Mental health problems and self-harm

We know that most young people who present to hospital following self-harm have mental health problems, especially depression, substance misuse, anxiety disorders, and eating disorders. It is less clear whether this is the case for young people who self-harm in the community and do not seek help from the health service, although they do report more symptoms of depression and anxiety than those who do not self-harm.

Many of the young people whose parents we talked to had mental health problems which played a part in their self-harming behaviour. Depression was the most common illness mentioned, but other mental health problems included eating disorders, borderline personality disorder, bipolar disorder, obsessive compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder and anxiety. It could be worrying for parents when doctors couldn’t agree on a diagnosis. Jo said she’d feel a lot better if she knew what her daughter’s diagnosis was.

Fiona found it difficult when doctors changed their minds about her son’s diagnosis.

Age at interview 57

Gender Female

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And then the cycle, one of the cycles that my youngest son gets into, I mean he was diagnosed with bipolar. Then they told him it wasn’t bipolar. It was just the ADHD and so hes had sort of various inputs and medications and things but it’s just such a mish-mash because you see one person and they say, It’s definitely this. And you go, start going down that road and then they turn round, you see someone else and they say, It’s absolutely not that, it’s this. So you’re constantly trying to battle with the medical world, as well as all the trauma that’s going on. And one of his cycles is he will sort of sort himself out, get on a more even keel but as soon as everything starts going really well for him, he can’t handle it. Hes not comfortable with that so he will create chaos, either by taking a massive overdose.

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Ann’s daughter was given several diagnoses. She cut herself during an episode of dissociation’ (feeling detached from reality)

Age at interview 47

Gender Female

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Currently, they say that, well, the latest diagnosis is that shes got borderline personality disorder. She has got an, it’s what they call EDNOS, which is eating disorder not otherwise specified and that’s just because she dips in and out of different eating disorders and just generally has a very poor relationship with food. She either wants it or she doesn’t and it can be quite challenging for her, for everybody really.

Anxiety disorder, dissociative disorder, she can dissociate, which scares the life out of me because theres no predicting when it can happen. She can be sit here having conversation watching the TV and then all of a sudden, shes not there and it’s happened when shes been out and about as well and shes gone walking in the middle of the road, not really knowing what shes doing. She cut her neck, we think that was during an episode of dissociation. She doesn’t remember doing it.

And theres been other times when shes tried to put ligatures round her neck and she doesn’t remember and times that shell talk, you know, shell be talking, you can’t hear what shes saying, but her lips are going ten to the dozen and shes having this conversation with somebody and it’s odd but that hasn’t happened for a long while.

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Nicky thinks the Child and Adolescent Mental Health Service (CAMHS) team’s refusal to discuss a possible diagnosis of bipolar disorder made her daughter’s behaviour more extreme.

Age at interview 48

Gender Female

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So she carried on self-harming. Things didn’t get any better. Things got progressively worse. Her behaviour got worse. She started indulging in behaviours, I’m not sure, I think if you look at self-harm as a broader topic, you probably would consider them to be self-harm, although at the time I never did, but part of her, she was diagnosed with borderline personality disorder just short of her eighteenth birthday. They’re very reluctant to diagnose mental, to give mental health diagnoses prior to eighteen, particularly BPD but I think, but she shed researched it when she was about fourteen or fifteen and decided that that was probably what was wrong with her and she found it very unhelpful that CAMHS [Child and Adolescent Mental Health Service], that the person she was seeing at CAMHS, because we had family counselling at CAMHS and she had individual counselling at CAMHS, she found it very unhelpful that the person she saw individually at CAMHS wouldn’t engage with her in a discussion that this was a possible diagnosis. It’s one of the things, when weve talked about the things that made life difficult for her when she was a teen, is the fact that the person involved wouldn’t even have a conversation going, I can understand why you feel like that, [daughter’s name], we can certainly talk about it but you must understand, we don’t diagnose until eighteen. She would have been quite happy with that.

But instead, what she felt she got was a, I’m not discussing it period. And I think that what that did was it prevented her from engaging fully with CAMHS and I think, as a result of that, the destructive behaviours that we witnessed might, in some ways, have been more extreme because I think she felt she had a point to make by then.

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Nicky’s daughter’s research had probably come up with the right diagnosis. However, two of the fathers we interviewed thought their sons might have used the internet to find out about symptoms of various mental health conditions in an unhelpful way. One dad said ‘He’s starting to get uncomfortably glib in the terminology. He can reel off OCD [obsessive compulsive disorder] quite convincingly.’

Some young people had more than one mental health problem. Jane S thought that her daughter’s depression and obsessive compulsive disorder gave rise to an eating disorder which might have been prevented if she had been treated earlier. Eating disorders were seen as another form of self-harm, often resulting from low self-esteem and self-hatred. In addition, evidence shows that eating disorders are often accompanied by self-harm. Jim said his daughter turned to self-harm about six months into the onset of her anorexia. A few parents worried that alcohol and drug abuse contributed to their child’s self-harming behaviour.

Although for many parents their child’s self-harm was a major feature of their mental illness, usually depression, some saw it as just a part of their wider problems, or even as a way of coping with their mental illness. Alexis thought her daughter’s self-harming (cutting) was ‘almost separate from her depression’, which had resulted in two serious overdoses. She said ‘I don’t know whether I’d ever thought that she would try and kill herself. I wanted to believe that self-harming doesn’t have to lead to that she was obviously a young woman with a mental health problem. So this wasn’t just about self-harming. It had gone on from there’ (Alexis). ‘Although some people who self-harm are at a high risk of suicide, many people who self-harm don’t want to end their lives. In fact, the self-harm may help them cope with emotional distress, so they don’t feel the need to kill themselves’ (NHS Choices June 2015). This is true even when people hear voices telling them to kill themselves.

