Self harm and suicide

Question 1

What is the definition of deliberate self harm?

Answer 1

Deliberate self-harm (DSH) refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act. It is usually an expression of
emotional distress

Question 2

Methods of self injury

Answer 2

Cutting
Burning
Hanging
Stabbing
Swallowing objects
Shooting
Jumping

Question 3

Methods of self-poisoning

Answer 3

Medication (prescribed or OTC)
Illicit drugs
Household substances
Plant material

Question 4

RFs for Deliberate self harm

Answer 4

DSH Largely Comes Via Self-Poisoning
Divorced/single/living alone
Severe life stressors
Harmful drug/alcohol use
Less than 35 (age)
Chronic physical health problems
Violence (domestic) or childhood maltreatment
Socioeconomic disadvantage
Psychiatric illness, e.g. depression, psychosis

Question 5

Epidemiology of DSH

Answer 5

DSH affects 2 in 1000 people in the UK.
It is more common in ♀ at a ratio of 1.5:1, but this varies greatly with age.
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DSH is more common in adolescents and young adults. Incidence peaks
in ♀ aged 15–19 years, and in ♂ aged 20–24 years.
It is 20–30 times more common than suicide.
The rate of suicide in people who have self-harmed increases to between 50–100 times
greater than that of the suicide rate in the general population.

Question 6

Clinical features of self harm

Answer 6

DSH can take the form of:
Self-poisoning in the form of overdose.
Self-injury in the form of cutting, burning, slashing.
In the UK, 90% of DSH cases are a result of drug overdose. Commonly ingested
medications are non-opioid analgesics including paracetamol and salicylates (aspirin),
anxiolytics (including benzodiazepines), and antidepressants (self-harmers are commonly
depressed).
10% of DSH cases are due to self-injury. Common locations for cuts with razors or glass are
the forearms and wrists
Other less common methods of self-injury include jumping in front of moving vehicles or
from great heights and attempting to drown oneself (Fig. 9.1.1).
About half the men and a quarter of women who self-harm have taken alcohol in the 6
hours prior to the act, indicating that alcohol is a key risk factor.
The two commonest complications of DSH: (1) Permanent scarring of skin and damage to
tendons and nerves as a result of self-cutting. (2) Acute liver failure due to paracetamol
overdose.

Question 7

How does self harm differ from suicide?

Answer 7

Act with intent to hurt self
Includes cutting, overdose (less lethal)
No intention to kill self
Self harm is more common in girls

Act with intent to kill self

Includes jumping from height, hanging (more lethal)

Intention includes desire to be dead (?how to check for intent)
Suicide is more in boys/males

Question 8

History for self-harm

Answer 8

What were their intentions before and during the act? (intention)
Does the patient now wish to die? (suicidal ideation)
What are the current problems in their life? (severe life stressors)
Is there a psychiatric disorder? (psychiatric illness)
Collateral history from relatives, friends or the GP is important.

Question 9

Motives behind deliberate self-harm

Answer 9

DRIPS
Death wish: genuine wish to die.
Relief: seeking unconsciousness or pain as a means of temporary relief and escape from
problems.
Influencing others: trying to influence another person to change their views or behaviour
(e.g. making a spouse feel guilty for not caring enough).
Punishment: to punish oneself.
Seeking attention: trying to get help or seek attention (expression of emotional distress).

Question 10

Mental health issues that cause self harm

Answer 10

Coping (Defence mechanisms)
Emotional dysregulation/Behavioural
Impulsive/Influenced by impulsivity (ADHD)
Personality traits (conduct disorder, borderline)
Depression
Psychosis
Eating disorder

Question 11

Self harm in low mood

Answer 11

Pervasive
Persistent – at least 2 weeks
Unresponsive to circumstances
Anhedonia
Helplessness, hopelessness, worthlessness
Sleep
Appetite

Question 12

Depression in young people

Answer 12

Recently becoming less active
withdrawn
Less time on TV/Play
Decreased or increased sleep
Decreased appetite
Somatic complaints
Irritability
Difficulty concentrating
Regression

Question 13

What are signs of regression in a child

Answer 13

Thumb sucking
Bed wetting
Clinging more to parents
3 wish test

Question 14

Causes of Self harm which can become dangerous

Answer 14

Intent – planning ahead/timing/letter/obligations
Lethality – multiple methods
Comorbid mental illnesses
Depression
Psychosis - hallucinations
Past history of serious self harm
Family history of suicide
Substance abuse

Question 15

Link between hearing voices and self harm

Answer 15

Hallucinations- what are they?
Hallucinations can be normal: Can you give examples?
Commanding voices
Thought Echo
Discussing auditory hallucinations

Is there any associated hallucinatory behaviour?
Is there any loss of touch with reality (not delirium)
Is there any family history of psychosis and suicide?

