Non-suicidal Self-Injury in Clinical Practice

Exploring the cessation process from adolescence to young adulthood in individuals with lived experience of nonsuicidal self-injury: a qualitative study

INTRODUCTION

Nonsuicidal self-injury (NSSI) is a common and concerning behavior in adolescents. However, most adolescents cease NSSI as they transition into adulthood. Increased knowledge of the cessation process is needed. This study aimed to qualitatively explore the factors contributing to NSSI cessation in individuals with lived experience of NSSI, providing valuable insights for treatment strategies.

METHODS

Twenty-six individuals assigned female sex at birth, between ages 20-22 years, from Sweden were interviewed between 2021 and 2023 in Linköping, Sweden. Of these, 21 individuals perceived themselves as having ceased NSSI and were included in the analysis. Thematic analysis and Hooley and Franklins' Benefits and Barriers Model of NSSI were used to analyze the transcripts.

RESULTS

Three overarching themes were generated: "Something inside me changed", "Something in my close relationships changed", and "Something in my life context changed". The cessation of NSSI was associated with several key factors. Improved well-being and envisioning a different future were pivotal in initiating the cessation process. Additionally, interpersonal relationships and support from others were interpreted as powerful motivators for change. Transitioning to a new social context and leaving behind a destructive environment provided opportunities for personal growth and enhanced well-being, interpreted as initiators in the participants' broader life context.

CONCLUSION

This study underscores the complexity of the NSSI cessation process and highlights the need for a comprehensive understanding of the underlying factors. Access to emotion regulation skills was perceived as a significant barrier to NSSI engagement. Clinical implications and different interventions to support NSSI cessation are discussed.

Non-Suicidal Self-Injury in Eating and Feeding Disorder Patients: Characteristics and Clinical Implications in a Group of Referred Female Adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) and Feeding or Eating Disorders (FEDs) often coexist during adolescence with reciprocal influences on their clinical picture. The present study aimed to identify differences and similarities in the clinical presentation of young patients with both conditions compared to those with the two non-comorbid disorders.

METHODS

We consecutively recruited forty-five female patients aged between 11 and 18 at our third-level hospital and subdivided them into three groups (NSSI: n = 15; FED: n = 15; NSSI + FED: n = 15). Patients underwent a full clinical assessment.

RESULTS

Based on our results, the NSSI + FED group was characterized by higher rates of binging/purging behaviors, greater prevalence of Cyclothymic Disorder, and a more severe clinical presentation compared to the non-comorbid groups. Moreover, higher levels of suicidal ideation were found in the NSSI + FED group. Pharmacological treatment patterns also differed, with SSRI being prescribed more frequently to NSSI + FED patients while mood stabilizers were prescribed more frequently to NSSI ones. A Principal Component Analysis identified four main dimensions: "Body Image" impairment was more pronounced in NSSI + FED patients, indicating negative attitudes towards their own body; "Metacognition" deficits were higher in NSSI than FED.

CONCLUSIONS

The present study underscores distinctive clinical features in patients with comorbid NSSI and FED, emphasizing the urgent need for tailored intervention strategies focusing on specific symptom domains.

Positive effects of parent-child group emotional regulation and resilience training on nonsuicidal self-injury behavior in adolescents: a quasi-experimental study

Background

Nonsuicidal self-injury (NSSI) among adolescents is a growing global concern. However, effective interventions for treating NSSI are limited.

Method

A 36-week quasi-experimental study design of parent-child group resilience training (intervention group) for adolescents aged 12-17 years was used and compared with treatment-as-usual (control group). The primary endpoint was the frequency of NSSI assessed with the Ottawa Self-Injury Inventory (OSI), and the secondary endpoints were the levels of depression, hope, resilience, and family adaptability and cohesion as assessed by the 24-item Hamilton depression rating scale (HAMD-24), Herth Hope Scale (HHS), Connor-Davidson Resilience Scale (CD-RISC), and Family Adaptability and Cohesion Evaluation Scale, second edition (FACES-II-CV), respectively.

Result

A total of 118 participants completed the trial. Both groups showed a significant reduction in NSSI frequency after 12, 24, and 36 weeks of intervention (p< 0.05), although the intervention group did not differ significantly from the control group. After 12, 24, and 36 weeks of intervention, the CD-RISC, HHS, HAMD-24, and FACES-II-CV scores in the intervention and control groups improved over baseline (p< 0.05). Furthermore, the intervention group had higher scores on the CD-RISC, HHS, and FACES-II-CV and lower scores on the HAMD-24 than the control group after 12, 24, and 36 weeks of intervention (p  < 0.05).

