Deliberate Self-harm Patients Research Articles

Survey of Attitudes to Self-Harm Patients Within a Burns and Plastic Surgery Department.

This study aims to build on the small body of evidence in previously published study exploring professional attitudes toward deliberate self-harm (DSH) patients from a predominantly burns and plastic surgery perspective. The authors distributed a short paper-based questionnaire within the burns and plastics department at the Queen Elizabeth Hospital, Birmingham, where the authors gathered a mixture of qualitative and quantitative data surrounding this issue. Professionals generally agree that DSH patients require input from multiple services and that surgery is not always the best option. The most common frustration among healthcare professionals regarding the care of DSH patients includes inconsistencies in care, lack of training/understanding, and the need for a policy to guide and standardize treatment. Improving training in line with UK National Institute of Health and Care Excellence (NICE) guidance along with introducing guidelines for the care of DSH patients may help smooth out inconsistencies in care and reduce frustrations among staff members.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm.

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations. Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm. The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care. The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Personal Goals, Well-Being and Deliberate Self-Harm

The present study sought to understand the perceived well-being value of future goals as a possible explanation for why persons who are suicidal remain attached to goals that are seen as unattainable. Deliberate self-harm patients (DSH; N = 24) were compared with matched hospital controls (N = 24) on a range of measures including current well-being and perceived future well-being in the context of imagined goal attainment. Despite the DSH group having substantially lower current levels of well-being, there was no difference between the groups when forecasting their future well-being in the context of imagined attainment. For DSH participants the thought of achieving an important future goal is seen as necessary and sufficient for attaining normal levels of future well-being, which may function to keep them attached to goals that are perceived as relatively unattainable.

Profile of deliberate self-harm patients presenting to Emergency Department: A retrospective study

Background:Deliberate self-harm (DSH) is a major under-recognized epidemic in the low- and middle-income countries. This is a large retrospective study form the Emergency Department (ED) of Tertiary Care Center of South India to describe the clinicodemographic features of DSH cases.Materials and Methods:This is a retrospective study conducted at ED of Christian Medical College, Vellore, India from January 01, 2011 to December 31, 2013. All cases of DSH were included in the study. The demographic details, mode of DSH and clinical outcome were extracted from the electronic medical record. Descriptive statistics are presented. Chi-square test was used to compare categorical variables. For all tests, a two-sided P ≤ 0.05 was considered statistically significant.Results:Total of 1228 patients were admitted to ED for DSH during the study period. Male and female occurred in equal ratio. More than half of the cases occurred among age group below 30 years. Consumption of pesticides (agricultural chemicals) was the single most common mode of DSH (46%), especially among men, followed by medication overdose (29.8%). Consumption of plant poison and tablet overdose was higher among women. Overall mortality due to DSH was low (1.5%) in our study.Conclusion:DSH is under-recognized major public health problem in low-middle income countries like India. Most cases occur among young and productive age group and in equal frequencies among men and women. Timely and the appropriate institution of treatment can decrease the morbidity and mortality due to DSH remarkably.

Risk factors for deliberate self-harm in patients presenting to the emergency departments of Karachi.

To determine the risk factors for Deliberate Self-Harm (DSH) in patients presenting to the Emergency Departments (EDs) of three tertiary care hospitals of Karachi, Pakistan. Multicentre matched case control study. EDs of the Aga Khan University Hospital, Karachi, Civil Hospital, Karachi and Jinnah Postgraduate Medical Centre, Karachi, from March 2011 to February 2012. A total of 201 cases and 201 matched controls were taken from three hospitals situated in Karachi. All patients of 16 years and above presenting to the EDs of the hospitals with DSH attempt were invited to participate in the study. Controls were ED patients with complaints other than DSH. A control was matched with case for hospital, gender and age. Two questionnaires were used to collect information on the risk factors of DSH. Conditional Logistic Regression (CLR) was used to assess the association of various risk factors with DSH. Risk factors of DSH in Karachi included current history of mental disorder (OR = 4.53, 95% CI = 1.59 - 12.92), not sharing problems with someone (OR = 4.67, 95% CI = 2.4 - 9.0), living in rented houses (OR = 2.58, 95% CI = 1.37 - 4.84), Pathan ethnicity (OR = 5.05, 95% CI = 1.01-25.38) followed by others (OR = 3.88, 95% CI = 0.77 - 19.69) and Urdu speaking (OR = 2.71, 95% CI = 0.59 - 12.45). Absence of physical illness in the past month had an inverse association with DSH (OR = 0.17, 95% CI = 0.07 - 0.37). Mental illnesses, low socio-economic status and loneliness were the risk factors of DSH patients presenting to the three EDs of Karachi. Physical illness in the last month was protective against DSH in these patients. Psychiatric evaluation of DSH patients in the ED is important for early diagnosis and management of mental disorders.