Question 16

MSE for self harm

Answer 16

Obvious self-inflicted injuries may be seen. The patient may be tearful or exhibit
signs of neglect. Behaviour may reflect an underlying mental disorder
(depression, schizophrenia).
Thoughts may include feelings of guilt, worthlessness or helplessness.
Hallucinations may be present in cases of schizophrenia and depression with
psychosis where DSH is triggered by command hallucinations.
Concentration is often impaired and insight can vary

Question 17

Investigations for DSH

Answer 17

Bloods including: Paracetamol levels (accurate between 4 and 15 hours after
ingestion), salicylate levels if suspected overdose, U&Es (renal function), LFTs
and clotting (synthetic hepatic function).
Urinalysis for possible toxicological analysis.
CT head if an intracranial cause for altered consciousness is suspected (in selfpoisoning).
Lumbar puncture if intracranial infection (e.g. meningitis) suspected (in selfpoisoning).

Question 18

DDs for DSH

Answer 18

Biological: Includes treating any overdose with the appropriate antidote (see Key facts) and
suturing (and anti-tetanus treatment if appropriate) for deep lacerations.
Psychological: Includes counselling and CBT for underlying depressive illness.
Psychodynamic psychotherapy may be appropriate if the individual has a personality
disorder. However, this is a long term treatment and needs appropriate assessment.
Social: Social services input and voluntary organizations (e.g. the Samaritans, Mind).

Question 19

General points for DSH

Answer 19

Risk assessment is mandatory as there is an immediate risk of suicide and risk of repeat
acts of self-harm. Need for hospitalization should be assessed ± use of the MHA Section 2.
There is often involvement of the Crisis team in the community as an alternative to hospital
admission (see Chapter 1, Introduction to psychiatry).
If the patient refuses medical treatment for the consequences of self-harm (e.g. acute liver
failure, deep lacerations) a mental capacity assessment will be required.
Treat any underlying psychiatric illness with medication and/or psychological therapies.
Consider safety in overdose of antidepressants for co-morbid depression. TCAs are most
dangerous as they can cause arrhythmias and convulsions in overdose.
Psychosocial assessment is required. Many patients have personal, relationship or social
problems for which they can be offered help (e.g. counselling and social service input).
Ensure that the patient is followed up within 48 hours of discharge

Question 20

Principles behind managing deliberate self harm

Answer 20

Acute management: Specific antidotes, suturing, surgical input for complex wounds
Manage high suicide risk: Full risk assessment, consider inpatient psychiatric assessment (+MHA)
Treat any psychiatric disorder: Antidepressants or CBT for depression
Enable patient to resolve any difficulties that led to the DSH: Manage psychosocial needs, refer to drug/ alcohol services if appropriate, offer financial and occupational rehab advice
Enable patient to manage future crises: Follow up, offer written and verbal info, remove access to means of DSH

Question 21

Young person management for self harm

Answer 21

Risk assessment
safety plan/ Crisis plan derived
Methods for maintaining safety, and ensuring no access to lethal suicidal methods

Hospitalization is recommended when safety is unpredictable and provides removal from a stressful environment.
If it is not safe to be discharged – advice admission

Question 22

Whats involved in the Risk assessment for a young person?

Answer 22

Intent and lethality
Any active suicidal plans
Psychotic
Hopeful about future?
Agrees to safety plan
Ensuring NO access to lethal suicidal methods

Question 23

Drugs and their antidotes

Answer 23

Drug Antidote
Paracetamol NAcetylcysteine
Opiates Naloxone
Benzodiazepines Flumazenil
Warfarin Vitamin K
Beta-blockers Glucagon
TCAs (e.g.
amitriptyline)
Sodium
bicarbonate
Organophosphates Atropine

Question 24

Features of Toxbase

Answer 24

can be viewed for information on rarer
poisons. The UK National Poisons Information
Service (NPIS) can also be contacted for further
information.