Erica’s daughter heard voices telling her to kill herself.

Age at interview 48

Gender Female

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But I remember one particular night where she had a terrible psychotic episode. She wasn’t psychotic but she was having psychotic episodes. What it transpired that before shed overdosed, she had been hearing voices.

Right.

And seeing a dead version of her telling her that she was coming to get her.

And the voices were telling her to kill herself but, when she was in the hospital, one of the nights she came back home and she was screaming in the car. It took me half an hour to get her out of the car in to the front door and [sighs] and all I remember was the kindness of some neighbours who passed by.

Yes.

And they didn’t know and they said, Do you need a hand? [laughs]. I said, No, no. It’s all under control. [laughs]. And by then they said, Do you want us to call somebody? And I said, Actually, I’m on the phone to the hospital. Which I was.

But thank you. And it was so kind because they could have run a mile and they didn’t. That was a bad evening because she was screaming and screaming and shes saying, Shes there. And it was this dead version of herself, And shes coming to get me. And I had to be physically very close to her and saying, Shes not coming to get you. And she said, Actually, she is. Look, she already has. And she lifted up her sleeve and she had huge burn marks there and she said, Look. Shes done that. And she carried on like that for quite a few hours and I was on the phone to the hospital and I think, with hindsight, they were very good keeping those strict boundaries because they was saying, We can’t have her here tonight. She has to be with you. She has to be at home. She has to learn that shes at home.

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When Sharon’s daughter developed an eating disorder the self-harm began to seem less important.

Age at interview 37

Gender Female

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It’s, yeah, it was all very quick. I was just, it was literally a few weeks, months of discussing about self-harming with her and her getting over getting over that or appearing to be over that and then shed cut, taken an overdose, hospitalised and then refusing to eat and just everything within a week. It all hell broke loose and the self-harm became just an element then, rather than being a large concern, it became an element of this stuff that had been going on. And what to deal with first and the most important thing was to get her eating and to stop the weight loss, to get her body well so we could then engage with therapy and trying to find out the reasons behind or what had come towards the depression and the self-harm in the first place, when it first started. It’d obviously become a coping mechanism of some description now but, at the time, it wasn’t important to find out what had kicked that off. It was more important to get her well and save her life, at the time.

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Audrey thought that her husband used self-harm to cope with the stress of post-traumatic stress disorder.

Age at interview 30

Gender Female

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A lot of the drug abuse that he did has obviously, created paranoia but hes been clean from drugs for four years in this January, four years and he has been clean from alcohol for three years. So hes taken all the steps towards getting better but people who suffer post traumatic stress disorder, they suffer flashbacks and my husband’s flashbacks usually come at night time and normally, it’s the flashbacks that he, he won’t go into too much detail about them.

This is why he needs the CBT therapy to try and help change the way that he thinks, try and help change the way that his brain works because he has, the only way hes known how to deal with anything is to store it all, chuck it to the back and every so often little bits filter through. And hes got no control over it. It’s just whatever decides to come through and he needs to properly address all the issues in relation to his past so that we can get him better.

This is where the self-harming comes in because this is the only way that my husband knew how to deal with, if anything got too stressful, if it got too much that his brain was just completely overloaded, where he just thought, I can’t, I’m already coping with enough. I can’t cope anymore. And he didn’t know how to release the frustration that he had, the only way that he knew how was to self-harm and this is obviously, in relation to the PTSD as well.

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Several parents described their own mental health problems, which some thought might have contributed to self-harm in their children. There is some evidence that children of adults with mental health problems are more likely to develop mental health problems themselves. In many cases this may be genetic*. Some of the parents we talked to felt better able to understand and help their child because of their own experiences.

Roisin thought her depression was caused by a genetic chemical imbalance. She linked her daughter’s self-cutting to her own early eating disorder and said this brought them closer.

Age at interview 45

Gender Female

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Going back to what I said earlier about me not being altogether, necessarily, surprised, what I mean is I’ve got a, a history of episodes of clinical depression. Not for any reason. Not that theres anything wrong with my life. It is a chemical thing, as far as I’m concerned and that started when I was a teenager, a young teenager and I also, you know, had an eating disorder when I was a lot younger. So the fact that my thirteen year old daughter would be doing something, to me, cutting was just another expression of how I expressed myself with eating. I mean it’s the same thing just doing something different. So the fact that my thirteen year old daughter ended up doing something like that wasn’t really an enormous surprise. It just sort of further cemented my belief that theres a very big hereditary, genetic factor, not necessarily environmentally hereditary, but I believe theres a big factor, genetically, that some people have a genetic predisposition to do these sorts of things. I believe I have that because I come from a long line of people like me. So that’s what I mean when I said it wasn’t really an enormous surprise. Yeah, and in a strange sort of way, it’s brought us much, brought us a lot closer, strangely enough. Yeah, so I think in a, in some ways, like shes going to be going off to university next year. Shes doing her A levels now. Shes a very bright girl and perhaps her having done this at a younger age, of course I would rather she didn’t have done it and hadn’t done it, but perhaps, having had the experience and going through the CBT, will better equip her to deal emotionally with whatever she faces, when she, you know, flies the nest next year. I don’t know.

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See also ‘What parents and carers think‘ and ‘Family history of mental health problems‘, and the modules on young people’s experiences of ‘Depression and low mood‘, and ‘Eating disorders‘.

* Cross-Disorder Group of the Psychiatric Genomics Consortium. Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysisThe Lancet. Published online February 28 2013.

Family history of mental health problems

Mental health problems are common in the general population. A history of mental illness in the family, especially depression, can contribute to self-harm in young...