Deliberate Self-harm Associated With Violent Criminality Interview with:

Hanna Sahlin MSc, Lic psychologist, Lic psychotherapist Specialist in clinical psychology PhD-student Departement of Clinical Neuroscience Karolinska Institutet National Self-harm project Centre for Psychiatry Research, CPF Stockholm, Sweden

Hanna Sahlin

Hanna Sahlin
MSc, Lic psychologist, Lic psychotherapist
Specialist in clinical psychology
Departement of Clinical Neuroscience
Karolinska Institutet
National Self-harm project
Centre for Psychiatry Research, CPF
Stockholm, Sweden

What is the background for this study? What are the main findings?

Response: This study is the result of wanting to find a more conclusive answer to whether individuals who engage in non-fatal deliberate self-harm are more prone to aggression towards others. There has long been a debate on whether aggression to oneself and aggression towards others co-occur, but the studies that have been conducted thus far have been on smaller samples or with clinical or forensic cohorts. Also, the studies have had great variability regarding the definition of both “deliberate self-harm” and “violence”. Thus, it has been difficult to establish an ”overall” effect size for this association, or to draw firmer conclusions on how and if this association plays out in the general population.

We had the opportunity to study this association in several large nationwide population-based registries including all Swedish citizens, and with high specificity regarding the ingoing variables of interest – i.e., non-fatal deliberate self-harm (as registered in the National Patient Register) and violent crime convictions (as registered in the National Crime Register).

We found a five times increased crude risk (hazard) of being convicted of a violent crime if one had received self-harm associated clinical care, and vice-versa, that there was an equally increased risk of self-harm if one had been convicted of a violent crime. After controlling for relevant psychiatric comorbidities and socio-economic status, an almost doubled risk of violent crime conviction remained among self-harming men and women compared to individuals not exposed to self-harm. It is important to notice that our study did not find any evidence suggesting that self-harm behaviours cause violent criminality. Therefore, we conclude that the engagement in violence towards oneself and towards others share an underlying vulnerability to impulsive and aggressive behaviours. What should readers take away from your report?

Response: Primarily we want guidelines, assessment and treatment of self-harming and violent individuals to consider this association. Clinicians treating self-harming individuals (mostly women if the setting is within psychiatric care) needs to assess violence towards others in their patients. Also, clinicians working within forensic or substance abuse settings (where it is more common for men to receive treatment) needs to ask their patients about self-harm, and assess self-harming behaviours in aggressive individuals. Unfortunately, harming oneself and harming others are behaviours that patients often want to hide from their treatment providers, as both behaviours may be met by judgments from others, and are associated with shame and stigma. Therefore, by including assessments of self-harm and violence in a non-judgmental and professional manner, we may help patients reduce stigma and receive help to target both these behaviours. What recommendations do you have for future research as a result of this study?

Response: We need research that explores how and under which conditions these behaviours co-occur and are expressed, and how they best can be treated. Treatments involving emotion regulation strategies have shown great promise regarding self-harm, perhaps the treatment agenda could be extended to include more aggressive behaviours as well. Conducting registry research enables us to ask broad questions to large samples, however, the sensitivity of the results is low, and therefore we hope to inspire research addressing the “how”, “why” and “when” of this association. Is there anything else you would like to add? Any disclosures?

Response: One thing I am very happy about in this study is that we conducted sex-specific analyses, as women’s expression of violence differs from men’s. We did find women exposed to self-harm to be at particularly high risk of violent crime compared to women not exposed to self-harm. This may be an especially vulnerable group, in need of highly qualified health care and treatment.

We do not have any disclosures to report.


Sahlin H, Kuja-Halkola R, Bjureberg J, Lichtenstein P, Molero Y, Rydell M, Hedman E, Runeson B, Jokinen J, Ljótsson B, Hellner C. Association Between Deliberate Self-harm and Violent Criminality. JAMA Psychiatry. Published online April 05, 2017. doi:10.1001/jamapsychiatry.2017.0338

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on April 7, 2017 by Marie Benz MD FAAD