Self Harm Flashcards
What is parasuicide?
An act of non-fatal outcome, in which an individual has deliberately attempted to harm themselves
Both self harm and attempted suicide fall under this term
Definition of suicide…
The act of killing oneself deliberately, initiated and performed by the individual with full knowledge and expectation of the outcome
Assessment of self harm patient…
- Secure airway if reduced consciousness
- Recovery position - if patient vomits
- Gain IV access - take full bloods and toxicology screen
- Exposure of patient to look for: cuts, burns/scalds, ligature marks, scratching
- Focussed examination - looking for signs of drug misuse, alcoholism, psychiatric disorders
What are the five components of suicide risk assessment?
- Details about current attempt:
- Trigger/ precipitating event
- Impulsive/ planned?
- Have they put plans in place e.g. written a will
- Method used
- Effort to avoid being found
- Intention
- Did they seek help after the attempt - Assessment of risk factors:
- Previous suicide attempts/ DSA
- Past psych history: affective disorders, schizophrenia
- PMH- chronic pain, insomnia
- Substance misuse
- Bereavement
- Financial difficulty
- Relationship problems - Assessment of current mood
- Protective factors - what is stopping them?
- Current thoughts/ plans about suicide attempt
Further investigations for self harm…
- Toxicology tests
- Plasma paracetamol and salicylate levels
- FBC, U&Es, LFTs
- VBG
- Drug misuse urine screen
Management of self harm patient…
Drug overdose:
- Activated charcoal within 1 hr of ingestion
- TOXBASE guidelines for all overdoses - follow treatment protocol accordingly
Injury to self:
- Superficial wound closure
- Referral for wound assessment and exploration for: wounds >5cm, deep wounds, wounds affecting deep structures
Further psychological management dependent on risk:
- Admission to psychiatric services
- Home with home treatment team
- Home with referral to secondary mental health services
- Home with GP follow up - NOT recommended for attempted suicide
What are the different types of domestic abuse?
- Emotional abuse
- Sexual abuse
- Physical abuse
- Psychological abuse
- Financial abuse
HARKS questions to screen for domestic abuse…
Humiliation - do you feel embarrassed? made to feel like you have done something wrong?
Afraid - are you afraid of your partner?
Rape - have you had sex against your will?
Kicking: have you ever been physically harmed by your partner?
Safe: do you feel safe at home?
Signs of domestic abuse…
- Bruising or injury that is inconsistent with history
- Inappropriate delay to presenting to healthcare
- Contradicting histories from both partners
- Pathological relationship between partners
- Repeated visits to different EDs
- Unusual pattern of injury - bruises/ fractures of different ages
Management of domestic abuse victim…
- Need to ensure patient is aware they are safe and what they reveal is confidential!
- Identify if there are any children at home - if so, child safeguarding need to be informed ASAP
- Refer patient to police services - if refused, offer information about charitable agences that can offer support
- If there are no children involved and patient does not want police involvement, this decision must be respected
What 2 initial questions can be asked to screen for depression?
- ‘In the last month, have you been bothered by feeling down, depressed or hopeless?’
- ‘In the last month, have you been bothered by having little interest in doing things?’
If answer is yes to either question - further assessment should be carried out.
DSM IV criteria for grading depression…
Symptoms occurring nearly every day - lasting > 2weeks:
- Depressed mood most of the day
- Anhedonia
- Significant weight changes
- Insomnia/ hypersomnia
- Psychomotor agitation/ retardation
- Fatigue
- Feelings of worthlessness
- Difficulty concentrating
- Suicidal thoughts
Grading:
- Sub-threshold depression = <5 symptoms
- Mild depression = 5+ symptoms with minor functional impairment
- Moderate depression = more symptoms and greater functional impairment
- Severe = most symptoms, which significantly impair functioning
What tools are used to assess severity of depression ?
- Beck Depression Index
- Hospital Anxiety and Depression
- Patient Health Questionnaire
Management of depression…
Sub-threshold = low-intensity psychosocial interventions e.g. computerised CBT, physical activity programme
Mild = high intensity psychological tx e.g. CBT - 1st line
Moderate/severe = antidepressants: 1st line = SSRI - 4-6 week trial 2nd line = alternative SSRI 3rd line = venlafaxine/ mirtazapine *Can be augmented by combining mediations and adding antpsychotics
Resistant depression = ECT (6-12 sessions over 3-6wks),
psychosurgery e.g. cingulotomy
What are the main clinical features of borderline personality disorder?
