Repetition Of Deliberate Self-harm Research Articles

Predictive modelling of deliberate self-harm and suicide attempts in young people accessing primary care: a machine learning analysis of a longitudinal study

PurposeMachine learning (ML) has shown promise in modelling future self-harm but is yet to be applied to key questions facing clinical services. In a cohort of young people accessing primary mental health care, this study aimed to establish (1) the performance of models predicting deliberate self-harm (DSH) compared to suicide attempt (SA), (2) the performance of models predicting new-onset or repeat behaviour, and (3) the relative importance of factors predicting these outcomes.Methods802 young people aged 12–25 years attending primary mental health services had detailed social and clinical assessments at baseline and 509 completed 12-month follow-up. Four ML algorithms, as well as logistic regression, were applied to build four distinct models.ResultsThe mean performance of models predicting SA (AUC: 0.82) performed better than the models predicting DSH (AUC: 0.72), with mean positive predictive values (PPV) approximately twice that of the prevalence (SA prevalence 14%, PPV: 0.32, DSH prevalence 22%, PPV: 0.40). All ML models outperformed standard logistic regression. The most frequently selected variable in both models was a history of DSH via cutting.ConclusionHistory of DSH and clinical symptoms of common mental disorders, rather than social and demographic factors, were the most important variables in modelling future behaviour. The performance of models predicting outcomes in key sub-cohorts, those with new-onset or repetition of DSH or SA during follow-up, was poor. These findings may indicate that the performance of models of future DSH or SA may depend on knowledge of the individual’s recent history of either behaviour.

Clinical determinants of hospital treated deliberate self-harm repetition: A time to recurrent event analysis.

Psychiatric disorders are strongly associated with hospital treated deliberate self-harm (DSH). However, the effect of specific disorders on risk for DSH repetition in sex-age-subgroups is understudied. The present study aims to assess the influence of various specific psychiatric disorders on risk for subsequent DSH repetition by way of time to recurrent event analysis on a national cohort of DSH patients. Individuals aged 18 and older presenting to somatic hospital for DSH during the period 2008-2018 was identified through national registers. A parametric shared frailty survival analysis was used to investigate the impact of various psychiatric disorders on risk of DSH repetition. The cohort consisted of 39,508 individuals of which 8634 (21.8%) presented with 24,028 repeated episodes of hospital treated DSH. Borderline personality disorder increased the risk of DSH repetition in females (adjusted HR 1.49, CI 1.41-1.57), while alcohol use disorder (HR 1.12, CI 1.04-1.19) and substance use disorders (adjusted HR 1.22, CI 1.14-1.32) increased the risk of repetition in males. The strongest impact of psychiatric disorder on risk of repetition was found among the elderly. Previous history of DSH was associated with the highest increased risk of repetition. Prior history of DSH was strongly associated with DSH repetition, but the influence of psychiatric disorder varied significantly by specific diagnoses and by sex and age of the patients. Efforts to prevent DSH repetition should be age and gender specific and designed to meet the needs of people with different specific psychiatric disorders.

Psychiatric disorders among adults treated for deliberate self-harm in general hospital: A national register study

BackgroundPsychiatric disorders are common among individuals treated for deliberate self-harm (DSH) in general hospitals. However, few large-scale studies have explicitly addressed psychiatric disorders among adult DSH patients. AimTo examine the presence of psychiatric disorders among adults presenting to general hospitals following DSH, and further to establish clinical and sociodemographic determinants of being diagnosed with a psychiatric disorder in this patient population. MethodData from several national registers were interlinked to identify all individuals aged 18 and older presenting to general hospital for DSH during the period 2008–2018. Logistic regression was used to examine the association between psychiatric disorders (ICD-10) and clinical and sociodemographic characteristics of the DSH patients. ResultsAltogether 39,534 subjects with 63,622 episodes of DSH were included in the study with a gender ratio (F:M) of 1.48. The majority were unmarried and had low income and education. Psychiatric disorders were present in 58.5 % of all episodes and in 54.3 % of the index episodes. Affective disorders displayed the highest prevalence (18.3 %), followed by alcohol use disorder (16.4 %). Personality disorders were highly prevalent among young females with multiple DSH episodes. Middle-aged individuals had the highest prevalence of psychiatric disorders. Presence of psychiatric disorders was significantly associated with DSH repetition. LimitationsData was restricted to variables available in the registers. ConclusionsPsychiatric disorders were common among DSH patients in the present cohort, but distributed differently between the genders. DSH repetition and middle-age was associated with being diagnosed with a psychiatric disorder.