Emergency department admission and mortality rate for suicidal behavior. A follow-up study on attempted suicides referred to the ED between January 2004 and December 2010.

The international literature reports that for every completed suicide there are between 8 and 22 visits to an Emergency Department (ED) for attempted suicide/suicidal behavior. To describe the characteristics of admission to emergency departments (EDs) for suicide-related presenting complaints in the metropolitan area of Bologna; to estimate the risk for all-cause mortality and for suicide; to identify the profiles of subjects most at risk. Follow-up of patients admitted to the EDs of the metropolitan area of Bologna between January 2004 and December 2010 for attempted suicide. A Cox model was used to evaluate the association between sociodemographic variables and the general mortality risk. We identified 505 cases of attempted suicide, which were more frequent for female subjects, over the weekend, and at night (8:00 p.m./8:00 a.m.). The most used suicide methods were psychotropic drugs, sharp or blunt objects, and jumping from high places. In this cohort, 3.6% of subjects completed suicide (4.5% of males vs. 2.9% of females), 2.3% within 1 year of the start of follow-up. The most common causes of death were drug use and hanging. In the multivariate analysis, those who used illicit drugs 24 hr prior to admission to the ED (hazard ratio [HR] = 3.46, 95% CI = 1.23-9.73) and patients who refused the treatment (HR = 6.74, 95% CI = 1.86-24.40) showed an increased mortality risk for suicide. Deliberate self-harm patients presenting to the ED who refuse treatment represent a specific target group for setting up dedicated prevention schemes.

The DiaS trial: dialectical behavior therapy versus collaborative assessment and management of suicidality on self-harm in patients with a recent suicide attempt and borderline personality disorder traits - study protocol for a randomized controlled trial

BackgroundIn Denmark 8,000 to 10,000 people will attempt suicide each year. The Centre of Excellence in Suicide Prevention in the Capital Region of Denmark is treating patients with suicidal behavior, and a recent survey has shown that 30% of the patients are suffering from borderline personality disorder. The majority of patients (70% to 75%) with borderline personality disorder have a history of deliberate self-harm and 10% have a lifetime risk to die by suicide. The DiaS trial is comparing dialectical behavior therapy with collaborative assessment and management of suicidality-informed supportive psychotherapy, for the risk of repetition of deliberate self-harm in patients with a recent suicide attempt and personality traits within the spectrum of borderline personality disorder. Both treatments have previously shown effects in this group of patients on suicide ideation and self-harm compared with treatment as usual.Methods/DesignThe trial is designed as a single-center, two-armed, parallel-group observer-blinded randomized clinical superiority trial. We will recruit 160 participants with a recent suicide attempt and at least two traits of the borderline personality disorder from the Centre of Excellence in Suicide Prevention, Capital Region of Denmark. Randomization will be performed though a centralized and computer-generated approach that conceals the randomization sequence. The interventions that are offered are a modified version of a dialectical behavior therapy program lasting 16 weeks versus collaborative assessment and management of suicidality-informed supportive psychotherapy, where the duration treatment will vary in accordance with established methods up to 16 weeks. The primary outcome measure is the ratio of deliberate self-harming acts including suicide attempts measured at week 28. Other exploratory outcomes are included such as severity of symptoms, suicide intention and ideation, depression, hopelessness, self-esteem, impulsivity, anger, and duration of respective treatments.Trial registrationClinical Trial.gov: NCT01512602.

Triglycerides as a biological marker of repeated re-hospitalization resulting from deliberate self-harm in acute psychiatry patients: a prospective observational study

BackgroundBiological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments.This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH.MethodsIn this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge.ResultsHigh triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients).ConclusionThe triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio-psychosocial approach appears promising, but further research is necessary to refine and validate this method.

Emergency Department Recognition of Mental Disorders and Short-Term Outcome of Deliberate Self-Harm

