Psychiatry - Self Harm

Question 1

Self Harm?

Answer 1

• Intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act
• It is an expression of emotional distress
• Be mindful when prescribing drugs to people at risk of self-harm, and their relatives
• Primary care presentation: Urgently establish the likely physical risk and the person’s emotional and mental state

Question 2

Self Harm?

Answer 2

Deliberate self-harm may be caused by one or more of the following:

• A behaviour (e.g. self-cutting) intended to cause self-harm
• Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose
• Ingesting a recreational or illicit drug that was an act that the person regarded as self-harm
• Ingesting a non-ingestible substance or object

Deliberate self-harm is not usually an attempt at suicide:

• It is an attempt to maintain control in very stressful situations or emotional pressures – e.g. bullying, abuse, academic pressure or work pressure
• Self-harm is usually done in private and hidden from anyone else

Question 3

Self Harm?

Epidemiology?

Answer 3

• Self-harm is common with lifetime prevalence estimates of at least 5-6% in the UK and USA
• Self-harm is particularly common among younger people
• Self-harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold above the rest of the population in a 12-month period
• Associated with a wide range of psychiatric problems
• Other risk factors: Victims of domestic violence, socio-economic disadvantage, and those with eating disorders. There is an increased risk in South Asian women

Question 4

Self Harm?

Initial Management?

Answer 4

• Could Hx and examination
• Acute poisoning management, TOXBASE
• Medical emergency protocols for bleeding from self harm
• Psychological, pharmacological and psychosocial support
• Patient is expressing distress – perform risk assessment, care planning

Question 5

Self Harm?

Prognosis?

Answer 5

• Risk of repetition of self-harm and of later suicide is high
• 5% of people who have been seen at a hospital after self-harm will have committed suicide within nine years
• Some young people self-harm on a regular basis while others do it just once or a few times
• For some people it is part of coping with a specific problem and they stop once the problem has resolved
• Other people self-harm for years whenever certain kinds of pressures or feelings arise
• Physical health and life expectancy are severely compromised in people who self-harm

Question 6

Self Harm?

Prevention?

Answer 6

• Protective factors - parent support and positive affect
• Promotion of avoidance of alcohol and illicit drug plus healthy sleep
• Suicide note - indication of a failed but serious attempt at suicide = higher risk of future completed suicide
• For patients at risk of self-poisoning, medications prescribed for the patient or relatives should be the least dangerous in overdose and should be prescribed as a small number of tablets at any one time