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

BackgroundHospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia.Methods/designOur study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge.DiscussionThis study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense.Trial registration and ethics approvalThis trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370. Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).

Non-Fatal Deliberate Self-Harm in Three Remote Indigenous Communities in Far North Queensland, Australia.

Background: Indigenous Australians experience a suicide rate over twice that of the general population. With nonfatal deliberate self-harm (DSH) being the single most important risk factor for suicide, characterizing the incidence and repetition of DSH in this population is essential. Aims: To investigate the incidence and repetition of DSH in three remote Indigenous communities in Far North Queensland, Australia. Method: DSH presentation data at a primary health-care center in each community were analyzed over a 6-year period from January 1, 2006 to December 31, 2011. Results: A DSH presentation rate of 1,638 per 100,000 population was found within the communities. Rates were higher in age groups 15-24 and 25-34, varied between communities, and were not significantly different between genders; 60% of DSH repetitions occurred within 6 months of an earlier episode. Of the 227 DSH presentations, 32% involved hanging. Limitations: This study was based on a subset of a larger dataset not specifically designed for DSH data collection and assesses the subset of the communities that presented to the primary health-care centers. Conclusion: A dedicated DSH monitoring study is required to provide a better understanding of DSH in these communities and to inform early intervention strategies.

A prospective study of repetition of self-harm following deliberate self-poisoning in rural Sri Lanka.

IntroductionRepetition of deliberate self-harm is an important predictor of subsequent suicide. Repetition rates in Asian countries appear to be significantly lower than in western high-income countries. Methodological differences in studies, and the impact of access to means of self-harm with comparatively higher lethality have been suggested as reasons for these reported differences. This prospective study determines the rates and demographic patterns of deliberate self-poisoning (DSP), suicide and repeated deliberate self-harm resulting non-fatal and fatal outcomes in rural Sri Lanka.MethodsDetails of DSP admission in all hospitals (n = 46) and suicides reported to all police stations (n = 28) in a rural district were collected for the years 2011, 2012 and 2013. Demographic details of the cohort of patients admitted to all hospitals in 2011 due to deliberate self-poisoning (N = 4022), were screened to link with patient records and police reports of the successive two years with high sensitivity using a computer program. Then high specificity manual matching of all screened links was performed to identify repetition within 2 years of initial presentation. Life time repetition was assessed in a randomly selected subset of DSP patients (n = 433).ResultsThere were 15,639 DSP admissions, aged more than 9 years, and 1078 suicides during the study period. The incidence of deliberate self-poisoning and suicide in the population within the study area were 248.3/100,000 and 20.7/100,000 respectively, in 2012. Repetition rates at four weeks, one-year and two-years were 1.9% (95% CI 1.5–2.3%), 5.7% (95% CI 5.0–6.4) and 7.9% (95% CI 7.1–8.8) respectively. The median interval between two attempts were 92 (IQR 10–238) and 191 (IQR 29–419.5) days for the one and two-year repetition groups. The majority of patients used the same poison in the repeat attempt. The age and duration of hospital stay of individuals with repetitive events were not significantly different from those who had no repetitive events. The rate of suicide at two years following DSP was 0.7% (95% CI 0.4–0.9%). The reported life time history of deliberate self-harm attempts was 9.5% (95% CI 6.7–12.2%).ConclusionsThe comparatively low rates of repetition in rural Sri Lanka was not explained by higher rates of suicide, access to more lethal means or differences in study methodology.