The authors sought to characterize the short-term risks of repeat self-harm and psychiatric hospital admission for deliberate self-harm patients discharged from emergency departments to the community, focusing on recognition of mental disorders in the emergency department. A retrospective longitudinal cohort analysis of national Medicaid claims data was conducted of adults 21-64 years of age with deliberate self-harm who were discharged from emergency departments (N=5,567). Rates and adjusted risk ratios are presented of repeat self-harm visits and inpatient psychiatric admission during the 30 days following the initial emergency visit. Approximately 9.7% of self-harm visits were followed by repeat self-harm visits and 13.6% by inpatient psychiatric admissions within 30 days after the initial emergency visit. The rate of repeat self-harm visits was inversely related to recognition of a mental disorder in the emergency department (adjusted risk ratio [ARR]=0.66, 95% CI=0.55-0.79) and directly related to recent diagnosis of anxiety disorders (ARR=1.56, 95% CI=1.30-1.86) or personality disorders (ARR=1.67, 95% CI=1.19-2.34). Recognition of a mental disorder in the emergency department was inversely related to repeat self-harm among patients with no recent mental disorder diagnosis (ARR=0.57, 95% CI=0.41-0.79); any recent mental disorder diagnosis (ARR=0.70, 95%=0.57-0.87); and depressive (ARR=0.71, 95% CI=0.54-0.94), bipolar (ARR=0.70, 95% CI=0.51-0.94), and substance use (ARR=0.71, 95% CI=0.53-0.96) disorder diagnoses. Recognition of a mental disorder was also inversely related to subsequent inpatient psychiatric admission (ARR=0.81, 95% CI=0.71-0.93). Adults who are discharged to the community after emergency visits for deliberate self-harm are at high short-term risk of repeat deliberate self-harm and hospital admission, although these risks may be attenuated by clinical recognition of a mental disorder in the emergency department.

Can early follow-up after deliberate self-harm reduce repetition? A prospective study of 325 patients

BackgroundPatients who deliberately harm themselves often repeat their self-destructive acts. The objective of this study was to assess whether a follow-up visit within 10 days to a psychiatric consultant could reduce the frequency of repeated deliberate self-harm (DSH). MethodsA cohort of 325 consecutive DSH patients attending two large emergency departments in Stockholm, Sweden, were included and followed for 6 months. Any visit to a psychiatric consultant within 10 days was registered as an early follow-up. Repeated DSH episode within 6 months among the 325 patients was detected via nationwide registers.Main outcome measure: Repeated DSH within 6 months. ResultsAt 6 months follow-up 22 (24%) of 92 patients with an early follow-up had repeated their DSH acts compared to 58 (25%) of 233 patients without an early follow-up (OR 1.06 (95% CI: 0.60–1.85) p-value 0.85). After adjustment for possible confounders, multivariable analysis showed an OR of 1.22 (95% CI: 0.62–2.38, p-value 0.56). LimitationsEarly follow-up was registered as any visit to a psychiatric consultant and no information regarding actions taken at the visit were obtained. ConclusionAfter adjusting for other factors associated with repetition there was an association of patients who were offered and thereafter attended an early follow-up visit and a decreased risk of repeated DSH.

Deliberate self-harm patients in the emergency department: who will repeat and who will not? Validation and development of clinical decision rules

Objectives(1) Validate an existing clinical tool for assessing risk after deliberate self-harm (DSH), Manchester Self-Harm Rule, in a new setting and new population, (2) develop a clinical decision rule based...

A survey of psychiatric services for people who attempt suicide in south India

Background and Aims:Self-harm is a major public health problem in the southern parts of India. This survey was undertaken to assess the nature of psychiatric services available in hospitals attached to medical colleges for those who have attempted suicide.Materials and Methods:After reviewing the relevant literature, a questionnaire was prepared. We sent this questionnaire to 94 medical colleges in South India.Results:The response rate of the survey was 50%. Psychiatric assessment of suicide attempters in the casualty department are done by mental health professionals in 23 (66%) hospitals. Psychotropic medications are prescribed for appropriate patients in 33 (94%) hospitals, while talking therapies are available in 31 (89%) hospitals. Six (17%) centers have training sessions for casualty staff in mental health assessment of patients who have attempted suicide. A majority of hospitals have medical students posted in the psychiatry department.Conclusions:The services available for people who have attempted suicide appear to be patchy in south Indian teaching hospitals. Training of frontline staff in the assessment and management of people who have attempted suicide is extremely important.

A Study of Deliberate Self-Harm and Its Repetition Among Patients Presenting to an Emergency Department

Marked differences have been found in the characteristics of people dying by suicide in Western and Asian countries. However, there is less information available on possible differences for deliberate self-harm (DSH). To compare the characteristics of people presenting to hospital in Hong Kong and Oxford (UK) with DSH, and to assess the outcome of those persons in Hong Kong. A sample of DSH patients admitted to the accident and emergency (A&E) department of a regional hospital in Hong Kong was assessed and followed up 6 months later to assess the risk of repetition of DSH, and was then compared with such patients in Oxford. The majority of patients in Hong Kong were female (male:female ratio of 1:2.4), young (59% were under 35), and had used self-poisoning (78%). Over one-third were single (37%) and one-fourth unemployed (26%). About half (49%) scored in the high or very high categories of the Beck's Suicide Intent Scale, considerably more so than in Oxford; 44.6% of patients defaulted psychiatric outpatient service during the 6-month follow-up period. The repetition rate within the following 6 months was 16.7%. The number of self-reported adverse life problems, history of childhood sexual and physical abuse, and repetitive self-mutilation were shown to be the factors most strongly correlated with the risk of re-attempt. Alcohol problems were much lower than in Oxford. The findings show that DSH patients in Hong Kong show some marked differences compared to those in Oxford. Implications for the prevention of repeated DSH in Hong Kong are discussed.

