Self Harm and Suicidality Flashcards
Suicide
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)
Presentation with Suicidal Ideation
• 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
Deliberate Self Harm
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)
Patterns of Suicide
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
Epidemiology of Suicide
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)
Social Risk Factors for Suicide
Elderly, Social Isolation, Lack of Family/Support, Stress, Publicity (copycat methods);
Medical Risk factors for suicide
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)
Adolescent Suicide
Associated with Broken Homes, Social Isolation, Depression, Violence
and Impulsive Behaviours
Doctors Suicide
Higher rates believed to be due to availability to drugs, Substance Abuse, Stressors,
Reluctance to seek treatment for Depressive Disorders and Personality Predisposition
Assessment of Suicide Risk
• 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
Suicide Prevention
- 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
Management of Patients at High Risk
• 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
Harm Prevention
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
Surviving Relatives/Friends
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
Support for other Professional Staff
Case should also be reviewed carefully not for fault but if
there are useful lessons for future clinical practice
Deliberate Self Harm Background
• 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
Drug Overdose DSH
• 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
Self Injury
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
DSH Outcomes
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)
Medical Causes of Deliberate Self Harm
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
Predisposing Social Factors,
Early Parental Loss, Neglect or Abuse; Long term social problems
(Family, Employment, Financial), Poor physical health, Stressful life problems
Risk Factors for Repeated Deliberate Self-Harm
• 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
Assessment of Deliberate Self-Harm Part 1
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
Assessment of Deliberate Self Harm Part 2
• 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
