Self Harm and Suicidality

Question 1

Suicide

Answer 1

Suicide accounts for about 1% of deaths; M>F Rare in children, uncommon in adolescent
o Social Factors (especially Isolation) and Medical Factors (E.g. Depressive Disorder,
ETOH, Abnormal Personality)

Question 2

Presentation with Suicidal Ideation

Answer 2

• Referral to Specialist services and possible admission if strong suicidal intentions, severe
associated psychiatric illness, or person lacking social support
o If admission is not required, management depends on ensuring good support,
offering resources to obtain help, etc

Question 3

Deliberate Self Harm

Answer 3

Deliberate self-harm is usually by drug overdose; May also be Self-injury, Lacerations and
more dangerous methods (e.g. Jumping, Shooting, Drowning)
o More common in younger people;
Predisposition from Childhood difficulties,
Adverse Social Circumstances, Poor Health;
Precipitants include Stressful Life events;
Only a minority have Psychiatric disorder
o 1 – 2% risk of Suicide (100× more than
general population)

Question 4

Patterns of Suicide

Answer 4

Most Completed Suicides are planned; Precautions against Discovery are often taken; 1/6
leave Suicide notes (which may include pleas for forgiveness, accusations); In most cases,
some warning of indication is given to relative, friends or healthcare providers
o History of Deliberate Self-harm in up to half

Question 5

Epidemiology of Suicide

Answer 5

Suicide Rate has decreased in UK to about 10 per 100,000/yr males and, 3 per 100,000/yr
females; Underestimated as uncertain cases are not counted
o Highest in Older, Male, Divorces/Unmarried; Drug overdose accounts for 2/3 of
female suicide and 1/3 of male suicide; Remainder Physical (Hanging, Shooting,
Wounding, Drowning, Jumping, Moving vehicles)

Question 6

Social Risk Factors for Suicide

Answer 6

Elderly, Social Isolation, Lack of Family/Support, Stress, Publicity (copycat methods);

Question 7

Medical Risk factors for suicide

Answer 7

Depressive Disorder, ETOH/Drugs. Schizophrenia, Personality Disorder, Chronic
o 15% LTR of suicide in Severe Depression; 10% LTR in Schizophrenia (Especially
younger patients with retained insight in prognosis)

Question 8

Adolescent Suicide

Answer 8

Associated with Broken Homes, Social Isolation, Depression, Violence
and Impulsive Behaviours

Question 9

Doctors Suicide

Answer 9

Higher rates believed to be due to availability to drugs, Substance Abuse, Stressors,
Reluctance to seek treatment for Depressive Disorders and Personality Predisposition

Question 10

Assessment of Suicide Risk

Answer 10

• Evaluation of Intention – Asking about Intentions does not make suicide more likely if asked
sympathetically; Do you feel that life is not worth living? Followed by questions about
Thoughts, Plans, Preparatory Acts; Assessed by Beck Suicide Intent Scale
• Previous Acts of Deliberate Self-Harm – Especially if Continuing Death Wish, Previous Acts, or
Sociodemographic factors
• Psychiatric Disorder – Especially Depressive Disorder (Severe Mood Changes, Hopelessness,
Insomnia, Anorexia, Weight Loss or Delusions), Schizophrenia, Personality Disorder,
Substance Misuse Disorders
• Factors that may reduce risk – Including Good Support from Family and others to assist with
Social, Practical and Emotional Difficulties
• Homicidal Ideas in Suicidal Patients – Typically of Partner, or Children to spare intolerable
suffering; Taken seriously, since they might be acted upon

Question 11

Suicide Prevention

Answer 11

• Early Recognition and Help for those at risk
• Support for those at risk – Primary Care and Social Agencies; Charitable sector (e.g. Samaritans 24h support 116123)
• Reducing the means for suicide – Prescribing decisions, Admission
• Education, Public Health, Social and Economic Policy

Question 12

Management of Patients at High Risk

Answer 12

• Ψ Referral – Suicidal Intentions are clearly expressed; Any change in presentation in patient
who repeatedly Self-Harmed, Severe Associated Psychiatric Illness, Lack of Social Support
• Risk should be considered in any patient who is Depressed, or Behaviour/Talk gives any
suggestion about possibility of Self-Harm
o Inpatient and ED setting – Seek Specialist Advice regarding admission
o Can consider non-residential management if reliable relatives who wish to care for
patients and are responsible and willing
o If hospital treatment is necessary but patient refusal, MHA Section powers
• Treatment of any associated Mental Illness
• Encouragement of Positive View of the Future, Hope, Concern for problems
• Problem Solving methods – Improvement through piecemeal approach