Deliberate self-harm in rural and urban regions: A comparative study of prevalence and patient characteristics

In countries like the UK, people living in urban regions are more likely to suffer poor physical and mental health than rural populations, and to have increased rates of psychiatric disorder. Urban/rural differences in suicidal behaviour have most frequently focussed on variations in the occurrence of suicide. We have investigated rates of deliberate self-harm (DSH) in urban and rural districts of Oxfordshire, England, and compared characteristics of DSH patients resident in these two areas. Information was collected on 6833 DSH episodes by 4054 persons aged 15 years and over presenting to the local general hospital between 2001 and 2005. We found that urban DSH rates were substantially higher than rural rates amongst both males and females aged between 15 and 64 years. This relationship was sustained even when socio-economic deprivation and social fragmentation were taken into account. There was little difference between urban and rural rates for patients aged 65 years and over. Urban DSH patients were more likely to be younger, non-white in ethnic origin, unemployed, living alone, to have a criminal record, to have previously engaged in DSH, and to report problems with housing. Rural DSH patients were more likely to suffer from physical illness, and to have higher suicide intent scores. Results of studies such as this can help identify where resources for preventive initiatives should be primarily directed and also what types of individuals may be at most risk in different areas. However, since variation by area will in part be due to differences at the individual level, further research utilising multi-level modelling techniques would be useful.

Religious beliefs, coping skills and responsibility to family as factors protecting against deliberate self-harm

<p><strong>Background.</strong> Deliberate self-harm (DSH) ranges from behaviours aiming to communicate distress or relieve tension, but where suicide is not intended, to actual suicide. Not all individuals are prone to DSH, which suggests that there are factors that protect against it. Identifying these could play an important role in the management and prevention of DSH.</p><p><strong>Objectives.</strong> This study examined whether religious beliefs, coping skills and responsibility to family serve as factors protecting against DSH in Kota Kinabalu, Sabah, Malaysia. <strong></strong></p><p><strong>Method.</strong> A cross-sectional comparative study assessed DSH patients consecutively admitted or directly referred to Queen Elizabeth General Hospital and Hospital Mesra Bukit Padang during the period December 2006 - April 2007. DSH patients (N=42) were matched with controls (N=42) for gender, age, religion, race, occupation and marital status. The DSH and control groups were compared using psychosocial tests that assess coping skills, religious beliefs and responsibility to family.</p><p><strong>Results.</strong> There were significant differences in religious beliefs (p=0.01) and responsibility to family (p=0.03) between the DSH patients and the control group. There were also significant differences in coping skills, DSH patients tending to use emotion-orientated coping (p=0.01) as opposed to task- and avoidance-orientated coping.<strong> </strong></p><p><strong>Conclusion.</strong> Consistent with international studies, coping skills (i.e. task-orientated skills), religious beliefs and responsibility to family were more evident in patients who did not attempt DSH than in those who did. These findings imply that treating DSH should not start only at the point of contact. Protective factors such as religious beliefs, responsibility to family and coping strategies can be inculcated from a very young age. However, caution is required in generalising the results owing to limitations of the study. Further extensive research on religious and psychotherapeutic interventions and prospective studies on protective factors will be helpful.</p>

Prevalence of Borderline Personality Disorder and its Clinical Correlates in Chinese Patients with Recent Deliberate Self-Harm

This study examined the point prevalence of Borderline Personality Disorder (BPD) and its clinical correlates in patients with recent deliberate self-harm (DSH) in Hong Kong. A representative consecutive sample (n = 160) of patients with DSH referred to Prince of Wales Hospital from April 1, 2007 to March 31, 2008 was recruited. Their BPD status was determined according to the BPD subscale of the Chinese version of Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). The point prevalence of BPD was calculated. Subjects with and without BPD were compared in terms of demographic and clinical characteristics. Thirty out of 160 (18.8%) DSH patients were found to suffer from BPD. DSH patients with BPD were more likely to be female (p = .020), more often reported history of childhood physical (p = 0.043) and sexual abuse (p < 0.001), history of past DSH (p = 0.010), being younger at first DSH (p = 0.039), and more likely to suffer from current alcohol and substance use disorder (p = 0.043) and eating disorder (p = 0.040) than those without BPD. Being female, having history of childhood sexual abuse and current alcohol and substance use disorder were found to be independent predictors of BPD status by binary logistic regression.