Mental health follow-up after deliberate self-harm and risk for repeat self-harm and death

Morbidity and mortality after deliberate self-harm (DSH) are high, so mental health care shortly after DSH is recommended. Using population-level health data we determined the association between a mental health visit and risk for repeat DSH with or without intensive care unit (ICU) admission or all-cause death. Over two years, 23,140 individuals had emergency department treatment for DSH. Within 30 days, 10.7% had a family physician mental health visit, 17.1% visited a psychiatrist, 3.6% visited both and 68.6% neither. Individuals who received mental health follow-up had more chronic and severe mental illness and higher acuity DSH. Over five years, repeat DSH occurred in 4792 (20.7%). Repeat DSH was more common in those who had a mental health visit within 30 days. Adjusting for baseline characteristics attenuated these differences. Similar results were found for DSH with ICU admission (5.0%) and death (7.6%). More frequent follow-up was not associated with better outcome. Timely access to mental health care after DSH was poor at 31%. Follow-up care had virtually no association with subsequent risk, so treatment as usual is insufficient. Post-DSH care augmented with evidence-based interventions is required.

High alcohol use a strong and significant risk factor for repetitive self-harm in female and male youth: a prospective cohort study

Background: Deliberate self-harm (DSH) is reported by between 5 and 17% of youth aged 14–25 years. Current management measures focus on repetition prevention in high-risk groups. Objectives: To examine risk factors and predictors of DSH and DSH repetition in a community sample, by gender. Methods: A prospective cohort of 20 822 young adults (aged 17–24 years) was recruited when obtaining their driving license. A random sample of 5000 was approached for follow-up 12–18 months; 2991 (60%) responded and formed the cohort for this analysis. Patterns of self-harm, using a modified Beck Suicide Inventory, were investigated with logistic regression. Results: DSH was reported by 4.1% (123/2991) at baseline. Over the following 12 months, 3.0% (90/2991) reported new instances of DSH which included 20% (25) respondents who had engaged in DSH at baseline. Psychological distress was a risk factor for engaging in DSH in the past 12 months, OR 3.55 (95% CI 2.06–6.14). Although several clinical risk factors differed between genders, high alcohol use, OR 23.6 (95% CI 3.64–153) and psychological distress, OR 4.97 (95% CI 1.08–22.9) were significant risk factors for repeat DSH in both males and females. Conclusion: In this community cohort, 1 in 25 youth had self-harmed in the year prior; of these, 4 in 5 did not repeat DSH over the following year. High alcohol use stands out as a strong risk factor for DSH repetition. Assessing alcohol use may help clinicians identify those who are at greatest risk for repetitive self-harm.

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...

The Incidence and Repetition of Hospital-Treated Deliberate Self Harm: Findings from the World's First National Registry

BackgroundSuicide is a significant public health issue with almost one million people dying by suicide each year worldwide. Deliberate self harm (DSH) is the single most important risk factor for suicide yet few countries have reliable data on DSH. We developed a national DSH registry in the Republic of Ireland to establish the incidence of hospital-treated DSH at national level and the spectrum and pattern of presentations with DSH and repetition.Methods and FindingsBetween 2003 and 2009, the Irish National Registry of Deliberate Self Harm collected data on DSH presentations to all 40 hospital emergency departments in the country. Data were collected by trained data registration officers using standard methods of case ascertainment and definition. The Registry recorded 75,119 DSH presentations involving 48,206 individuals. The total incidence rate fell from 209 (95% CI: 205–213) per 100,000 in 2003 to 184 (95% CI: 180–189) per 100,000 in 2006 and increased again to 209 (95% CI: 204–213) per 100,000 in 2009. The most notable annual changes were successive 10% increases in the male rate in 2008 and 2009. There was significant variation by age with peak rates in women in the 15–19 year age group (620 (95% CI: 605–636) per 100,000), and in men in the 20–24 age group (427 (95% CI: 416–439) per 100,000). Repetition rates varied significantly by age, method of self harm and number of previous episodes.ConclusionsPopulation-based data on hospital-treated DSH represent an important index of the burden of mental illness and suicide risk in the community. The increased DSH rate in Irish men in 2008 and 2009 coincided with the advent of the economic recession in Ireland. The findings underline the need for developing effective interventions to reduce DSH repetition rates as a key priority for health systems.

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.

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.

