Self-harm and suicide

Question 1

Suicide is highest amongst

Answer 1

Males

social class I and V

middle aged 40-54

over 80 years old

Question 2

Suicide and self-harm aetiology

Answer 2

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

Question 3

Self-harm and suicide aetiology: psychiatric illness

Answer 3

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

Question 4

Theories: mentalisation

Answer 4

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

Question 5

Theories: self-preservation

Answer 5

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

Question 6

Suicide prevention strategies at a national level

Answer 6

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

Question 7

Clinical presentation: preparation

Answer 7

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

Question 8

Clinical presentation: method

Answer 8

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

Question 9

clincial presentation: self-harm functions (and lethality)

Answer 9

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

Question 10

Clinical presentation: discovery

Answer 10

calling an ambulance, messaging a friend less concerning than if they were accidentally discovered (and resisted assistance)

Question 11

clinical presentation: self-cutting

Answer 11

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

Question 12

clinical presentation: overdose

Answer 12

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

Question 13

Mx: biological

Answer 13

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

Question 14

NAC and paracetmol overdose

Answer 14

Question 15

Mx: RA

Answer 15

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

Question 16

Mx: risk management

Answer 16

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

Question 17

Mx: follow up

Answer 17

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

Question 18

Mx: biological follow-up

Answer 18

meds wioth lowest risk toxicity

review regularly to prevent stockpiling

tx of physical illness and chronic pain (RFs for suicide) is optimised

Question 19

Mx: psychological follow up

Answer 19

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)

Question 20

Mx: social follow-up

Answer 20

stressors triggering self-harm/depression tackled

recruit family and friends for support network for times of crisis

psychoeducation and harm reduction

Question 21

self-harm: risk factors for complete suicide

Answer 21

Question 22

Strategies to reduce or prevent self-harm

Answer 22

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

Question 23

After suicide mx

Answer 23

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)

Question 24

self-harm and suicide hx tips

Answer 24

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

Question 25

screening for self-harm and suicide

Answer 25

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?

Question 26

Hx: beforehand

Answer 26

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?

Question 27

Hx: during

Answer 27

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?

Question 28

Hx: afterwards

Answer 28

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?

Question 29

Hx: future

Answer 29

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?

Question 30

Hx: risks and protective factors

Answer 30

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…