Self-harming or suicidal behaviour

Self-harming behaviour includes non-suicidal self-injury (NSSI) and suicidal behaviour. Both are clinical concerns warranting evaluation and intervention. Effective evidence-based treatments exist; recovery is the typical outcome with sustained engagement.

Overview

Self-harming behaviour encompasses two clinically distinct but often overlapping phenomena: Non-Suicidal Self-Injury (NSSI) — deliberate self-inflicted damage to body tissue without suicidal intent, typically for emotion regulation purposes — and suicidal behaviour, including suicidal ideation, suicide planning, suicide attempts, and suicide completion.

The DSM-5 (2013) and DSM-5-TR include Non-Suicidal Self-Injury Disorder in Section III (“Conditions for Further Study”) as a discrete proposed diagnosis. Suicidal behaviour Disorder is also in Section III. Suicidal behaviour and NSSI also occur as features of other conditions including major depressive disorder, borderline personality disorder, post-traumatic stress disorder, and substance use disorders.

NSSI is most common in adolescents and young adults; lifetime prevalence approximately 17% in adolescents and 13% in young adults internationally. Forms include cutting, burning, hitting, scratching, hair pulling, and others. NSSI is typically used for emotion regulation (distress tolerance, distraction from emotional pain, sense of control, self-punishment) rather than suicidal intent. The two phenomena are clinically distinct: most NSSI is not suicide attempt; however, NSSI is one of the strongest single predictors of subsequent suicide attempts.

Suicide is a major Canadian public-health issue. Approximately 4,500 Canadians die by suicide each year, making it a leading cause of death (third for ages 15-34). For every suicide death, approximately 25-30 suicide attempts occur; many more individuals experience suicidal ideation. Approximately 1.6% of Canadians have made a suicide attempt; 3-4% have considered suicide in the past year.

Risk factors for suicide include: prior suicide attempts (strongest single predictor), mental illness (mood disorders, substance use disorders, psychotic disorders, eating disorders), recent loss or stressor, social isolation, access to lethal means, family history of suicide, chronic illness, and certain demographic factors (older men, Indigenous youth, LGBTQ+ youth, military veterans).

Effective treatment is available. Dialectical behaviour Therapy (DBT) has the strongest evidence for both NSSI and suicidal behaviour; CBT for suicide prevention, attachment-based interventions, safety planning, means restriction, and treatment of comorbid mental-health conditions all support recovery. Recovery is the typical outcome with sustained engagement.

Signs and symptoms

Self-injury behaviour — Cutting, burning, hitting, scratching, head-banging, hair pulling, or other deliberate self-inflicted injury.
Suicidal ideation — Thoughts of death, wishing to be dead, thoughts about how one might die, more specific plans about means, time, place.
Suicide planning — Specific plans about means, time, location; obtaining means (firearms, medications); preparing for suicide (writing notes, giving away possessions).
Suicide attempts — Self-injurious behaviour with suicidal intent; may or may not result in injury or medical care.
Hopelessness — Persistent sense that things will not improve; hopelessness is one of the strongest single predictors of suicide attempts and completions.
Acute psychological pain — Intense emotional pain that feels intolerable; "psychache" (Shneidman); driving force for many suicide attempts.
behavioural changes — Withdrawal from activities and relationships; giving away possessions; saying goodbye; sudden calm after distressed period (sometimes indicating decision made).
Emotional dysregulation — Inability to tolerate or modulate intense emotions; particularly characteristic of NSSI used for emotion regulation.
Comorbid mental-health conditions — Mood disorders, substance use disorders, BPD, PTSD, eating disorders, anxiety disorders all commonly comorbid with self-harm and suicidal behaviour.
Specific risk factors — Prior attempts (strongest single predictor), recent discharge from psychiatric care, recent loss, access to lethal means, social isolation.

Diagnostic context

The DSM-5-TR includes two relevant conditions in Section III (“Conditions for Further Study” — research category):

Non-Suicidal Self-Injury Disorder:

5+ days of intentional self-inflicted damage to body surface in the past year, with the expectation that the injury will lead to only minor or moderate physical harm (i.e., no suicidal intent).
The behaviour is engaged in for one or more of: relief from negative feeling/cognitive state; resolution of interpersonal difficulty; induction of positive feeling state.
Associated with at least one of: interpersonal difficulties or negative feelings/thoughts immediately prior; preoccupation prior to engaging; frequent thinking about the behaviour.
Not socially sanctioned (tattooing, piercing) and not restricted to scab-picking or nail-biting.
Causes clinically significant distress or impairment.
Not better explained by another mental disorder or medical condition.