The effect of referral for brief intervention for alcohol misuse on repetition of deliberate self-harm: an exploratory randomized controlled trial

Referral for brief intervention among people who misuse alcohol is reported to be effective but its impact among those who present to services following deliberate self-harm (DSH) has not been examined. Consecutive patients who presented to an Emergency Department (ED) following an episode of DSH were screened for alcohol misuse. Those found to be misusing alcohol were randomly assigned to brief intervention plus a health information leaflet or to a health information leaflet alone. The primary outcome was whether the patient reattended an ED following a further episode of DSH during the subsequent 6 months. Secondary outcomes were alcohol consumption, mental health and satisfaction with care measured 3 and 6 months after randomization. One hundred and three people took part in the study. Follow-up data on our primary outcome were obtained for all subjects and on 63% for secondary outcomes. Half those referred for brief intervention received it. Repetition of DSH was strongly associated with baseline alcohol consumption, but not influenced by treatment allocation. There was a non-significant trend towards the number of units of alcohol consumed per drinking day being lower among those randomized to brief intervention. Referral for brief intervention for alcohol misuse following an episode of DSH may not influence the likelihood of repetition of self-harm. Longer-term interventions may be needed to help people who deliberately harm themselves and have evidence of concurrent alcohol misuse.

Predicting Deliberate Self‐Harm in Adolescents: A Six Month Prospective Study

Few studies have investigated the extent to which psychosocial/psychological factors are associated with the prediction of deliberate self-harm (DSH) among adolescents. In this study, 737 pupils aged 15-16 years completed a lifestyle and coping survey at time one and 500 were followed up six months later. Six point two percent of the respondents (n = 31) reported an act of DSH between Time 1 and Time 2. In multivariate analyses, worries about sexual orientation, history of sexual abuse, family DSH, anxiety, and self-esteem were associated with repeat DSH during the course of the study, but history of sexual abuse was the only factor predictive of first-time DSH. The findings suggest that school-based programs focused on how young people cope with psychosocial stressors may offer promise.

Deliberate Self-Harm in the Emergency Department

Suicidal behavior is an understudied subject in Pakistan, a South-Asian developing country with a predominantly Muslim population. This study examined the characteristics and management of patients presenting with Deliberate Self-Harm (DSH) to the Emergency Department (ED) of a tertiary care teaching hospital in Karachi, Pakistan. A retrospective chart review of all patients (n = 98), over a period of 12 months was carried out. The demographic details of patients; method of DSH and, if drugs were used, their type, route, and quantity; reason for DSH; past psychiatric history; and outcome were recorded. The mean age of subjects was 23.5 years. The majority of patients were female; most had used drugs for DSH. After initial treatment in the ED, 34 patients were admitted to medical wards for further treatment, 12 were discharged from ED, while 52 patients left against medical advice. The main reasons for leaving against medical advice were financial constraints and fear of legal issues. Seven patients had at least one previous episode of DSH. Patients who left the ED without psychosocial assessment are at increased risk for repetition of DSH as well as suicide.

Age–sex differences in medicinal self-poisonings

Deliberate self-harm (DSH) is related to suicide and DSH repetition is common. DSH hospital presentations are often self-poisonings with medicinal agents. While older age and male sex are known risk factors for suicide, it is unclear how these factors are related to the nature and severity of medicinal self-poisoning (SP). Such knowledge can guide prevention strategies emphasizing detecting and treating mental illness and controlling access to means. Medicinal SP presentations by 18,383 residents of Ontario, Canada, aged 12 years and older, who presented to a hospital emergency department in that province between April 1, 2001-March 31, 2002 were characterized by the agents taken, identification of deliberate intent and medical severity. We found distinct age-sex differences in the nature and severity of medicinal SP. In youths, aged 12-17, about 40% of presentations involved analgesics, typically not prescribed and most often the acetaminophen agent-group. Females aged 12-64 were identified as deliberate more often than their male counterparts and this pattern occurred in most agent-groups, even among those who took antidepressants. The acetaminophen agent-group was most consistently associated with medical severity and this effect was strongest among female youths. Although medicinal SP was less frequent in the elderly, these presentations tended to be more medically serious and less often identified deliberate. The high proportion of medicinal SP in youths involving agents typically not prescribed and the medical severity of the acetaminophen agent-group underscore how prevention strategies must extend beyond controlling access to antidepressants. Despite a higher risk for suicide, males and the elderly may not have their deliberate intent detected and therefore, may not receive appropriate treatment. The emergency department can serve as important link to mental health care and usage patterns can provide feedback about the need for system-level enhancements and DSH surveillance.