Conclusion

Parent-child group emotional regulation and resilience training showed promise as treatment options for NSSI among adolescents, leading to increased hope, resilience, and improved family dynamics among NSSI teens. Moreover, NSSI frequency significantly decreased in the intervention group compared to baseline.

Non-suicidal Self-injurious Thoughts and Behaviors Among Adolescent Inpatients

Non-suicidal self-injury (NSSI) is a serious public health concern that typically onsets during early adolescence. Adolescents (N = 980, ages 12-19 years) admitted for acute, residential psychiatric treatment completed baseline clinical interviews assessing mental disorders and questionnaires measuring demographics, early life adversity, and symptom severity. Prevalence rates of NSSI for lifetime (thoughts: 78%; behaviors: 72%), past year (thoughts: 74%; behaviors: 65%), and past month (thoughts: 68%; behaviors: 51%) were high. Although effect sizes were modest, the presence of a lifetime depressive disorder, sexual abuse, and comorbidity (i.e., three or more current disorders) were significant correlates of experiencing NSSI thoughts and behaviors. Furthermore, lifetime depressive disorder, current anxiety disorder, and comorbidity were associated with a greater odds of persistent NSSI thoughts and/or behaviors. Longitudinal studies are needed to determine whether targeting these factors reduces the persistence of NSSI thoughts and behaviors.

Association between life events, anxiety, depression and non-suicidal self-injury behavior in Chinese psychiatric adolescent inpatients: a cross-sectional study

Background

Non-suicidal self-injury (NSSI) is a major public health concern among adolescents. Further research is needed into contributors to this behavior, in particular among adolescents with psychiatric disorders. The aim of the present study was to explore the impact of life events and emotional stress on NSSI among hospitalized psychiatric adolescents.

Methods

In this cross-sectional study, 505 Chinese psychiatric adolescent inpatients 10-19  years old completed questionnaires about sociodemographic characteristics and NSSI as well as the Adolescent Self-Rating Life Events Checklist (ASLEC), the State-Trait Anxiety Inventory Form Y, and the Center for Epidemiological Studies Depression Scale. Chi-square test was used to compare the incidence of NSSI in psychiatric adolescent patients with different sociodemographic. T-test was used to compare the total scores and dimension scores of the ASLEC, STAI-Y, and CES-D between the NSSI group and the non-NSSI group. A binary logistic regression model was built to explore the relationships among sociodemographic characteristics, questionnaire scores and NSSI.

Results

Most psychiatric adolescent inpatients (393, 77.8%) reported NSSI behavior. The higher risk for NSSI was observed among female (odds ratio [OR] 2.665, 95% confidence interval [CI] 1.575-4.510), younger adolescents (10-14 years; OR 2.021, 95% CI 1.258-3.245), with a suicide history (OR 2.479, 95% CI 1.549-3.967), or with depression symptom (OR 3.217, 95% CI 1.572-6.582) and those with higher scores of ASLEC (OR 1.019, 95% CI 1.010-1.029).

Conclusion

Our study in China is one of the first to apply to adolescent inpatients the diagnostic criteria of NSSI in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Our analysis suggests that NSSI prevalence is disturbingly high among adolescents with mental illness in China. A better understanding of contributing factors, especially negative life events and negative emotions, may guide interventions that can reduce its prevalence.

A validation of the Swedish self-concept and Identity Measure (SCIM) and its association with mental health problems

Pathological disturbance to one's identity is closely linked with mental illness and in particular personality disorders. Current measures of identity pathology within clinical research are nevertheless inconsistently used and present with substantial limitations such as disproportionate focus on adolescence. The Self-Concept and Identity Measure (SCIM) identifies pathological and non-pathological identity disturbance by implementing a measurement for clinical components of identity, as well as introducing the Lack of Identity concept. This study thus explores the psychometric properties (factor structure, internal consistency, and criterion validity) of the Swedish SCIM in a large sample of Swedish university students (N = 1500). Model fit indices for the three-dimension model of identity pathology consisting of consolidated-, disturbed-, and lack of identity subscales were deemed acceptable and the Swedish SCIM scores correlated with measures of psychopathology in the expected direction, together concluding that the Swedish SCIM was satisfactorily valid and reliable. The results further reveal a significant positive correlation between identity pathology and non-suicidal self-injury, two concepts that co-occur in psychopathologies, such as borderline personality disorder, but have not yet been studied in a Western population with this tool. The potential clinical use of this translated dimensional tool needs to be tested in a Swedish clinical population, however, we conclude that it already offers insight into the complexities of identity functioning and correlations with clinical symptoms.