- Erratic mood swings
- Emotionally unstable
- Multiple unstable relationships
- Impulsive behaviours - spending, sex, substance abuse
- Recurrent suicidal behaviour
- Difficulty controlling temper
Management of borderline personality disorder…
Psychotherapy:
- psychodynamic psychotherapy
- CBT
- interpersonal therapy - improving interpersonal relationships
- group psychotherapy
*Long term management for avoiding crises is important as they are likely to have recurrent admissions for DSA
What is psychotic depression?
Form of major depression that is associated with signs of psychosis.
This includes delusions (intense feelings of worthlessness and failure) and hallucinations (auditory hallucinations telling you that you are worthless)
Unlike schizophrenia - the thoughts are often in theme with feelings of depression i.e. tend to be more bizarre
Management of psychotic depression…
- Treat the depression with antidepressants
- Treat the psychosis with anti-psychotics
What is the definition of bipolar disorder?
Episodes of hypomania/mania along with alternating episodes of depression with complete recovery inbetween
What is the difference between hypomania and mania?
Hypomania = abnormally elevated mood lasting > 4days WITHOUT pscyhosis
Mania= abnormally elevated/ irritable mood with delusions and hallucinations - lasting > 7 days
Management of bipolar disorder…
- Mood stabiliser: Lithium = 1st line, valproate = 2nd line
- Acute mania: Olanzapine/ Haloperidol - stop antidepressant if taking one
- Bipolar depression: Fluoxetine = antidepressan tof choice
Procedure after remission of acute sx:
- Maintain therapeutic dose of mood stabiliser
- Slowly withdraw additional antipsychotic
- When euthymia is achieved , taper down antidepressant dose over 8 weeks
What is factitious disorder?
Condition where individual (without malingering motive) will deliberately feign or lie about symptoms to acquire the sick role.
It may involve the individual contaminating test results and injecting material into them which can lead to harm/ illness.
Signs of factitious disorder…
- Long elaborate histories that may be inconsistent
- Symptoms that are only present when the patient is alone
- Eagerness to take part in tests/ scans/ operations
- Medical textbook definitions of their illness
- Multiple visits to other hospitals/ EDs
- Sabotaging discharge plans/ becoming more ill as they are about to be discharged
First rank symptoms of schizophrenia…
- Thought disorder: insertion, withdrawal, broadcasting, echo
- Running commentary
- Passivity of thought (controlled by external force)
- Third person auditory hallucinations
- Delusions
Negative symptoms of schizophrenia…
- Catatonic behaviour
- Apathy/ blunting
- Decreased motivation
- Poverty of speech/ thought
Diagnosis of schizophrenia…
- At least 1 first rank sx OR 2 other sx
- Lasting longer than 1 month
Management of schizophrenia…
1st line = 2nd gen antipsychotic e.g. risperidone/ olanzapine
*Need adequate 6-week trial before retrialling a different antipsychotic
Clozapine = indicated after 2 failed 6 week trials - need to titrate very gradually
Admission under MHA indicated when: patient is non-compliant, treatment failure, risk of harm to self/others
Why must clozapine administration be carefully done?
Risk of AGRANULOCYTOSIS:
Need weekly FBC checks initially as patient is gradually tapered up.
Other S/Es = reduced seizure threshold, constipation, hypersalivation
Common side effects seen with antipsychotics…
Typical (1st gen) antipsychotics:
- Parkinsonism
- Acute dystonia (sustained muscle contractions)
- Akathisia (severe restlessness)
- Tardive dyskinesia (choreathetoid movements e.g. chewing and pouting of jaw)
Atypical (2nd gen) antipsychotics:
- Weight gain
- Hyperprolactinaemia
Timeline of features of alcohol withdrawal…
6-12 hours: anxiety, tremor, tachycardia, sweating
36hrs: withdrawal fits (tonic-clonic seizures - treat with diazepam 10mg IV)
48-72hrs: delirium tremens begins (lasting about 3-5 days)
Features of delirium tremens…
- Delirium - acute confusional state
- Tremor - severe
- Hallucinations - vivid, chaotic, bizarre
