipolar disorder, (occurrence, type)
psychiatric hospital
Wright et al. (2004) [113] Adolescents with history 664 399 with wall-hitting as 13–17 (15±1.2) Standardized self-report 7 Cronbach
of sexual abuse, pediatric most frequent DSH questionnaire: alpha reported
hospital patients and Self-Destructive
students; students Behaviors Inventory
without sexual abuse (unpublished
manuscript) with
9 items on self-harm
Young et al. (2006) [114] Male offenders receiving 242 43 with DSH Not reported Semistructured/ 4 None reported
psychiatric treatment 199 without DSH structured ad hoc 2
in prison interview, not described;
review of medical
records
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485
 486
Table 1 (continued)
Study Sample Deliberate self-harm assessment
Authors (year Psychometric
of publication) Reference Kind/Setting N n/n Age Assessment instruments Category validation data
Zlotnick et al. (1996) [115] Psychiatric inpatients; 148 103 with DSH 33±9.2 Ad hoc self-report 7 None reported
females 45 without DSH questionnaire (type,
frequency, duration),
including items on
bingeing, reckless
driving, etc.
Zlotnick et al. (1999) [54] Psychiatric outpatients 256 85 with DSH 40.6±14.0 Ad hoc self-report 7 Cronbach alpha
171 without DSH questionnaire (type, 5 reported

H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

frequency);
semistructured/
structured interview for
DSM-IV personality
Zoroglu et al. (2003) [116] High-school students 839 175 with DSH 14–17 (15.9±1.8) Ad hoc self-report 7 None reported
664 without DSH questionnaire (types)
Zweig-Frank [117] Patients with borderline 150 48 with DSH 18–48 Single item from Revised 6 None reported
et al. (1994) or other personality 152 without DSH BPD: 28.3±6.3 Diagnostic Interview for
disorder Non-BPD: 29.7±7.2 Borderlines [118]
[“During the last two
years, have you ever hurt
yourself deliberately
without intending to
commit suicide (e.g.,
cutting your skin, burns,
hitting yourself, breaking
windows with your fists
hitting walls, hitting
your head)?”]
DSH, deliberate self-harm; BPD, borderline personality disorder; single item's texts are included if reported in the paper or available. Assessment categories: 1=no information; 2=case ascertainment/medical
records; 3=standardized clinician-administered rating; 4=ad hoc interviews; 5=validated interviews; 6=single items, self-report/interview; 7=ad hoc questionnaire; 8=validated questionnaire (assignment to
assessment category is given in parentheses if information is insufficient to judge).
 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493 487

Table 2
Overview of empirical evidence of correlates or risk factors of self-harm behavior
Strength of
Variable Studies Design evidence Annotation
Sociodemographic factors
Age [49,107] CS ++ Highest rates in adolescents and
young adults (15–24 years)
[23] LT (12 months) +++ Highest recurrence of DSH for
age group 25–54 years
Sex [11,26,27,49,52,67] CS 00/(++) 6 studies found no sex
differences in adults
[107] 1 study found more females among
medical patients treated for self-harm
[45,87,92,93,102,109,110] 6 studies on adolescents found a higher
prevalence in females (2:1 to 4:1);
1 study on adolescents found no
sex differences
[69] LT (1–2 years) 000 Not predictive of DSH recurrence
[23] LT (12 months)
Unemployment [78,99] CS +++
[90] LT (6 months) Predictive of DSH recurrence
[23] LT (12 months)
No partnership [78] CS +++
[90] LT (6 months) Predictive of DSH recurrence
(except when widowed)
[23] LT (12 months)
Distal factor
Parental separation [87] CS +++
[109] LT (age 12/15)
[85] LT (age 8/18)
Psychological problems [109] LT (age 12/15) +++ Significant aspects: mother's
of a parent nervousness and low well-being
Health problems [45] CS +++
in the family [109] LT (age 12/15)
[85] LT (age 8/18)
Experience of separation [68,84,95,99,112] CS ++
in childhood [23] LT (12 months) +++ Not predictive of DSH recurrence
Childhood [35,63,68,83,84,87,95, CS ++
physical abuse 100,101,110,112,113]
Childhood [63,84,100,110] CS ++
psychological abuse
Childhood [63,75,84,92,93,100,112] CS ++
emotional neglect
Childhood sexual abuse [35,49,63,65,72,75,81,82, CS ++ Except: no association found by
84,87,91,93,100,103,104, Rodriguez-Srednicki [103]
110,112,113,115–117]
[23] LT (12 months) +++ Predictive of DSH recurrence
Proximal factors
Somatic complaints/ [45,72,85] CS +++/−−−
health problems [69] LT (6 months) Predictive of DSH recurrence
[23] LT (12 months)
[109] LT (age 12/15)
Negative affect [83] CS +
intensity/reactivity
Anxiety [26,35,67,72,87,102,108] CS +++
[109] LT (age 12/15)
Depression [26,45,52,64,67,70,72,76,87, CS +++ Except: no difference found by
99,102,105,108,111,113] Schaffer et al. [105]
[109] LT (age 12/15) Predictive of DSH recurrence
(2 studies) and incidence (1 study)
[85] LT (age 8/18)
[23] LT (12 months)
Impulsivity [35,87,88,102,105,108] CS ++ Except: Portzky et al. [102] yielded
significance in univariate analyses but
not in multiple regression
(continued on next page)
(continued on next page)
488 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