The effects of childhood maltreatment on adolescent non-suicidal self-injury behavior: mediating role of impulsivity

Background

Non-suicidal self-injury (NSSI) severely challenges mental health in adolescents. Childhood maltreatment experience acts as high-risk factor for adolescents to engage in NSSI behaviors. On the other hand, impulsivity or loss of control sets the threshold for NSSI execution. Here we examined the effects of childhood maltreatment on adolescent NSSI-related clinical outcomes and the potential role of impulsivity.

Methods

We assessed the clinical data of 160 hospitalized NSSI adolescents and recruited 64 age-matched healthy subjects as a control group. The clinical symptoms of NSSI are expressed by the NSSI frequency, depression, and anxiety measured by the Ottawa Self-Injury Inventory, the Beck Depression Inventory, and the Beck Anxiety Inventory. Childhood maltreatment and impulsivity were assessed with Childhood Trauma Questionnaire and Barratt Impulsiveness Scale.

Results

The results showed that when compared to HC group, NSSI group is more likely to experience childhood maltreatment. Notably, NSSI group with Childhood maltreatment accompanies higher trait impulsivity and exacerbated clinical outcomes, such as NSSI frequency, depression and anxiety symptoms. Mediation analyses indicated that the association between childhood maltreatment and NSSI-related clinical outcomes was partially explained by impulsivity.

Conclusion

We found that NSSI adolescents have a higher proportion of childhood maltreatment. Impulsivity plays a mediating role between childhood maltreatment and NSSI behaviors.

Harsh parenting and adolescent non-suicidal self-injury: A moderated mediation model of alienation and cognitive reappraisal

OBJECTIVE

Harsh parenting has been shown to be associated with non-suicidal self-injury (NSSI) in adolescents. Based on the integrated theoretical model of the development of NSSI and the cognitive-emotional model of NSSI, we proposed a moderated mediation model to investigate "how" and "when" harsh parenting is associated with adolescent NSSI. Specifically, we tested whether feelings of alienation mediated the association between harsh parenting and NSSI, and whether this indirect effect was weakened by cognitive reappraisal as an adaptive emotion regulation strategy.

METHODS

A total of 1638 Chinese adolescents (54.7 % girls; ages 12-19 years) completed self-report questionnaires in their classrooms. The questionnaires assessed harsh parenting, feelings of alienation, cognitive reappraisal skills, and incidents of NSSI.

RESULTS

Path analyses showed that harsh parenting positively predicted NSSI, and alienation mediated this association. Both the direct effect of harsh parenting on NSSI and the indirect effect through alienation were moderated by cognitive reappraisal. Specifically, cognitive reappraisal skills weakened the direct and indirect associations between harsh parenting and NSSI.

CONCLUSIONS

Adolescents may benefit from interventions that decrease feelings of alienation and increase cognitive reappraisal strategies to reduce the risk of NSSI in the context of harsh parenting.

Risk factors, theoretical models, and biological mechanisms of nonsuicidal self-injury: a brief review

Nonsuicidal self-injury (NSSI) refers to the direct, deliberate infliction of harm to one's body tissue without the intention to die. The prevalence of NSSI has increased significantly globally in recent years and has become an important public health problem affecting the health of people, especially adolescents. The occurrence of NSSI in adolescents is the result of the interaction of different factors. Many scholars have proposed various theoretical models to explain the mechanism of NSSI behavior based on previous research on the influencing factors of NSSI. Moreover, advances have been made in genetic and neuroimaging mechanisms related to NSSI. Understanding the genetic and neuroimaging mechanisms of NSSI is important for both describing and treating the disorder. This literature review discusses the progress made on the risk factors, theoretical models, and biological mechanisms of NSSI.

Exploring the association of addiction-related genetic factors with non-suicidal self-injury in adolescents

Background

Non-suicidal self-injury (NSSI) is self-injurious behavior without suicidal intent commonly seen in the adolescent population and poses a serious threat to the life safety of adolescents. Related researches suggest a possible correlation between addiction and the occurrence of NSSI. This study aimed to explore the correlation between addiction and NSSI from a molecular biological perspective by analyzing the differential expression of addiction-related genes in NSSI patients.

