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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Self-harm = intentional self-injury (cutting, burning) or self-poisoning (overdose) irrespective of suicidal intent
- Most common method of self-harm presenting to ED: self-poisoning (paracetamol is the most common drug used)
- Every presentation of self-harm requires: medical treatment + comprehensive psychosocial assessment + safety planning (NICE NG225)
- Do NOT use risk assessment tools/checklists to predict suicide — they are not accurate enough. Use clinical assessment
- Risk factors for suicide: male sex, older age, social isolation, previous attempts, chronic pain, substance misuse, mental illness, access to means
- Safety plan: collaborative, personalised — warning signs, coping strategies, support contacts, means restriction
Overview
Self-harm refers to any act of intentional self-injury or self-poisoning, irrespective of the degree of suicidal intent. It is a major public health concern and one of the strongest risk factors for completed suicide. Self-harm presentations encompass a wide spectrum from impulsive acts with minimal injury to carefully planned attempts with high lethality. Common methods include self-poisoning (overdose — paracetamol, NSAIDs, antidepressants), self-cutting, and other self-injury. Self-harm serves various functions: emotional regulation, self-punishment, communication of distress, escape from intolerable situations. It is essential to assess each presentation individually rather than making assumptions about intent or seriousness. NICE NG225 (2022) provides comprehensive guidance on assessment, management, and prevention of recurrence.
Epidemiology
Self-harm is the most common reason for acute hospital admission in women under 35. Approximately 200,000 people present to EDs in England annually with self-harm. Self-harm is more common in females (self-cutting, overdose), while completed suicide is more common in males (who use more lethal methods). Self-harm rates peak in 15–24 year olds. Key risk factors for self-harm include female sex, younger age, mental illness, previous self-harm, substance misuse, childhood adversity, relationship breakdown, and LGBT+ identity. Risk factors for suicide include male sex, older age, living alone, recent bereavement, chronic pain, terminal illness, mental illness (depression, schizophrenia, substance misuse), and previous suicide attempts (strongest predictor).
Clinical Features
Symptoms
Self-poisoning: overdose with paracetamol, NSAIDs, SSRIs, benzodiazepines, other medications
Self-cutting: superficial lacerations to forearms, thighs, abdomen — often with concealment
Other self-injury: burning, hitting, hair pulling, head banging, ingestion of objects/substances
Suicidal ideation: passive ("wish I were dead") to active (specific plan, intent, timeline)
Hopelessness: feeling that things will never improve — strongest cognitive predictor of suicide
Final acts: giving away possessions, writing notes, saying goodbye, putting affairs in order
Signs
Fresh or healed scars from cutting/burning (forearms, thighs)
Evidence of overdose: altered consciousness, nausea, vomiting, clinical features of specific toxidrome
Distress, guilt, shame, or emotional numbness
Calm and collected presentation after a high-lethality attempt (suggests resolved intent — may be higher risk)
Investigations
First-line
Medical assessment and treatmentTreat the acute medical consequences: paracetamol levels and NAC protocol, wound care, toxicology as appropriate
Comprehensive psychosocial assessmentCircumstances and motivation, intent (did they expect to die?), planning vs impulsive, current mental state, psychiatric history, social supports, ongoing suicidal ideation
Mental state examinationAssess mood, hopelessness, ongoing suicidal thoughts, psychosis, intoxication, capacity
Second-line
Risk formulation (NOT tick-box tools)Individualised clinical formulation of risk: acute dynamic factors (current crisis, intoxication, mental state) + chronic static factors (previous attempts, diagnosis, social isolation)
Collateral historyFamily, friends, GP, mental health team — context, previous episodes, recent changes
Specialist
Specialist psychiatric assessmentIf high-risk features, complex presentation, or uncertainty about diagnosis/management
1
Acute management
- Treat medical consequences of self-harm (overdose management, wound care)
- Treat with the same care, respect, and dignity as any other patient — stigma is harmful and dangerous
- Do NOT refuse treatment or make the person wait as a deterrent — this is explicitly against NICE guidance
- Assess capacity if treatment refused
2
Psychosocial assessment
- Should be carried out by trained mental health professional for every self-harm presentation
- Assess: events leading to self-harm, intent, current mental state, psychiatric history, social circumstances, ongoing risk, protective factors
- Do NOT use risk assessment scales or checklists to predict future suicide or self-harm (NICE NG225) — they lack predictive accuracy
- Clinical judgement + structured psychosocial assessment is the standard
3
Safety planning
- Collaborative safety plan: personalised, written, given to patient and shared with GP/team
- Components: warning signs, personal coping strategies, social contacts for support, professional contacts for crisis, means restriction, reasons for living
- Means restriction: discuss and facilitate — removing access to means (medications, ligatures, firearms) saves lives
4
Follow-up and preventing recurrence
- Offer follow-up within 48 hours of ED discharge
- Brief psychological intervention: problem-solving therapy (3–12 sessions)
- Treat underlying mental illness (depression, personality disorder, PTSD) per respective guidelines
- Do NOT discharge without a follow-up plan — transitions in care are high-risk periods
Complications
- Completed suicide: Self-harm is the strongest predictor — 1% within 1 year, 3–5% within 5–10 years
- Repetition: ~25% repeat within 1 year. Risk of escalation in method lethality
- Medical complications: Liver failure (paracetamol), tendon/nerve damage (cutting), infection, aspiration
- Stigma and poor care: Judgemental attitudes worsen outcomes — compassionate care reduces repetition
- Impact on family and carers: Significant psychological burden — offer family support
UKMLA Exam Tips
- 1Self-harm is a PRESENTATION, not a diagnosis — always assess underlying cause and mental state
- 2Paracetamol is the most common substance used in overdose. 4-hour level + Rumack-Matthew nomogram → NAC if above treatment line
- 3NEVER use tick-box risk scales to predict suicide (NICE NG225). Use structured clinical assessment
- 4Hopelessness is the strongest cognitive predictor of suicide — more important than depression severity alone
- 5Male sex + older age + social isolation + previous attempt + chronic pain + access to lethal means = highest suicide risk profile
- 6Safety plan ≠ no-harm contract. Safety plans are collaborative, practical, and evidence-based; contracts are NOT recommended
- 7Calm, resolved presentation after a high-lethality attempt may indicate ongoing high risk — do not assume safety
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