Suicidal behaviour Disorder:

Within the last 24 months, has made a suicide attempt.
The act does not meet criteria for non-suicidal self-injury.
Diagnosis is not applied to suicidal ideation or to preparatory acts; only to actual attempts.

NSSI and suicidal behaviour also occur as features of multiple other DSM-5-TR conditions including borderline personality disorder, major depressive disorder, post-traumatic stress disorder, eating disorders, and substance use disorders.

Validated assessment instruments include the Columbia Suicide Severity Rating Scale (C-SSRS), the Self-Injurious Thoughts and Behaviors Interview (SITBI), and the Beck Scale for Suicide Ideation. Comprehensive risk assessment is part of clinical evaluation when self-harm or suicide concerns are present.

Causes and risk factors

Self-harm and suicidal behaviour arise from interaction of biological, psychological, and social factors:

Biological factors: heritability of suicide attempts approximately 30-50%; family history of suicide is a robust risk factor independent of mental illness. Neurobiological factors include serotonergic dysregulation, HPA axis abnormalities, and structural and functional brain differences.

Mental illness: mood disorders (~50% of suicide deaths), substance use disorders, psychotic disorders, eating disorders, BPD, PTSD all substantially elevate risk. Untreated and inadequately treated mental illness substantially elevates risk.

Recent stressors: recent loss (relationship, job, financial), recent discharge from psychiatric care, legal problems, public humiliation, recent discovery of major life-disrupting event.

Specific demographic groups: older men have highest rates of completed suicide in Canada despite lower attempt rates; LGBTQ+ youth have substantially elevated risk; Indigenous youth in some regions have very elevated rates; military veterans; healthcare professionals.

Means access: access to firearms, lethal medications, or other lethal means substantially elevates risk. Means restriction is one of the most evidence-supported suicide prevention interventions.

Social factors: social isolation, recent bereavement, exposure to suicide (contagion effect, particularly in adolescents), discrimination, marginalization.

Childhood adversity: ACE exposure substantially elevates lifetime suicide risk.

NSSI-specific factors: emotion regulation difficulties, BPD or BPD features, history of childhood adversity, eating disorders, substance use, peer modelling (particularly in adolescents).

Prior attempts: prior suicide attempt is the strongest single predictor of subsequent attempts and completions; approximately 10-15% of attempters eventually die by suicide.

Typical treatments

Effective treatment for self-harm and suicidal behaviour includes:

Dialectical behaviour Therapy (DBT; Linehan): strongest evidence base. Targets emotion dysregulation, distress tolerance, interpersonal effectiveness, and mindfulness through individual therapy + skills group + phone coaching + consultation team. Strongly evidence-supported for BPD, NSSI, and suicidal behaviour.

Cognitive behavioural Therapy for Suicide Prevention (CBT-SP): structured approach focused on suicide-specific cognitions, behavioural patterns, and safety planning.

Mentalization-Based Treatment (MBT): develops mentalizing capacity; strong evidence for BPD with self-harm and suicidal behaviour.

Collaborative Assessment and Management of Suicidality (CAMS): structured framework focused on collaborative assessment and treatment planning around suicidal ideation.

Safety planning: structured safety plan (Stanley & Brown protocol) addressing recognizing warning signs, internal coping strategies, social contacts for distraction, contacts for crisis support, professional resources, and means restriction. Strong evidence base.

Means restriction: reducing access to lethal means (firearms, medications, particularly during periods of elevated risk) is one of the most evidence-supported suicide prevention interventions. Includes firearms safety planning, lockboxes for medications, and other approaches.

Crisis intervention: 24/7 crisis lines (988, Talk Suicide Canada), mobile crisis teams, emergency department evaluation, brief crisis stabilization.

Treatment of underlying mental illness: evidence-based treatment of comorbid depression, BPD, PTSD, substance use, eating disorders, psychotic disorders.

Pharmacotherapy:

Lithium has unique anti-suicide effects in mood disorders (particularly bipolar disorder).
Clozapine has unique anti-suicide effects in schizophrenia.
SSRIs and other antidepressants treat underlying mood/anxiety; use in adolescents requires careful monitoring (FDA black-box warning) but untreated depression carries higher suicide risk than treated.
Ketamine and esketamine have rapid anti-suicide effects in treatment-resistant depression.

Hospitalization: appropriate for acute suicide risk, particularly with plan, means, recent attempt, or inadequate outpatient resources.