Methods

(1) The association between addiction and non-suicidal self-injury in a Chinese adolescent population was verified with the help of questionnaires on substance and non-substance addictions and non-suicidal self-injury among 1,329 adolescents in China, (2) Screening for key genes associated with addiction by bioinformatics analysis, and (3) RT-qPCR experiment was performed to validate key genes and Receiver Operating Characteristic curves were plotted for target genes.

Results

(1) Substance and non-substance addictions were all significantly correlated with non-suicidal self-injury, (2) Four target genes: SERPINA3, SLC14A1, RPS6 and RPS3A were screened by bioinformatics technique, and (3) Relative quantitative analysis by RT-qPCR revealed that the expression levels of SLC14A1 (p < 0.01), RPS6 (p < 0.05) and RPS3A (p < 0.01) were significantly higher in NSSI patients than in healthy controls.

Conclusion

(1) The significant association between addiction and NSSI exists in the Chinese adolescent population and (2) Addiction-related genes SLC14A1, RPS6, and RPS3A are differentially expressed in adolescents with NSSI. The genes have the potential to become biological markers for the diagnosis of NSSI.

Are PID-5 personality traits and self-harm attitudes related? A study on a young adult sample pre-post COVID-19 pandemic

Introduction

Different studies confirm a stronger link between maladaptive personality traits and Non-suicidal Self-injury (NSSI). Additionally, the interest in the relationship between the experience of the COVID-19 pandemic and NSSI is growing. The present study aims (a) to investigate differences in personality traits between individuals with NSSI, suicidal ideation, NSSI and suicidal ideation co-occurrence and none; (b) to observe which personality traits predominantly influence the occurrence of self-harm acts; (c) to evaluate the difference in self-harm attitudes pre and post COVID-19 pandemic.

Method

270 (108 males and 162 females) participants aged between 18 and 25 were included in the study. Everyone participated in a clinical interview and completed an assessment consisting of the Personality Inventory for DSM-5 (PID-5) and the Health of the Nation Outcome Scales (HoNOS). A multivariate analysis of variance (MANOVA), a multiple hierarchical regression analysis, controlling for age and gender and a T-test for independent samples were conducted.

Results

The individuals with the highest levels of negative affectivity, detachment, antagonism, and psychoticism are those who simultaneously present suicidal ideation and NSSI. Moreover, age and detachment predicted higher scores in self-harm attitudes. Our results unexpectedly do not confirm an upward trend of NSSI and suicidal ideation during the pandemic period.

Limitations

The study is cross-sectional, and no causal links can be assumed; the groups involved were not homogeneous for numerosity.

Conclusions

The results testify that the study of maladaptive traits is fundamental to a greater understanding of NSSIs. Working clinically on those could potentially reduce.

Non-suicidal self-injury motivations in the light of self-harm severity indicators and psychopathology in a clinical adolescent sample

Introduction

Adolescents with psychiatric problems are also considered a vulnerable population in terms of non-suicidal self-injury (NSSI). In the current study, we examined the associations of interpersonal and intrapersonal NSSI motivations with several NSSI severity indicators and psychopathological characteristics.

Materials and methods

In a cross-sectional research design, 158 adolescents (83.5% girls; mean age = 16.10 years; SD = 1.49) who have received inpatient or outpatient psychiatric treatment completed the Inventory of Statements About Self-Injury, the Strengths and Difficulties Questionnaire, and the Self-Critical Rumination Scale.

Results

More than two-thirds of the sample (75.3%; n = 119) reported at least one episode of NSSI in their life, and 45.38% (n = 54) have engaged in NSSI in the past month (current self-injury). The results indicated that only intrapersonal NSSI functions were linked to NSSI severity indicators (current and repetitive NSSI, versatility), interpersonal functions were not. Furthermore, a number of psychopathological features (co-occurring mental disorders, presence of a mood disorder, more internalizing mental illness symptoms, and more pronounced self-critical rumination) were associated with engaging in NSSI for intrapersonal reasons. We also identified other differences within the specific intrapersonal NSSI motivations. It should be highlighted that the anti-suicide function of NSSI behaved in exactly the opposite way as the other intrapersonal motivations.

Discussion

All this points to the fact that in clinical settings, detailed assessment of NSSI motivations and severity indicators can help to develop a more effective treatment plan.