Table 2 (continued)
Strength of
Variable Studies Design evidence Annotation
Aggressiveness/ [45,67,108] CS +++
hostility [109] LT (age 12/15)
[85] LT (age 8/18)
Psychopathy [114] CS
Derealization/ [35,49,54,74,79,84, CS ++
Dissociation 95,100,112,115–117]
Alexithymia/Lack of [83,97,101,115] CS ++
emotional expressivity
Low self-esteem [35,64,79,87,94,102] CS ++
Self-blame/ [26,73,88] CS ++
Self-derogation
Critical life events [102] CS +
in previous year
Perceived stress [52] CS +
Low self-efficacy [80] CS +
Hopelessness [98,108] CS ++
[23] LT (12 months) +++ Predictive of DSH recurrence
Lack of coping skills, [67,86,89,96,98] CS ++
lack of problem-solving
abilities, maladaptive coping
Protective factors
Self-esteem [96] CS + Self-esteem buffers association between
passive-avoidant coping and self-harm
Adaptive coping [67] CS 0 No differences found
CS, cross-sectional design/test correlates; LT, longitudinal design/test predictors; +, positive evidence; −, negative evidence; 0, no association.

factor. “+” indicates positive evidence from only one cross- included only male participants, assessed at age 8 (t1) and
sectional study. “++” indicates positive evidence from at again at age 18 years (t2). Here, prevalence of deliberate
least two cross-sectional studies. “+++” indicates positive self-harm at age 18 pertaining to the past 6 months was
evidence from at least one prospective study. A zero means 2.2%. There was, however, no information offered
no association was found. concerning whether any or how many of these self-
harmers had also exhibited self-harm behavior at the age of
8 years. It may well be assumed that, at age 18, the rate of
Results new cases in the self-harm group was high but, again, no
separate analyses were reported.
Study design Consequently, we conclude that—with the possible
exception of the latter study [85]—no study yielded evidence
Only 5 of the 59 original studies test predictors of for risk factors of new incidences of deliberate self-harm
deliberate self-harm in a longitudinal design behavior [55].
[23,69,85,90,109]. They each include two time points of
measurement, with intervals ranging from 6 months to 10 Sociodemographic correlates and risk factors
years. Three of the longitudinal studies [23,69,90]
investigated patients who were medically treated for Deliberate self-harm behaviors may occur at all ages.
deliberate self-harm at t1. The predicted criterion at t2 Yet, notably high rates have been found in adolescents and
was not new onset but recurrence of deliberate self-harm. young adults [49,107]. Patients who utilized medical
In a Finnish epidemiological study [109], a representative treatment for self-harm were more often female [23,107].
birth cohort sample of adolescents was assessed at the age In adolescents, six studies found higher self-harm rates for
of 12 (t1) and again at the age 15 years (t2). Occurrence of females [45,87,92,93,102,109]. Only one study found no
deliberate self-harm at t2 was predicted. Among those who such difference [110]. In three studies involving young
exhibited self-harm at t2, there were new cases of self- adults [11,26,67] and in three studies involving adult
harm and repeaters. Self-harm rates at age 12 were 2.7% samples of a large age range [27,43,49], there was no
for girls and 3.1% for boys. At age 15, rates had risen to gender difference found. One study yielded no gender
12.6% for girls and 4.6% for boys. Thus, at age 15, the effect on recurrence of deliberate self-harm [23].
majority were new cases. However, no separate analyses There were no studies on socioeconomic status or level of
for new cases and repeaters were reported. Another sample education and self-harm in adults. In adolescents, self-harm
of the aforementioned Finnish epidemiological study [85] rates were associated with a lower level of education [45].
 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493 489