Family involvement: family education, support, and (when appropriate) family therapy support recovery and risk reduction.

Peer support: survivor-of-suicide-attempt peer support, BPD peer support, mental-health peer support all complement clinical care.

When to seek help

If you are having thoughts of suicide right now, free 24-hour Canadian crisis support is immediately available:

9-8-8 — Suicide Crisis Helpline (call or text). Free, 24/7, available across Canada.
1-833-456-4566 — Talk Suicide Canada (call); text 45645, 4 PM–midnight ET.
1-855-242-3310 — Hope for Wellness Helpline (Indigenous-led; counselling in English, French, Cree, Ojibway, Inuktitut; 24/7).
1-866-925-4419 — Indian Residential Schools Crisis Line (24/7).
1-800-668-6868 — Kids Help Phone (under 20; call or text CONNECT to 686868; 24/7).
1-800-883-6094 — Veterans Affairs Canada Assistance Service (24/7).
911 or local emergency department if you are in immediate danger or unable to keep yourself safe.

Professional support is indicated when:

You are engaging in self-injury behaviour or have urges to do so.
You are having thoughts of suicide — passive (wishing to be dead) or active (planning).
You have made a suicide attempt — recent or in the past — and are continuing to struggle.
You are experiencing intense emotional pain that feels intolerable.
You have a mental-health condition (depression, BPD, PTSD, eating disorder, substance use disorder) that elevates risk.
You are recently bereaved by suicide — survivor-of-suicide-loss support is appropriate.
You are concerned about a friend or family member.

For families and friends: if you are concerned about someone, ask directly — research consistently shows that asking about suicide does not increase risk and may save lives. Stay with them; help them connect to crisis resources or take them to emergency department; remove or secure lethal means (firearms, medications) when possible. Centre for Suicide Prevention (suicideinfo.ca) provides resources for families.

Frequently asked questions

Is asking about suicide harmful?

No. Research consistently shows that asking about suicide does not increase risk and frequently reduces it by allowing the person to be honest about their experience and connect to support. Direct asking ("Are you having thoughts of suicide?") is appropriate and important when concerned.

How is non-suicidal self-injury different from suicide attempts?

NSSI is intentional self-injury without suicidal intent, typically used for emotion regulation, distress tolerance, or other functions. Suicide attempts are intentional self-injury with intent to die. The two phenomena often coexist; NSSI is one of the strongest single predictors of subsequent suicide attempts despite their distinct intent.

Can people who self-harm or attempt suicide recover?

Yes. Effective treatment — particularly DBT for individuals with BPD or chronic self-harm patterns, evidence-based treatment of underlying conditions, safety planning, and means restriction — substantially reduces self-harm and suicide risk. Recovery is the typical outcome with sustained engagement.

Will medication for depression increase suicide risk?

There is a small short-term elevation of suicidal ideation in some adolescents and young adults starting SSRIs (FDA black-box warning). However, untreated depression carries substantially higher suicide risk than treated. Careful monitoring during medication initiation addresses this; medication remains an important part of suicide prevention for treatable underlying conditions.

How can I help a friend or family member with suicidal thoughts?

Ask directly about suicide; listen without judgment; do not minimize or argue; help them connect to crisis resources (988, crisis line) or take them to emergency department; remove or secure lethal means when possible; involve other supports (family, healthcare); maintain contact in the period after — support is needed beyond the acute crisis.

How long does treatment take?

Standard DBT is a 12-month commitment with significant improvements within that period. Treatment of underlying conditions varies. Safety planning and crisis management can produce immediate impact. Sustained recovery typically takes years; many people benefit from ongoing maintenance support after intensive treatment.

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). APA.
Linehan, M. M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.
Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and behavioural Practice, 19(2), 256–264.
Mann, J. J., et al. (2021). Improving suicide prevention through evidence-based strategies: A systematic review. American Journal of Psychiatry, 178(7), 611–624.
Centre for Suicide Prevention (Canada). (n.d.). Resources for individuals, families, and clinicians.

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ShiftGrit Psychology & Counselling is professionally regulated, certified, and recognized by leading psychology and mental-health organizations across Alberta and Canada. These associations reflect our commitment to ethical practice, clinical standards, and evidence-informed therapy through Identity-Level Therapy and Reconditioning.

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The ShiftGrit Clinical Editorial Team combines the insight of registered psychologists, provisional psychologists, and trained writers to create accessible, evidence-informed therapy resources. All content is clinically reviewed by a Registered Psychologist.