Identity, self-blame, and body regard in NSSI: A test of moderated-mediation

BACKGROUND

Prior work suggests that an unstable identity is an important developmental factor impacting risk for non-suicidal self-injury (NSSI), partly because it can foster lowered self-esteem and self-blame coping styles. Theoretical models suggest that how one regards the self, including experiences of and reactions to one's body (e.g., body regard), impact how factors such as identity instability and coping styles influence NSSI behavior. This study tested whether body regard moderated the mediational effect of self-blame coping on the relationship between poor self-concept clarity and past-year NSSI.

METHODS

A sample of 1906 university students had complete data from an anonymous online questionnaires measuring self-concept clarity, self-blame coping, and past-year NSSI behaviors.

RESULTS

Past-year NSSI was reported by 23.5% of the sample. Moderated mediational regression analyses using the PROCESS macro for SPSS were run. Body regard significantly moderated the effects of self-blame coping and poor self-concept clarity on NSSI such that neither risk factor was associated with NSSI when body regard was high. Poor self-concept clarity also retained a significant, although weakened, direct relationship with NSSI in the full model.

CONCLUSIONS

Positive body regard is protective and appears to mitigate the strength of the relationships between poor self-concept clarity and self-blame coping on past year NSSI. When body regard is low or average, poor self-concept clarity is associated with increased NSSI, partly through the effect of self-blame coping. Treatments that address body- and self-perceptions related to self-concept may enhance the effectiveness of interventions used to reduce NSSI behavior.

Cognitive emotion regulation strategies in relation to treatment outcome in a clinical sample of adolescents with personality disorders

The aim of this study was to examine cognitive emotion regulation strategies (CERS) of help-seeking adolescents diagnosed with personality disorders. At pre-treatment, patients (N = 116) were found to use some maladaptive but also some adaptive CERS more often than adolescents from the general population. Less than 4% of these pre-treatment CERS predicted treatment outcome. In patients whose treatment outcome according to the Symptom Checklist-90 (SCL-90) showed significant improvement (N = 75), a reduction of maladaptive CERS and an increase of adaptive CERS occurred. Patients that were unchanged or deteriorated (N = 41) showed no significant changes in CERS. In conclusion, pre-treatment CERS are not predictive for treatment outcome in this sample of adolescents diagnosed with personality disorders. Even though patients who use more adaptive and less maladaptive CERS have fewer symptoms, the relationship between these CERS and symptoms in this group of severe patients remains unclear.

Meaning in Life Moderates Relations between Personality and Temperament and Nonsuicidal Self-Injury in Hospitalized Adolescents

Previous research indicates that sensation seeking, emotion dysregulation, and impulsivity are predictive of non-suicidal self-injury (NSSI). A body of research supports that meaning in life predicts improved mental health and well-being, including fewer suicidal thoughts and attempts, yet no research has examined the moderating effects of meaning in life on the relations between personality and temperament and NSSI. Given the growing incidence rates of NSSI among adolescents and the potential lifelong consequences of NSSI, it is imperative to better understand the factors that reduce the rates at which adolescents in a clinical sample engage in NSSI. The present study investigates if the protective factors of meaning in life moderate the relation between personality and temperament variables and NSSI among 126 adolescents (71% female, Mage = 16.1, SD = 1.1, range 13-18, 80% White) residing in an inpatient psychiatric hospital who endorsed NSSI in the last 12 months. Results from hurdle modeling indicate that two subtypes of meaning in life, presence of meaning in life and search for meaning of life, may serve as robust protective factors against engagement in NSSI among a clinical sample of adolescents. Additionally, results suggest that search for meaning, but not presence of meaning in life, variables moderate the relations between personality and temperament and NSSI. Results provide evidence that meaning in life is an understudied variable of importance in understanding how to prevent or treat NSSI. It also underscores the need to develop, refine, and test meaning-making interventions.

Voluntary sterilisation of young childless women: not so fast

An increasing number of bioethicists are raising concerns that young childless women requesting sterilisation as means of birth control are facing unfair obstacles. It is argued that these obstacles are inconsistent, paternalistic, that they reflect pronatalist bias and that men seem to face fewer obstacles. It is commonly recommended that physicians should change their approach to this type of patient. In contrast, I argue that physicians' reluctance to eagerly follow an unusual request is understandable and that whatever obstacles result from this reluctance serve as a useful filter for women who are not seriously committed to their expressed requests for sterilisation. As women already disproportionally bear the birth control burden, less resistance that men might be getting in terms of voluntary sterilisation works to women's advantage, providing a much needed balance. Societal attitudes towards women and motherhood should not be confused with individual physicians' reasonable reluctance to jump at a serious elective procedure at fairly mild expression of interest.