Prospective data yield that unemployment and having no correlative only. Self-harmers have more difficulties in
partnership are predictive of the recurrence of self-harm identifying or understanding their emotions and in
within 12 months [23,90]. expressing their emotions than individuals who do not
self-harm [83,97,101,115].
Distal correlates and risk factors
Stress and maladaptive coping
A large number of studies on deliberate self-harm One study showed a correlation between a higher level
investigate stressful traumatic experiences in childhood. of perceived stress in the last 4 weeks and deliberate self-
Virtually all studies find associations with self-harm harm behavior [52]; however, the time sequence was not
behavior. The following are significant factors: psychologi- assessed. A study in adolescents found an association
cal problems on the part of a parent, parental separation, and between the number of critical life events and self-harm
early or prolonged separation from a parent. Most frequently behavior, where both variables were measured retrospec-
found were associations between childhood experiences of tively for the preceding year [102]. Again, no time
emotional neglect, psychological or physical abuse, espe- sequence was assessed. Some cross-sectional results
cially sexual abuse, and adolescent or adult self-harm indicate associations between lower personal coping
behavior. We identified 21 studies reporting associations resources and deliberate self-harm. In several studies,
between deliberate self-harm behavior and sexual abuse. deliberate self-harm was associated with low self-esteem
Only one study did not report this particular association and low problem-solving abilities. Self-harmers showed a
[103], a fact that its authors attribute to the small statistical lower belief in self-efficacy [80] and had a higher tendency
power of the study. towards a self-blaming coping style [73] and to self-
However, with the exception of only one study, all derogation [26,88] than non-self-harmers.
responses were given retrospectively. Although the time
sequence of early biographical events and self-harm in Interaction between factors
adolescence or adulthood is plausible in itself, retrospection Distal and proximal factors may have more complex
is prone to various recall biases, which may lead to the than just additive effects. States and traits may also interact
overreporting or underreporting of biographical events. in the triggering of deliberate self-harm. Anxiety, depres-
In one longitudinal study [109], deliberate self-harm sion, aggressiveness, and low emotional expressivity have
was measured at the age of 15, where parental separation stronger trait aspects, whereas derealization and dissocia-
and the psychological problems of a parent—as biogra- tion have stronger state aspects. We found two cross-
phical factors—had been assessed at age 12. Here, too, sectional studies that tested the paths of various factors.
responses were given retrospectively, at least in part. Not One study showed that it was not low emotional
living in a family with two biological parents, mother's expressivity alone but childhood abuse and negative affect
health problems, somatic complaints, aggressiveness, and together with low emotional expressivity that made the
externalizing and internalizing problems at age 12 individual prone to deliberate self-harm [83]. The other
independently predicted deliberate self-harm 3 years later. study found both a direct path from childhood abuse to
In another, only male sample from the same longitudinal current self-harm and indirect paths via low self-esteem
study, self-harm behavior at age 18 was more likely when, and via dissociation [35].
at age 8, the child's school performances had been poorer
and when parents had lower educational levels [85]. Protective factors
Some studies yielded associations between low self-
Proximal correlates and risk factors esteem and low coping resources, on the one hand, and
deliberate self-harm, on the other. However, these studies
Individual factors adopted a pathogenic framework. In a study that did test
There is good correlative and prognostic evidence for within the salutogenic framework [96], high self-esteem
the relevance of general psychopathology, in the way of buffered the negative effect of passive-avoidant coping
anxiety, depression, and aggressiveness, in deliberate self- on self-harm. Although the overall study was long-
harm behavior. Self-harmers experience more frequent and itudinal, the fact that the said variables were assessed at
more negative emotions in their daily lives than persons the same measurement time needs to be mentioned. In
who do not self-harm. This heightened experience of one study [67], maladaptive and adaptive coping
negative emotion may be a principal reason for deliberate strategies were tested. Although self-harmers relative to
self-harm, as self-harm may acutely alleviate emotional non-self-harmers showed more maladaptive coping, like
distress. There is also an association between perceived behavioral disengagement and substance abuse, there
health problems and deliberate self-harm. The evidence for were no group differences for adaptive coping, like
those psychopathological factors deemed to be more active coping, acceptance, planning, or humor. Neither
specific to self-harm, such as derealization/dissociation were there any differences for seeking instrumental or
and alexithymia/lack of emotional expressivity, is good but emotional support.
490 H. Fliege et al. / Journal of Psychosomatic Research 66 (2009) 477–493