Question 13

Harm Prevention

Answer 13

Prevent access to Methods, and Close Observation
o Vigilance of staff, Agreed Assessment of Risk, Good Communication
o If great risk; Continuous Nursing so patient is not alone
o If Outpatient management – Safety netting if strength of ideas increases etc

Question 14

Surviving Relatives/Friends

Answer 14

Feelings of Loss, Guilt or Anger; Should offer to meet relatives as
soon as possible, and later stage if they believe helpful
o Relatives distress might be considerable; Might express indirectly as complaints about
medical care; Some relatives might have longstanding issues, including psychiatric

Question 15

Support for other Professional Staff

Answer 15

Case should also be reviewed carefully not for fault but if

there are useful lessons for future clinical practice

Question 16

Deliberate Self Harm Background

Answer 16

• Not usually failed suicide; Only 1/4 who have deliberately self-harmed say they wish to die;
Most were impulsive rather than re-mediated; Rest seek unconsciousness (as escape), trying
to influence the behaviour of others, uncertain about intention or seeking help
• Common; Rates risen progressively over last 30yrs; 10% of acute medical admissions in the
UK; More common among younger adults (very low <12yrs, declines sharply after 25yrs;
Young women and wives (particularly 15-20yrs), Low SES, Divorcees, Younger single adults

Question 17

Drug Overdose DSH

Answer 17

• 90% Drug Overdose – Anxiolytics, Non-Opiate Analgesics (E.g. Paracetamol, Aspirin),
Antidepressants in 20% (TCAs especially hazardous due to convulsions and arrhythmias)
• Concomitant ETOH use – Half of men, quarter of women use ETOH within 6hrs before act;
Often precipitant due to lack of Self-restraint

Question 18

Self Injury

Answer 18

5 – 15% of cases; Mostly Lacerations (Forearm, Wrist); Mostly young, low self-
esteem, impulsive or aggressive behaviour, unstable mood, difficulty in interpersonal

relationships and often ETOH or Drug Abuse
o Self-Injury ‘relieves’ period of increasing tension and irritability
o Multiple lacerations, often made with razor blade or piece of glass
• Less frequent and more serious – Deeper Lacerations, jump from height or in front of moving
vehicles, shooting and drowning
o More commonly occurring in people who intended to die but survived

Question 19

DSH Outcomes

Answer 19

Poor overall outcome in terms of personal and social adjustment, related to
predisposing factors; Between 15-25% recurrent, 1-2% commit suicide (100×)
o Non-dangerous method of self-harm does not necessary indicate low risk of
subsequent suicide (although higher risk if violence or dangerous method)

Question 20

Medical Causes of Deliberate Self Harm

Answer 20

Psychiatric Disorders, Personality Disorders, ETOH Misuse
o NB: Relationship to Psychiatric Disorder less important, C/f Common in Suicide
o Very few have psychiatric issues beyond Acute Stress Reaction, Adjustment Disorder
or Personality factors

Question 21

Predisposing Social Factors,

Answer 21

Early Parental Loss, Neglect or Abuse; Long term social problems
(Family, Employment, Financial), Poor physical health, Stressful life problems

Question 22

Risk Factors for Repeated Deliberate Self-Harm

Answer 22

• Previous Deliberate Self-Harm, Previous Psychiatric
Treatment, Personality Disorder
• History of Violence, Criminal Record, Substance Abuse,
Low SES, Unemployment
• Aged 25 – 54yrs; Single, Divorced or Separated

Question 23

Assessment of Deliberate Self-Harm Part 1

Answer 23

Need thorough assessment; Admission often necessary
to deal with physical consequences of act plus risk of recurrence (although referral might not be necessary if late reported, suicide intent is low,
and good social support)
All admissions need psychiatric and social assessment; If psychiatric disorder present or high
risk of further self-harm, should be seen by psychiatrist