Functions of nonsuicidal self-injury in a Hungarian community adolescent sample: a psychometric investigation

BACKGROUND

The Inventory of Statements About Self-Injury (ISAS) is a psychometrically valid tool to evaluate the motives of nonsuicidal self-injury (NSSI), but there are a few studies that test gender differences in the factor structure of the measurement. However, several differences across gender were identified in NSSI (e.g., in prevalence, methods, functions). Therefore, our study focused on further analyses of the dimensionality of the ISAS functions.

METHODS

Among Hungarian adolescents with a history of NSSI (N = 418; 70.6% girls; mean age was 16.86, SD = 1.45), confirmatory factor analysis and exploratory structural equation modeling frameworks were used to test the factor structure of the ISAS part II.

RESULTS

Results support the two-factor structure of the questionnaire. Intrapersonal and interpersonal motivation factors emerged in the whole sample, but this factor structure varied across gender. Among girls, intrapersonal motivation of NSSI was associated with higher loneliness, more inflexible emotion regulation, and a more pronounced level of internalizing and externalizing mental illness symptoms.

CONCLUSIONS

Our findings provide sufficiently solid arguments for the need to examine NSSI functionality separately for adolescent girls and boys because there were clear gender differences in the motives underlying NSSI. In addition, precise scanning of patterns of NSSI functions may further help us to identify the most at-risk adolescents regarding self-injury.

Role of Gender in Phemenon of Non-Suicidal Self-Injuries and Suicide Attempt Among Clinical Population of Adolescents

Non suicidal self-injury is defined as intentional self-inflicted injury without the intent to die. Suicide attempt is defined as a non-fatal, self-directed, potentially injurious behavior with the intent to die. Although distinct behaviors, they are frequently associated and possibly clinically related. The aims of this study are to explore demographic data, social-demographic differences between genders, co-occurrence of non-suicidal self-injuries with suicide attempt, their association with gender and clinical variables. Retrospective cohort study on 143 patient admitted in Clinic for mental disorders „Dr Laza Lazarevic“, aged 14 to 18 years, between January 2015 and January 2016. Information were obtained from database and included two categories of variables: socio-demographic (age, gender, education level, current living situation) and clinical variables (abuse, neglect, peer violence, aggressive behavior, non-suicidal self-injuries, suicide attempt and others). The mean age of adolescents was 15.8 years, with female being more frequent in the sample (51.4%). The incidence of Mood disorders was significantly higher (p<0.05) in female compared to male (χ2꞊3,96, df꞊1, rC꞊0.16, p꞊0.04). A significantly higher incidence (p<0.05) of non-suicidal self-injury (χ2꞊11.15, df꞊1, rC꞊0.27, p꞊0.001) and suicide attempt was found in female compared to male (χ2꞊5.38, df꞊1, rC꞊0.19, p꞊0.02). No statistically significant difference was found in their simultaneous occurrence compared to total population of hospitalized adolescents. The findings of the present study demonstrated that non-suicidal self-injury and suicide attempt occur in clinical population of adolescent more often among female then in male adolescents.

Liability and Patient Suicide

Suicide is one of the leading causes of liability against a psychiatrist treating adult patients. Reducing the risk of liability entails understanding the phenomenology of suicide, approaching suicide risk assessment from a clinical perspective, conceptualizing how malpractice cases unfold, examining the issues of foreseeability and proper risk assessment, and developing a risk management approach to mitigate against the potential for a bad outcome. The use of various suicide screening risk assessments in certain clinical contexts is a potentially useful first step in identifying the need for further risk assessment. In conducting a more detailed review of a patient's risk, nonsuicidal self-injury is typically distinguished from suicidal intent and action, although morbidity and mortality can also be associated with any deliberate self-injury. Understanding the concepts of means reduction and risk management planning are essential elements to assist in helping reduce risk. Special attention to risk reduction related to firearms has received increased attention in recent years. Proper assessment, and documentation thereof in clinical records can assist in reducing liability. This article reviews these basic elements for the general practitioner of adult psychiatry related to suicide risk, assessment, and liability surrounding patient suicide.