Self Harm

Question 1

What is self-harm?

Answer 1

Any intentional act done to oneself with the knowledge that it is potentially harmful
=Way to release overwhelming emotion

Question 2

Subtypes of self harm

Answer 2

-Self-poisoning
=Prescription, OTC or illegal drugs/ non drug poisons (bleach, fertiliser), can be taken with alcohol

-Physical harm (non-fatal)
=Cutting (superficial), burning, hitting

-Physical harm (potentially fatal)
=Cutting (deep), hanging, ligatures, jumping from heights, drowning, jumping in front of moving vehicles (trains), shooting

Question 3

Epidemiology of self-harm

Answer 3

-Self-harm is a top 5 reason for attendance at acute medical services (UK)
-1 in 10 young people will self-harm at some point (underestimate)
-Patients presenting with self-harm are 50-100 times more likely to die by suicide within a year
-Suicide is the commonest cause of death in anyone under the age of 35
-Men are more likely to complete suicide than women
-Women who complete suicide are more likely to have a history of past self-harm than men

Male, unmarried, unemployed, LGBTQIA+, isolation, incarceration, occupation (farmer, vet, nurse, doctor), low socioeconomic status

Question 4

Aetiology of self-harm

Answer 4

-Epidemiological
-Psychiatric disorder
=Personality 40 fold, unipolar depression 20 fold, schizophrenia 13 fold, increased risk in recent inpatient psychiatric care discharges

-Substance misuse
=Alcohol dependence 12 fold risk, cocaine 17 fold

-Physical illness
=Debilitating, chronic pain, terminal

-Family history
=Depression, suicide, alcohol dependence

-Recent adverse life event
=Bereavement, relationship breakdown, home/ family problems, legal/ financial difficulties

Question 5

Assessment of self=harm

Answer 5

1. Presence of suicide risk factors
   =Epidemiological factors, Psychiatric disorder, Debilitating physical illness, Recent adverse life-events
2. Is there suicidal intent? How intensely did they wish to end their life?
   =Advanced planning of attempt, writing a note or will
   =Dangerous method (hanging, firearm, jump from height)
   =Plans to avoid discovery/rescue or avoiding help after an attempt
   =Route of presentation (how were they discovered? Who called for help?)
3. Mental state examination
   =Current suicidality, Current mood, Other psychiatric illness, Evidence of future planning
4. Current social supports / protective factors
   =Family, children/other dependents, friends, enjoyable job

Question 6

Management of self-harm

Answer 6

-Immediate management:
=Decide if inpatient or crisis team psychiatric care is necessary for safety
=Reduce access to means of self-harm
=Involve existing social supports

-A crisis plan should also be created for everyone:
=To be used when feeling suicidal or wanting to self-harm
=Self-help techniques (breathing and other distraction exercises; apps available for this)
=Telephone counselling services
=Who to contact in emergency

-Long-term management
=Treatment of psychiatric illness and substance abuse
=Signpost to additional social supports

Question 7

Prognosis of self-harm

Answer 7

-Self-harm increases risk of death by suicide when compared to the general population
-The overwhelming majority of people with suicidal thoughts do not go on to complete suicide
-Protective factors such as a stable relationship and occupation can help prevent someone from committing suicide
-Early intervention and treatment of psychiatric problems can greatly reduce the risk of suicide

Question 8

Questions about suicidal ideation

Answer 8

-Have you been feeling that life isn’t worth living?
-Do you sometimes feel like you would like to end it all?
-Have you given some thought as to how you might do it?
-How close are you to going through with your plans?
-Is there anything that might stop you from attempting suicide?

Question 9

Questions about the features of the act of self harm

Answer 9

-Method
-Patient’s belief in the lethality of method: did the patient believe that the combination of tablets was likely to be fatal?
-Intent
-Length of planning: was the act impulsive or planned in advance (and for how long)?
-Triggers: was there a clear precipitant? Intoxication? Any direct gain (e.g. in custody)?
-Final acts: suicide note? Setting affairs in order?
-Precautions to avoid discovery: where? Would they anticipate being found? Did they signal or tell their intentions to another? Anyone else present at the time?
-Previous similar acts: repeat of previous non-fatal act? Any different features?
-Actions after act: what did they do after act? How did they end up coming to hospital? Circumstance of discovery
-Regret?

Question 10

Mental state after self harm

Answer 10

-Attitude to survival: relieved or disappointed to be alive? Do they have an ongoing wish to die? Absent/passive/active. How do they feel about the future and what plans do they have?
-Affective symptoms: low mood anhedonia, hopelessness, biological depressive features, stress
-Substance misuse
-Mental disorders
-Risk to others: intent to harm anyone else? Did the act put anyone else at risk?

Question 11

History questions general

Answer 11

-Previous harm to self or others
-Recent actions suggestive of impending harm (e.g. buying rope)
-Recent major stressors, physical illness, relationships, employment
-Protective factors
-Depressive disorder, psychosis, substance abuse, PD
-Psychotic symptoms delusions, mood disturbance
-Demographic factors
-Drugs, alcohol
-Social restlessness
-Exposure to suicide or self-harm among friends or family
-Easy access to potential weapons or victims