Deliberate self-harm and risk assessment

Question 1

Define Deliberate self harm (DSH)

Answer 1

• When someone injures or harms themselves on purpose rather than by accident. Common examples include `overdosing’ (self-poisoning), hitting, cutting or burning oneself, pulling hair or picking skin, or self-strangulation.
• Self -harm is always a sign of something being seriously wrong.

Question 2

Does suicide have a genetic link to it ?

Answer 2

Yes - MZ twins concordance rate of 13.2%

Question 3

How common is suicide in people who deliberately self harm (DSH)?

Answer 3

40% of people who commit suicide have a history of DSH

Hx of D.S.H. is the single strongest risk factor for suicide

Question 4

What are some of the risk factors for DSH?

Answer 4

• Northern Europe > Southern Europe
• Females > males (Except Finland)
• Low socio-economic status
• Previous DSH
• Personality disorder
• -OH or other drug abuse
• Previous Psych Rx
• Unemployed (N.E.E.T)
• Criminal record
• 25-54 years of age
• Single, separated or divorced

Question 5

What should all patients who are depressed in a history taking be asked to assess suicide risk ?

Answer 5

Specifically about thoughts of hopelessness, self harm, death or suicide

have you thought how you would kill or hurt yourself – have you made any plans or preparations?

Follow up would be how close have you actually came to carrying this out?

Question 6

Go over this history taking for assessing suicide risk and depression:

initiating the session:

• introduction of yourself and role, consent
• demonstrating interest, concern and respect
• opening question: re feelings

gathering information:

• listening, use of silence
• proceeding at the patient’s pace
• gauging the patient’s emotional state
• discovering and responding to patient’s feelings
• picking up, reflecting and checking out non-verbal and verbal cues
• eliciting the patient’s ideas and concerns and the effects of the illness on their life - has there been anything going on recently in their life e.g. bereavement, breakup etc
• facilitation through repetition, interpretation and paraphrase and use of silence
• using open questions
• asking directive questions re suicidal risk and depression
• building the relationship
• non verbal communication
• lack of premature reassurance
• support
• Beliefs about themselves, their own body and the future
• Ever had any unusual experiences e.g. heard or seen something unusual

Key information required to assess suicidal risk:

how does the patient feel now? are they still feeling low?

why did the patient take the overdose or self-harm in the way they did, what was going through their head?

does the patient regret the suicide attempt? – is the patient glad to be alive

how does the patient view the future? - i.e. hopelessness

what method did the patient use to harm themselves?

did the patient plan the suicide attempt or was it an impulsive action (note this is key to the assessment of a depressed patient prior to a suicide attempt – have you thought how you would kill or hurt yourself – have you made any plans or preparations – what is the closest you have come to actually doing it)

how did the patient plan it (i.e. final acts, avoid being found, what methods used to avoid detection by other people? violent method? alcohol?)

did the patient leave a suicide note?

does the patient think they might harm themselves in the future

is there anything that would stop them doing it e.g. kids, partner etc

social and personal circumstances of the patient particularly with regard to social isolation and unemployment

has the patient tried to harm themselves before – details of methods and seriousness of attempts.

were drugs or alcohol involved at the time of the attempt

symptoms of clinical depression:

• disturbance of mood
• hopelessness/helplessness
• feelings of worthlessness, low self-esteem
• poor concentration
• loss of interest or pleasure
• guilt/self-blame
• alterations in appetite and in weight
• difficulty in sleeping – sleep pattern
• agitation or retardation

Does the patient think he could be helped with the right treatment?

would they consider that?

Question 7

Basically treatment of DSH and suicide is if they are at a real risk to themselves your looking at admitting under emergency detention for assessment and if not at a real risk then treat whatever the underlying cause is