P.6.e.005 Relationship between personality dimensions, substance misuse and repetition of deliberate self harm

P.6.e.005 Relationship between personality dimensions, substance misuse and repetition of deliberate self harm

Repetition of Deliberate Self‐Harm: A Study of the Characteristics and Subsequent Deaths in Patients Presenting to a General Hospital According to Extent of Repetition

Repetition of deliberate self-harm (DSH) is common. Some patients repeat multiple times. We have investigated the characteristics of repeaters, and mortality in three groups of DSH patients by repetition status. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine the pattern of repetition of DSH patients presenting to a general hospital between 1990 and 1997. Each patient was tracked through the monitoring system with regard to repetition. Patients traceable through National Death Registers were followed up until 2000 with respect to mortality. A total of 4,167 patients were studied of which 1,022 (24.5%) repeated at least once during follow-up. Using multinomial regression, past history of DSH was the variable most strongly associated with frequent (4+) and less frequent (1-3) repetitions. Risk of suicide was significantly increased in females with frequent repetition (7.7% dying by suicide), compared with both those with 1-3 repetitions (2.3%) and those not repeating (1.0%). The analyses were repeated for the 2,167 patients with no past history of DSH at their first presentation. Using multinomial regression, personality disorder was the only variable that was associated with 4+ repetitions compared with no repetitions, although a number of variables distinguished between patients with 1-3 repetitions and no repeat episodes. For clinicians assessing DSH patients, past history of DSH is the best predictor of infrequent and frequent repetition. In patients with no past history of DSH the presence of personality disorder increases the risk of frequent repetition of DSH.

The Green Card Clinic: Overview of a Brief Patient-Centred Intervention Following Deliberate Self-Harm

The aim of this study was to present an overview of the Green Card Clinic, a novel brief intervention service for patients presenting to the emergency department following deliberate self-harm (DSH) or with suicidal ideation, to examine its effectiveness in terms of service utilization, and patient and clinician feedback, and to explore the correlates of repeated DSH. The aims and structure of the Green Card Clinic are described. We highlight our patient-centred approach involving self-identification of difficulties from a list of problem areas, coupled with tailored intervention strategies. Relevant data are presented and characteristics of repeat DSH patients are compared to the first-episode group. Between 1998 and 2005, 456 DSH patients were referred to the clinic. Of these, 75% (n = 344) attended the first session, 43% (n = 197) the second session, 26% (n = 117) the third session, and 16% (n = 73) completed a 3-15 month follow-up. Clinic attenders (mean age 31.6 years, 57% female) reported a diverse range of self-identified problems and repeat DSH patients reported worse depression, poorer health-related behaviours, and a greater number of problems than those presenting after first-episode DSH. The clinic achieved high rates of first session attendance. This may have been attributable to the use of a few specific strategies aimed at increasing compliance, such as the green card, next-day appointments and assertive follow-up of non-attenders. For repeat self-harmers, we advocate an approach aimed at 'lifestyle change' rather than based on current psychological stressors. The Green Card Clinic service, involving a range of interventions tailored to meet the multitude of presenting needs, appears to be an acceptable and flexible approach to brief intervention for DSH.

The role of autobiographical memory specificity in deliberate self-harm: Correlates and consequences

Background Several studies have identified reduced specificity of autobiographical memory in deliberate self-harm (DSH) patients. However it is not clear which clinical variables are associated with low memory specificity in this group, or whether low specificity is particularly associated with recent DSH. Method 68 individuals followed up seven years after an index episode of DSH were re-interviewed and data collected on current psychiatric disorder, repetition of DSH in the intervening period and autobiographical memory specificity. Data on history of sexual and physical abuse during childhood were available from the index assessment. Results A hierarchical regression analysis identified older age, current affective disorder and level of familial sexual abuse during childhood as independent predictors of reduced memory specificity. Sixteen participants who had a further episode of DSH in the year prior to the current assessment were classified as having ‘recent’ DSH. Results of logistic regression suggest that low memory specificity mediates the association between childhood sexual abuse and recent DSH and partially mediates the association between current affective disorder and recent DSH. Limitations The results are based on a relatively small sample of patients from a mixed clinical group, limiting the statistical power of the analysis. Conclusions The findings confirm the association between low memory specificity and DSH. They are consistent with a multi-factorial model of impaired specificity and suggest that low specificity may be one of the mechanisms through which abuse history and affective disorder increase an individual's vulnerability to deliberate self-harm.