Self-harm and suicide Flashcards
Suicide is highest amongst
Males
social class I and V
middle aged 40-54
over 80 years old
Suicide and self-harm aetiology
Genetics
- FHx self-harm and suicide
- 43% heritability
Childhood and life experiences
- childhood abuse, neglect or bullying
- subcultures LGBTQIA+, goth
- stressful life events in adulthood (e.g. domestic violence)
- complete suicide = loss events
Social isolation
- living alone, unemployed, divorced, widowed, single
- connectedness is a protective factor
Occupation
- access to lethal
- manual, male-dominated trades
Physical illness
- chronic, painful and terminal
- high in neurological (e.g. epilepsy) and stigmatised conditions (e.g. HIV)
Hx self-harm
- increased risk of future self-harm
- self-harm with suicidal intent is the strongest predictor of eventual suicide
Self-harm and suicide aetiology: psychiatric illness
Depression = may increase as severe depression lifts
BPAD
Personality disorders = dissocial, disinhibited and borderline traits
Schizophrenia = command hallucinations to self-harm in young, high-functioning, recently diagnosed people, with insihgt into the severity of illness
Anxiety disorders
Substane use disorders = intoxication exacerbeted distress and impulsivity , alcohol use
Theories: mentalisation
the ability to reflect on, process, and manage opinions
when childhood traumatic, abusive, neglectful -> little opportunity for reflection
learn behaviours to manage their mood/ventilate emotions (e.g. shopping, punching walls)
mentalisation underdeveloped = self-harm to deal with difficult emotions like anger, sadness and anxiety
Theories: self-preservation
coping strategy = attack only a part of the body to secure survival of whole purson
for some, painful non-lethal self-harm protects them from suicide
Suicide prevention strategies at a national level
limit paracetamol pack sizes and numbers purchased
install barriers, free telephones, and helpline posters at suicide hotspots
mandatory catalytic oconverters to cut CO in car exhaust fumes
media guidance for reporting: limited detail to prevent copying
Clinical presentation: preparation
research on methods, obtaining equipment, visitng potential locations, ad rehearsal, putting affairs in order (last acts) e.g. writing a will, rehoming pets, seeing friends, apologising to enemiesn
Clinical presentation: method
explore what the patient did in detail (location, timing, precautions taken against discovery e.g. locking doors, turning off phones), suicide notes (or signing off online), and drug and alcohol use
Methods:
- scratching, punching, head-banging
- cutting, burning, interfering with wounds
- self-poisoning
- inhaling toxic fumes or inert gases
- swallowing or inserting items
- self-stabbing
- jumping from a height or in front of trains/vehicles
- hanging asphyxiation
- shooting
- drowning
- self-immolation
clincial presentation: self-harm functions (and lethality)
coping strategy
relieve/regulate strong emotions
feel something instead of numbness
exchange emotional pain for physical pain
escape consciousness e.g. overdose to sleep
self-punishment
communicating distress
changing intolerable situations e.g. relationship issues
suicide
Clinical presentation: discovery
calling an ambulance, messaging a friend less concerning than if they were accidentally discovered (and resisted assistance)
clinical presentation: self-cutting
commonly knife/razorblade on concealed parts of ars or thights
relieve emotional tension and replace with calmness or mild elation
safety measures to prevent serious harm suggests lower risk of suicide e.g. cleaning blades, cutting safer fleshy areas, bandaging wounds
changed cutting pattern very worrying
clinical presentation: overdose
sx = unexplained sedation, confusion/coma, arrhythmia, brady/tachycardia, hypo/hypertension, respiratory depression
accidental OD may be deliberate
paracetamol
- N+V
- untreated - fulminant liver failure, jaundice, abdo pain, confusion, coma, death
- staggered OD (excess tablets taken over more than 1 hour) dangerous = blood paracetamol levels exceredingly low, damage is cumulative
NSAIDs
- headache, N+V, drowsiness, dizziness, blurred vision, sometimes tinnitus
- large OD = AKI, seizures, hepatic dysfunction, cardiovascular collapse, and coma
Mx: biological
Lacerations = suture under LA and closed, deep cuts needs surgical closure
OD = depends on substance, physical obs, blood tests, ECGs, sometimes over several hours, ToxBase for mx guidance for rarer overdoses
Antidotes for OD
- paracetamol = N-ac
- benzodiazepines = flumazenil
- Insulin = glucagon
- opiates = naloxone
- digoxin = digoxin-specific antibody fragments (Digibind)
- iron salts = DFO mesylate
Activated charcoal = binds many poisons e.g. anti-depressants, useful only within 1 hour
Active elimination = haemodialysis (e.g. lithium, salicylates, valproate), urine alkalinisation (e.g. salicylates), activated characoal (carbamazepine)
Gastric lavage (stomach pumping) = wash out stomach contents within 1 hour of ovderdose, rarely used and never for corrosive substances
transfer to IC for respiratory depression especially
NAC and paracetmol overdose
Mx: RA
once physical consequences dealt with, psychiatrist/psychiatric liaison nurse -> psychosocial assessment. Includes:
- details of current and previous self-harm
- social circumstances and stressors, and triggers for self-harm
- diagnosis of underlying mental illness and its relationship to self-harm
- evaluation of hopelessness, suicidal intent, and persistent plans to self-harm
- strengths and coping strategies
- risk and protective factors for future self-harm/completed suicide
Mx: risk management
address stressors and RFs (e.g. access emergency accomodation if homeless)
immediate risk = admit to psych hospital for further assessment and tx in safe, supportive environment
