Clinical Handbook - Self Harm and Suicide

Question 1

Give some risk factors for deliberate self harm (DSH)

Answer 1

DSH Largely Comes Via Self-Poisoning

Divorced/single/living alone
Severe life stressors
Harmful drug/alcohol use
Less than 35 (age)
Chronic physical health problems
Violence (domestic) or childhood maltreatment
Socioeconomic disadvantage
Psychiatric illness

Question 2

DSH can take the form of :

Answer 2

Self-poisoning in the form of overdose.
Self-injury in the form of cutting, burning, slashing.

Question 3

What can be the motive behind DSH?

Answer 3

DRIPS

Death wish: genuine wish to die.
Relief: seeking unconsciousness or pain as a means of temporary relief and escape from problems.
Influencing others: trying to influence another person to change their views or behaviour (e.g. making a spouse feel guilty for not caring enough).
Punishment: to punish oneself.
Seeking attention

Question 4

Ix for patient presenting with DSH?

Answer 4

Bloods including: Paracetamol levels (accurate between 4 and 15 hours after ingestion), salicylate levels if suspected overdose, U&Es (renal function), LFTs and clotting (synthetic hepatic function)

Urinalysis for possible toxicological analysis

CT head if an intracranial cause for altered consciousness is suspected (in self- poisoning)

Lumbar puncture if intracranial infection (e.g. meningitis) suspected (in self- poisoning)

Question 5

DDx for self poisoning?

Answer 5

Head trauma, intracranial haemorrhage, intracranial infection (e.g. meningitis, encephalitis), metabolic abnormalities (e.g. hypoglycaemia), liver disease

Question 6

Key DDx for self injury?

Answer 6

clotting disorder- easy bruising and bleeding

Question 7

Antidote for paracetamol overdose?

Answer 7

activated charcoal within one hour
N-Acetylcysteine

Question 8

Antidote to benzodiazepines?

Answer 8

flumazenil

Question 9

Antidote to warfarin?

Answer 9

vitamin K

Question 10

Antidote to Beta Blockers?

Answer 10

Glucagon

Question 11

Antidote to TCAs e.g. amitriptyline?

Answer 11

sodium bicarbonate

Question 12

Antidote to organophosphates?

Answer 12

atropine

Question 13

What are the key risk factors for suicide?

Answer 13

I’M A SAD PERSON

Institutionalized
Mental health disorders
Alone (lack of social support)
Sex (male)
Age (middle aged)
Depression
Previous attempts
Ethanol use
Rational thinking lost
Sickness
Occupation
No job

Question 14

What factors increase risk of sucessful completion of suicide?

Answer 14

Note: Planned Attempts Are Very Frightening!

1. Note left behind: usually written.
2. Planned attempt of suicide.
3. Attempts to avoid discovery.
4. Afterwards help was not sought.
5. Violent method.
6. Final acts: sorting out finances, writing a will.

Question 15

Key differences between self harm and suicide

Answer 15

suicide more common in males v SH more common in females

risk of suicide increases with age, SH more common in younger people

suicide may be well planned, SH is usually impulsive

Question 16

Differentials for a suicidal patient?

Answer 16

Depression

Depressive episode in bipolar- any episodes of feeling low in the past? have they had any previous periods where they felt particularly high or elated? Did you behave in a way that you wouldn’t normally? Did you spend any money that you wouldn’t usually?

EUPD - unstable relationships, repeated self harm?

Psychosis - voices telling them to kill themselves, trying to escape delusions of persecution?

Psychotic depression - nihilism ( do you ever feel like nothing is real or nothing has meaning) poverty ( how is your financial situation) hyperchondriasis ( have you had any concerns about your physical health), guilt (do you ever feel guilty about things that happened in the past)

Substance misuse/ alcoholism

Physical problems eg hypothyroidism