The following document was written by Dr Sayqa Azam (MBBS) Foundation year two in Psychiatry. March 2008.
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Deliberate Self Harm
One can make the mistake of confusing deliberate self harm and suicide hence I would like to define both first:
Deliberate self-harm is an acute non-fatal act of self-harm carried out deliberately with a high suicidal intent & high lethality or low suicide intent +low lethality.
While on the other hand suicide is defined as follows:
“Suicide” is defined as an act with a fatal outcome that is deliberately initiated and performed by the person with the knowledge or expectation of its fatal outcome.
Question arises as to what is self harm.Self harm can occur in various forms commonly presents as follows:
- Self-harm happens when someone hurts or harms themselves.
- take too many tablets.
- cut themselves.
- burn their body.
- bang their head.
- throw their body against something hard.
- punch themselves.
- stick things in their body.
- swallow inappropriate objects.
Statistics:
Statistically the figures noted are in UK, several thousand people take their own lives each year. Suicide accounts for 1 per cent of all deaths.
Male suicides outnumber female,while deliberate self harm is more common among women. Most occur in age ranges 22 to 54 and cases of DSH are 30 times more common than suicide.
Important point to note is that 10% of patients admitted in hospital following DSH commit suicide within 10 years hence a through assessment at presentation may prevent deaths in the future.
Risk factors for suicide include:
- Male gender (3 times more likely than women)
- Advancing age
- Unemployed
- Concurrent mental disorders
- Previous suicide attempt
- Alcohol and drug abuse
- Low socio-economic status
- Previous psychiatric treatment
- Certain professions - doctors, students,farmers.
- Low social support / living alone.
- Significant life events
- Institutionalized e.g. prisons, army.
- Family history of self harm.
Protective factors:
- Family Support, peer and emotional support.
- Access to good professional back up.
- Not using illicit drugs and not a heavy drinker.
- Stable job.
- Understanding of own mental illness.
- Compliant with medications.
- Unresolved issues if resolved decrease risk.
- Coping ability.
- Plan of protection.
Risk Assessment
Risk assessment of all clients presenting into psychiatry carries utmost importance. All hospitals have their own risk assessment tools but two commonly used are the following:
Beck’s suicide Scale and the Pierce Suicide intent scale.
Pierce Suicide Intent Scale and nearly all scales used follow the headings as below:
- Isolation. (someone there or not)
- Timing. (Timed so intervention possible)
- Precautions against rescue. (Level of precautions)
- Acting to get help. (Notification or not)
- Final acts in anticipation. (none or will made)
- Suicide note. (Presence or not)
All the above relate to the scoring of the circumstances preceding the event.
Other headings related to rating score are as below:
- Lethality (Thought would or would not kill)
- Stated Intent. (wanting to die or not)
- Premeditation. (planning in advance)
- Reaction to act. (remorse or sad)
- Predictable Outcome. (survival or death)
- Death without medical treatment.
The score depends on how much of the above are taken into account at the time of the self harm. Score would be higher if the above are taken into account at the time of self harm and vice versa.
History of Deliberate Self Harm
History plays an important role in the basic assessment of all patients. History for self harm revolves around the following headings:
- Circumstances leading to harm include:
- What happened?
- What triggered the event?
- Was a suicide note left?
- Was this what was expected
- Family and personal history.( Issues in family or personal reasons may be main cause for self harm)
- Intentions lying behind act. Wish to die or wish to escape life stresses.
- Present feelings and intentions.(How they feel now and do they still intend to die or not) It includes:
- Feelings about future.
- Thoughts about life not worth living.
- Thoughts about ending life.
- Plans for suicide or harm.
- If plans are there ask in detail what, when & how.
Management
- Medical Treatment. (Relating to specific overdoses and stabilizing patient. Remember Toxbase is a excellent source of help)
- Surgical Treatment. (If wound is there appropriate suturing or plasters accordingly).
- Most important from treatment point of view in Psychiatry is the psychosocial treatment.
Psychosocial Treatment
- Identify risks and psychological issues associated with further self harm.
- Offer needs assessment to all patients who self harm.
- Upon discharge inform GP and relevant mental health services of plan.
- Do not discharge without a follow up solely on basis of low risk and no mental illness.
- If patient is very distressed offer short admission.
- For patients with risk of repetition, offer an intensive service if discharging them like the crisis team intervention and a follow up with a psychiatrist. Involve a care coordinator and a CPN as required. Later offer CBT(Cognitive behavioural therapy).
What Help Is Available
- Talking with a non-professional.(Talking with an anonymous person may help)
- Self-help groups.(People who self harm give each other emotional support)
- Help with relationships.(If a relationship is the cause of self harm help is needed in this area.)
- Talking with a professional.(Includes all forms of therapy like cognitive behavioural therapy,problem solving and cognitive psychotherapy)
- Family meeting. (Family meetings with a therapist may help.)
- Group therapy.(A professional leads a group in a way helping people to deal with people)
Case Example:
- 30 year with a history of over dose.
- Ingested paracetamol.
- 4hrs later presented in A&E.
- No history from patient, he wants to die.
- Refuses to give blood for paracetamol levels.
Question: can he receive medical treatment without his consent?
Assess patient’s capacity to give consent. If lacking one can go ahead with treatment in best interests of patient based on his / her capacity.
What is Capacity?
Capacity: individuals should be able to:
- Understand in simple language what the medical treatment is.
- Its purpose and nature and why it is being proposed.
- Understand its principal benefits, risks and alternatives.
- Understand in broad terms what will be the consequences of not receiving the proposed treatment.
- Believe it.
- Retain the information for long enough to make an effective decision.
- Make a free choice (i.e free from pressure)
Summary
- DSH results in nonfatal injury carried out with high suicidal intent + lethality or low intent and lethality.
- Risk assessment: Assess risk and manage accordingly. Categorize as high, medium and low risk groups.
- Manage whole patient not just the complaint. Manage holistically.
- Provide patients with adequate support If discharging.
Hope this is sufficient information for you to grasp this delicate subject throughly.
References:
- www.patient.co.uk
- NICE guidelines
- Royal college of psychiatrists council report: assessment following self harm in adults.
Author:
Compiled by : Dr Sayqa Azam (MBBS)
Foundation year two in Psychiatry.
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