Question 24

Assessment of Deliberate Self Harm Part 2

Answer 24

• Intentions Before and During – Planning, Impulsivity, Precautions, Help-seeking, Dangerous
(Objective and Subjective Risk), Final acts (E.g. Suicide Notes, Wills)
• Intentions Now – Are you relieved to have required? Do you still feel like taking your own life?
• Current Problems – Relationships, Employment, Finances, Housing, Legal, Isolation,
Bereavement and other losses; Concomitant Psychiatric Disorders
• Patient’s Resources – Problem-solving Capacity, Material Resources, Support from others
• Management – Treatment of Psychiatric Disorders, Management of High Suicide Risk,
Resolving Difficulties leading to Self-Harm initially and ability to deal with future crises

Question 25

Deliberate Self Harm Outcomes

Answer 25

• 10% require Immediate Inpatient Psychiatric treatment; either due to Depressive Disorder or
ETOH dependence, or period of respite from overwhelming stressors
• 2/3 need care from OP Psychiatry or Primary Care Team
• 1/4 require no special treatment – Self harm was response to temporary difficulties and
carries little risk of repetition

Question 26

Management of Deliberate Self-Harm: Problem Solving

Answer 26

Encouraged to consider what step could be taken to resolve each of these
problems, and formulate practical plans to tackle one at a time
o Aim to get patient to do as much as possible themselves
o Interpersonal Problems might require Joint or Family Discussions

Question 27

Management of Deliberate Self-Harm: mothers of young children

Answer 27

Association with Child Abuse; Important to ask about feeling towards small children and possibly collateral regarding child welfare
o Also, association between Depression and Infanticide

Question 28

Management of Deliberate Self-Harm: Children and Adolescents

Answer 28

More common after 12yrs esp in girls; More often due to
communicating distress, escape from stress rather than suicide
o Associated with Broken Homes, Family History of Psychiatric Disorders, Child Abuse
o Often Precipitated by Interpersonal Difficulties or Schoolwork
o Few are repeated but ones who do often have severe Psychosocial Problems
o Treatment not just aimed at the young person, but also the family

Question 29

Management of Deliberate Self-Harm: Frequent Repeaters

Answer 29

Often at times of stress to reduce tension or gain attention; Typically,
Personality Disorders or Insoluble Social Issues
o Repeated Self-Harm can lead to relatives becoming hostile or unsympathetic
o Neither Counselling nor Intensive Psychotherapy is effective, and management is
limited to providing support
o Change in life circumstances can lead to improvement, but high risk of suicide

Question 30

Management of Deliberate Self-Harm: Deliberate Self-Laceration

Answer 30

Difficult to management repeated self-laceration; Often have
issues recognising feelings and expressing; Efforts to increase Self-esteem or find alternatives
to Relieve Tension
o Anxiolytics seldom helpful and might lead to disinhibition
o Typical Antipsychotics might be useful to reduce tension if necessary

Question 31

Risk to Others

Answer 31

• Clear majority of violent crime is committed by people who are not mentally unwell; People
with mental disorders are more likely to be victims of crime rather than perpetrators
• Disorders associated with Increased Risk of Harm to others include: Substance Abuse (8×),
Schizophrenia (5×), Bipolar Disorder (5×); Interactions (e.g. Schizophrenia plus Substance 22×)
• Violence might result directly from Psychopathology of disorder itself
o E.g. Hallucinations might command patient to act in certain way
• Also, might result from combinations of frustrations, difficulties and disabilities

Question 32

Risk to Others: Specific Clinical Situations

Answer 32

include Morbid Jealousy, Misidentification Syndromes, Depressive Disorder with Suicide Ideation in Mothers of Small Children, and Stalking
Assessment can include Psychopathy Checklist-Revised; Past Violence is good indicator

Question 33

Risk to Others: Management

Answer 33

Psychiatric disorders should be diagnosed and treatment if necessary with Compulsory
Detention; If there is clear evidence of harm of specific persons, Breaking Confidentiality
might be warranted

Question 34

Section 2

Answer 34

Assessment order
28 days
AMHP
2 doctors (at least 1 section 12 approved)

Question 35

Section 3

Answer 35

Treatment order
6 months
AMHP
2 doctors (at least 1 section 12 approved

Question 36

Section 4

Answer 36

Emergency order
72 hours
1 doctor

Question 37

Section 5 (2)

Answer 37

Holding order for patient already in hospital
72 hours
1 doctor

Question 38

Section 5 (4)

Answer 38

Holding order for an informal psychiatric inpatient
6 hours
1 registered mental health nurse or AMHP

Question 39

Section 136

Answer 39

Police order to remove a person to a place of safety
72 hours
Police officer