Discussion precursor of deliberate self-harm, buffering or moderating

effects were neglected for the most part.
We reviewed empirical studies on correlates and potential Although our review could identify a number of
risk factors of nonsuicidal, deliberate, self-harm behavior. correlates and several probable risk factors of deliberate
We included studies that were in accordance with an self-harm, a résumé of the evidence is limited by some
accepted definition of deliberate self-harm behavior [1]. methodological issues. Most importantly, the definition of
However, we considered some studies on suicidal behavior if deliberate self-harm varies across studies. Although we put
they also included nonsuicidal self-harm behavior. the focus on studies of self-harm without conscious suicidal
Sociodemographic and many other distal and proximal intent, a clear-cut distinction could not be made throughout.
correlates of deliberate self-harm could be identified. There Even if deliberate self-harm acts were defined by the studies'
were few longitudinal studies, but such studies did not investigators as having been carried out “without the intent to
always test the associations that we are focusing on die”, some overlaps between nonsuicidal and suicidal
prospectively. Nevertheless, most of the correlates are at behaviors may still have occurred. As a rule, suicidal intent
least suitable for inclusion in future prospective studies on was not assessed more closely; thus, it is virtually impossible
risk factors. to determine the extent to which the registered behaviors
Evidence of biographical stress and trauma in childhood encompassed nonsuicidal or suicidal intent. Therefore, we
was most frequent. Yet, the multitude of studies on childhood recommend that future studies should include psychometric
factors does not alter the fact that their validity is necessarily assessments of self-harm and intent in order to distinguish
limited by their retrospective design. nonsuicidal self-harm as precisely as possible.
With regard to proximal personal factors, evidence is Other limitations result from the variability in the
strongest for anxiety, aggression, and depression, as measurements. More specifically, deliberate self-harm is
indicators of general psychopathology, as well as for assessed by diverse methods. Although some advances in the
physical health problems. development and psychometric validation of instruments
Virtually all variables were investigated in a cross- [11,46,52] have been made, the assessments performed in
sectional design. Thus, following Kraemer et al. [55], they many of the reviewed studies were constructed ad hoc for the
can only be considered “correlates”. Even though the study. Only 15 studies used validated instruments or reported
temporal distance of biographical factors to the occurrence any information on the psychometric properties of their
of deliberate self-harm suggests that they are indeed risk assessments of self-harm. Properly validated instruments,
factors, there are methodological limits to this conclusion. like Gratz' Deliberate Self-Harm Inventory (DSHI) [11],
Precision of retrospective assessment is limited by various were rarely used. In some instances, the assessments were
factors, such as recall biases, which may result in the not even described at all. Finally, small and unequal group
overreporting or underreporting of events. sizes limit comparability.
With the exception of the person's sex, all variables were
modifiable variables [55]. This is a prerequisite for
Conclusions for research
considering them in interventions.
The pathogenic approach dominates the literature on
Knowledge on correlates and risk factors is important in
correlates and risk factors of deliberate self-harm. Studies
order to better predict, understand, and treat deliberate self-
report many potential risk factors, most frequently distal
harm behavior. Future research should include (a) long-
or biographical factors, such as emotional neglect,
itudinal studies; (b) a psychometrically sound assessment of
maltreatment, and abuse in childhood. More proximal
deliberate self-harm; (c) proximal stress factors (life events,
factors that are relevant in stress-coping models were
stress, daily hassles, or situational triggers) that occur prior to
investigated in few instances. Although one study
the onset of deliberate self-harm; (d) the coping with stress
measured stress in the past 4 weeks, it is not clear
dimension; (e) the potential role of social resources; (f)
whether this was a precursor, an accompanying condition,
models that test interactions or transactional relations
or even a consequence of self-harm. With respect to
between risk factors, including mediating and moderating
possible proximal factors, the self-harm literature is
effects, as well as interactions between dynamic risk factors
particularly incomplete. This state of knowledge is
and target behavior, including unidirectional and bidirec-
unsatisfactory, especially when we compare it with other
tional effects; and finally (g) models that test moderating
areas, such as depression, where there are comprehensive
effects of protective factors.
studies that successfully integrate distal and proximal
factors [56]. To our knowledge, there was only one study
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