Deliberate self-harm patients in the emergency department: factors associated with repeated self-harm among 1524 patients

Objectives(1) investigate risk factors associated with repeated deliberate self-harm (DSH) among patients attending the emergency department due to DSH, (2) stratify these patients into risk categories for repeated DSH and...

Living alone and deliberate self-harm: a case–control study of characteristics and risk factors

An increasing proportion of the UK population live alone. Little is known about deliberate self-harm (DSH) patients who live alone. We conducted a study of the characteristics of DSH patients who live alone using data from the Oxford Monitoring System for Attempted Suicide. Data on patients presenting to the general hospital in Oxford with an episode of DSH between 1993 and 2006 were analysed by gender and age group (15-24years, 25-54years and 55+ years) and according to whether or not they lived alone. In total, 1,163/7,865 (14.8%) patients lived alone. Having a problem with social isolation was more common in those living alone compared with those living with others, especially in those aged 55+ years. In the 25-54years age group several variables concerning psychiatric problems were more common in those living alone, as was higher suicide intent associated with the current DSH episode and past DSH, and for females, repetition of DSH within 12months. In patients aged 55+ years those living alone were more likely to have problems due to bereavement. Significantly more individuals living alone died from any cause. More also died by suicide, although the difference between the groups was non-significant after adjusting for age. These results have implications for psychiatric services assessing DSH patients who live alone, since, depending on the patient's age and living circumstances, different psychiatric and social interventions may be needed. Middle-aged DSH patients who live alone appear to be particularly vulnerable. DSH patients who live alone may not have supportive social networks and may be at increased risk of repetition of DSH and suicide.

Deliberate self-harm: the St Andrew’s experience

Deliberate Self-Harm (DSH) resulting in multiple cuts to the forearms and wrists is an increasingly common problem in the UK, providing a regular source of referrals for hand trauma services in the UK. It requires the input of both the mental health services and appropriate surgical services and frequently long-distance transfers to regional hand trauma centres. In providing for a minimum standard of care, as stipulated by the UK Department of Health in 1984 (Department of Health and Social Security 1984), for this often behaviourally challenging subset of patients, recommendations were made that all DSH patients have a mental health assessment prior to discharge. The care of such patients is frequently labour intensive in its demands on nursing staff demanding skills and expertise that may be better provided for by psychiatric staff (Royal College of Psychiatrists 1994), but little advice is available for the specific context in which plastic surgeons should manage this subset of patients. Retrospective data was gathered between 1996 and 2005 to ascertain the demographic profile of patients, previous self-harm and mental health history, and the patterns of injury and; to assess by long-term follow-up residual disabilities incurred by the injuries. In total, there were 228 individual patients presenting on 270 occasions with a male to female ratio of 3:2. The average duration as an inpatient was for 2–3 days. Being a large regional hand trauma unit, the catchment area within which such referrals are made, makes coordinating the safe discharge and appropriate follow-up of these patients particularly difficult. Despite the benefits of a large mental health unit on site, local versus regional funding issues have historically made patient care difficult. Multi-specialty cooperation and appropriate funding has significantly improved the level of patient supervision and quality of discharge for these patients in the last 10 years, but this has occurred with varying levels of success at a predominantly local level.

Painful engagement in deliberate self-harm: The role of conditional goal setting

Conditional goal setting is the tendency for people to see attainment of their future personal goals as necessary for their well-being. It has been argued that this represents an unhealthy way of relating to one’s goals, as well as being particularly problematic when goals are perceived as unlikely. High conditional goal setting has been found to be related to depression and to hopelessness. The present study examined conditional goal setting in deliberate self-harm, where problematic thinking about the future is very prominent. A group of individuals attending hospital for a recent episode of deliberate self-harm (N=25) were compared with controls attending hospital for minor injuries (N=25) as well as a psychologically disordered but non-suicidal control group (N=25). Participants generated goals and rated goal likelihood, the extent to which those goals were seen as necessary for their future well-being (conditional goal setting), and also the extent to which the goals were seen as sufficient for their future well-being (goal sufficiency). Deliberate self-harm patients showed a higher degree of both conditional goal setting and goal sufficiency than did both of the other groups, further confirming the idea of painful engagement with personal goals, rather than disengagement, as characterising deliberate self-harm.