- close observation (1:1 nursing)
- restricted leave
- tx of underlying problems (e.g. depression, psychosis)
- care plan before discharge = how they will handle future thoughts of self-harm, access crisis support, involve family and friends with person’s consent
Mx: follow up
arrange within a week (with CMHT, outpatient clinic, GP, therapist)
crisis/home tx team visit daily to monitor person’s mental state and risk and supervise medication, limiting impulsive ODs
Mx: biological follow-up
meds wioth lowest risk toxicity
review regularly to prevent stockpiling
tx of physical illness and chronic pain (RFs for suicide) is optimised
Mx: psychological follow up
psych interventions (3-12 sessions) reduce self0harm
CBT w/ problem-solving and psychodynamic technqies
coping strategies (e.g. distraction techniques and uplifitng activities)
for borderline/emotionally unstable PD = dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT)
Mx: social follow-up
stressors triggering self-harm/depression tackled
recruit family and friends for support network for times of crisis
psychoeducation and harm reduction
self-harm: risk factors for complete suicide
Strategies to reduce or prevent self-harm
prevention
- avoid things that trigger self-harm e.g. websites
- store tablets/sharp objects out of sight and wihtin easy reach
- contact friends when tempted to self-harm
- carry friend’s and helpline telephone numbers
- avoid drugs and alcohol (increase likelihood and severity of self-harm)
alternatives to painful, damaging self-harm
- snap a rubber band around the wrist
- squeeze ice cubes/plunge fingers into ice cream
- bite something strongly flavoured e.g. chilli, lemon
After suicide mx
obtain facts about death = names of key staff, method, injuries sustained, tx given
allow bereaved people to express feeling, seek support from family or friends
don’t avoid topic of organ donation = may salvage sense of purpose for person’s life
signpost potential supports e.g. chaplains/counsellors, the Survivors of Bereavement by Suicide charity
suspected suicides -> coroner’s inquest (comfort family that trust will investigate suicide to learn from it)
self-harm and suicide hx tips
NOT ‘why did you do this’ = find out what happened and the function
recognise ambivalence ‘a part of you wanted to die, and maybe a part of you didn’t’
self-care
screening for self-harm and suicide
a sequence:
- how do you see the future
- do you ever feel hopeless/life isn’t worth living
- d you ever want to harm yourself? or end your life? tell me about those thoughts
empathetic reasoning:
- i’d imagine that many people in your situation might feel life wasn’t worth living. Do you ever feel that way?
- it wouldn’t surprise me if this made you feel desperate sometimes - even suicide. Do you ever feel like that?
Hx: beforehand
it may be hard to talk about, but could you tell be what happened?
what made you think of harming/killing yourself? was there a final straw? did you have any problems/worries?
Planning:
- was this planned? tell me about that
- how long were you planning this?
- how did you prepare yourself?
- how did you choose this method?
- where did you get…?
- did you practice beforehand?
- did you put your affairts in order? will? say goodbye to anyone?
- did you do anything else becasue you wouldn’t get another chance?
- did you tell anyone what you were planning/how desperate you felt?
Hx: during
Method:
- talk me through exactly what you did…
- overdose = which tablets did you take, what did you know about them
- cutting = what did you use, where did you cut, how deeply, did you clean the blade beforehand, did you care for yourself afterwards, how were you feeling (before, during, after),
- did you write a note/leave a message online, what did it say
- did you take any drugs/alcohol
Precautions against discovery
- did you do anything to make sure you couldn’t be interrupted (locking doors, saying they were elsewhere, turning off phones), were you alone?
View at the time?
- what did you hope would happen? function: to die/something else?
- did you think this would kill you? how confident were you that you’d die, how confident were you that you would survive
- did you think anyone could save you if they found you
Discovery
- how did you come to hospital
- were you found?did you call for help? how do you feel about that?
Hx: afterwards
view now:
- looking back, how do you feel about trying to harm/kill yourself? regret it? what do you regret (trying/failing to die)? do you wish you’d died?
current problem:
- has anything changed/as bad as before?
- how do you feel now? (active sx, depression, psychosis)
- do family and friends and partner know you self-harmed? how did they react?
Hx: future
General:
- how do you see the future?
- are you looking forward to anything over the next week or so?
- what will you do if you leave the hospital today?
- what will you do if stressor happends again? other ways to cope?
- could anything make life easier for you? would you like any help?
Plans:
- do you still want to harm yourself? tell me about that?
- do you still want to end your life?
- what plans do you have? how will you do it? when? taken any steps towards this? is anything stopping you? is there anything that could push you to do it sooner?
Hx: risks and protective factors
RFs:
- have you tried to harm/kill yourself before
- have you had any mental health problems in the past
- do you think you’re still suffering from any mental health problems now?
- how’s your physical health? are you in pain?
- do you drink alcohol? do you take drugs?
Protective factors:
- who can you talk to about your worries?
- is there anyone you’d like me to contact now?
- are there things you srtill want to live for? tell me about them…
