Define self harm
Intentional act of self-poisoning or self-injury irrespective of the motivation or apparent purpose of the act
State some methods of self-injury
- Cutting
- Burning
- Stabbing
- Swallowing objects
- Hanging
- Shooting
- Jumping from heights
- Jumping in front of vehicles
State some methods of self-poisoning
- Medication (prescribed or OTC)
- Illicit drugs
- Household substances
- Plant materia
For self-harm, discuss:
- Prevalence
- Male to female ratio
- Common ages
- Impact it has on suicide risk
- Common (around 1 in 4 women and 1 in 10 men aged 16-24yrs reported self-harming at some point ~NICE based on 2014 evidence)
- Females > male (1.5:1)
- Adolescents & young adults
- Rate of suicide increases by 50-100 fold
What is the most common mechanism of self-harm in UK; self-injury or self-poisoning?
Self poisoning. Most commonly via medication overdose (paracetamol, aspirin, anxiolytics e.g. benzodiazepines, antidepressants)
State some risk factors for self harm
- Severe life stressors
- Age (adolescent/young adult)
- Chronic physical health problems
- Domestic violence
- Childhood abuse
- Harmful alcohol/drug use
- Psychiatric illness e.g. depression, psychosis
- Low socioeconomic class
- Harmful drug/alcohol use
- Divorced/single/living alone
- Availability of means
Suggest some reasons as to why people self harm
- Physical pain provides a relief from emotional/mental pain
- Cry for/seeking help
- Way of punishing themselves
- Genuinely want to die
- Trying to infuence another person to change their behaviour (e.g. make a partner feel guilty about threatening to end relationship)
- Way to feel in control
Many reasons which can be complex
State some common complications of self-harm
- Scarring of skin (self-cutting)
- Damage to tendons & nerves (self-cutting)
- Acute liver failure (paracetamol overdose)
State some key questions/aspects of history in self-harm case
Use the usual psychiatric history structure but key questions to think about/ensure you ask:
- What was the intention?
- Any suicidal ideation?
- Why?
- Current problems in life
- Previous self-harm
- Any psychiatric or medical illness
- Safeguarding
Discuss potential MSE of pt who has self-harmed
State some investigations you may do in a pt who has self-harmed
Bedside
- Urine drug screen
- ?ABG
Bloods
- Paracetamol levels
- Salcicylate levels
- U&Es: renal func
- LFTs: liver damage
- Clotting: liver function
Imaging
- CT head: if suspect intracranial cause for altered consciousness
- Lumbar puncture: if intracranial infection suspected for altered consciousness or other symptoms
Discuss general points in management of self-harm
*Not asking about biopsychosocial model, asking about other aspects of management that don’t fit into that model
- Risk assessment!!
- Do need admission or CHRT in community?
- Mental capacity assessment may be required if refuse medical treatment for consequences of self-harm
- Psychosocial assessment
- Ensure pt is followed up within 48hrs discharge
- Written and/or verbal information-with focus on what to do in time of crisis
Discuss the biopsychosocial management of self-harm
Biological
- Antidotes for self-poisoning
- Suturing (and possible tetanus vaccine) for deep lacerations
- Supportive care e.g. fluids
- Harm minimisation techniques in long term
Psychological
- Counselling
- CBT
- Family/systematic therapy e.g. couples therapy
- Psychodynamic psychotherapy (may be appropriate if pt has personality disorder)
Social
- Social services input for e.g housing, finances
- Support from voluntary organisations e.g. Mind, Samaritans
Which of the antidepressant drugs are most hazardous in overdose & why?
Tricyclic antidepressants
Risk of cardiac arrhythmias & convulsions
State the antidotes for following drugs that are commonly used to overdose:
- Paracetamol
- Opiates
- Benzodiazepines
- Warfarin
- Beta blockers
- TCAs
- Organophosphates
How long following discharge from hospital does a self-harm pt require follow up?
48hrs
What number of peopple who attend A&E following an act of self-harm will self-harm again within a year?
1 in 6
Which sex is suicide more common in?
Men (3x more likely to commit suicide. Chose more lethal methods)
What age group has highest rate of suicide?
45-49yrs (in both men & women)
State some of the most common methods of suicide
- Hanging
- Strangulation
- Suffocation
- Poisoning
State some protective factors against suicide
State some risk factors for suicide- think about biological, psychological & social risk factors
Biological
- Psychiatric illness e.g. depression, schizophrenia, substance miuse, personality disorder
- History of DSH or suicide
- Familly history
- Chronic physical illness
- Male
- Age 45-49
Psychological
- Childhood abuse
- Stressful life event
Social
- Low socioeconomic status
- Unemployment
- Occupation (vets, doctors, farmers- think about means!)
- Little social support e.g. living alone
- Single, divorced, widdowed
- Institutionalised
Discuss what should be involved in your risk assessment for suicide- 6 key sections
- Explore suicidal ideation
- Explore suicide intent
- Explore plans
- Notes left behind
- Final acts e.g. writing a will
- Were they alone?
- Precautions to avoid discovery?
- How did they end up with you now; did they seek help, did someone find them
- How do they feel about it now? Regret? Angry didn’t work?
- Risk factors
- Stress
- Previous DSH or suicide
- Psychiatric illness
- Chronic physical illness
- FH
- Social circumstances
- Protective factors
- Risk
- To others
- From others
- MSE
Management of a pt who is at risk of suicide depends on the level of risk; suggest some options for management
Key is to ensure safety of pt and others
- Treatment e.g. for depression
- Referral to secondary care
- Admission to hosptial or place of safety (may be under MHA)
- Involve CRHT to provide support immediately after discharge
*NOTE: if pt attempted suicide must medically stablise them
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Psychiatry Basics/Introduction17
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Psychiatric History Taking & MSE44
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Affective Disorders75
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Schizophrenia & Psychoses52
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Anxiety Disorders101
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Personality Disorders23
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Substance Misuse64
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Eating Disorders65
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Self Harm & Suicide26
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Psychotherapies36
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Psychopharmacology: Antidepressants & Antipsychotics80
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Psychopharmacology: Mood Stabilisers, Anxiolytics & Others46
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Legal Aspects of Psychiatry34
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Child & Adolescent Psychiatry63
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ECT16
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Liason Psychiatry8
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Psychological Problems Presenting with Physical Symptoms31