Question 25

Features of activated charcoal

Answer 25

for the majority of drugs taken
in overdose, early use of activated charcoal (within
one hour of ingestion) can prevent or reduce
absorption of the drug

Question 26

Definitions of suicide

Answer 26

Suicide: A fatal act of self-harm initiated with the intention of ending one’s own life.
Attempted suicide: The act of intentionally trying to take one’s own life with the primary aim
of dying, but failing to succeed in this endeavour.
Risk assessment: In a psychiatric context, it is assessing the risk of self-harm, suicide
and/or risk to others.

Question 27

Protective factors of suicide

Answer 27

Children at home
Pregnancy
Strong religious beliefs
strong social support
Positive coping skills
Positive therapeutic relationship
life satisfaction
Fear of suicide
Fear of disapproval by society
Hope for the future

Question 28

RFs for Suicide (Pneumonic)

Answer 28

IM A SAD PERSON
Mental health disorders, Alone (lack of social support), Sex (male), Age
(middle aged), Depression, Previous attempts, Ethanol use, Rational thinking lost, Sickness,
Occupation , No job (unemployed)

Question 29

Epidemiology for suicide

Answer 29

Suicide is the 13th leading cause of death worldwide, with about 1 million deaths every year
due to self-inflicted violence.
In 2012, in the UK there were 18.2 ♂ suicides per 100 000 population, and 5.2 ♀ suicides
per 100 000 population.
The most common methods of suicide are hanging, strangulation and suffocation
(58% of ♂ suicides and 36% of ♀ suicides), followed by poisoning (43% of ♀ suicides and
20% of ♂ suicides).

Question 30

Clinical RFs for suicide

Answer 30

History of DSH or
attempted suicide
The rate of suicide in people who have self-harmed increases and
is 50–100 times greater than in the general population.
Psychiatric illness Including depression, schizophrenia, substance misuse, alcohol
abuse and personality disorder.
Childhood abuse History of childhood sexual or physical abuse.
Family history Family history of suicide or suicide attempt in first-degree relatives
increases the risk.
Medical illness Physically disabling, painful or terminal illness

Question 31

Socio-demographic RFs of suicide

Answer 31

Male gender Males are 3x more likely than females. Male suicide attempts are
more likely to be violent and therefore successful.
Age Highest in the age group 40 to 44 in men.
Employment and
financial status
Those unemployed and who have low socioeconomic status are at
higher risk.
Occupation Vets, doctors, nurses and farmers are at higher risk of suicide.
Access to lethal
means
The most lethal means of suicide are firearms, followed by hanging,
strangling, and suffocation.
Social support Low social support, living alone, institutionalized, e.g. prisons,
soldiers.
Marital status Those that are single, widowed, seperated or divorced
Recent life crisis e.g. Bereavement, family breakdown.

Question 32

Clinical features of suicide

Answer 32

Preoccupation with death: Thoughts, fantasies, ruminations and preoccupations with death,
particularly self-inflicted death.
Sense of isolation and withdrawal from society.
Emotional distance from others.
Distraction and lack of pleasure: Often are ‘in their own world’ and suffer from anhedonia.
Focus on the past: They dwell on past losses and defeats and anticipate no future; they
voice the notion of Beck’s cognitive triad (see Section 3.2, Depressive disorder) that the
world would be better off without them.
Feelings of hopelessness and helplessness.

Question 33

Progression from low mood to suicide

Answer 33

Low mood
Hopelessness, Helplessness, Worthlessness
Loss/ Not seeking support/pillars
‘It is better to be dead than suffering this’
Death wishes (I wish I had died)
Plan
Attempt – self Harm
Suicide

Question 34

How can we Determine the risk of suicide following DSH

Answer 34

1. Note left behind: usually written.
2. Planned attempt of suicide.
3. Attempts to avoid discovery.
4. Afterwards help was not sought.
5. Violent method.
6. Final acts: sorting out finances, writing a will.

Question 35

Questions to explore suicidal ideation

Answer 35

1. Exploring suicidal ideation:
   ‘How do you feel about your future?’
   ‘Do you feel that life is worth living?’
   ‘Have you ever thought about taking your own life?’

Question 36

Questions exploring suicidal intent?

Answer 36

What precipitated the attempt? Was it planned?
What method did they use?
Was a suicide note left? Did they make any other preparations before acting? e.g.
writing a will.
Was the patient intoxicated with drugs or alcohol?
Was the patient alone?
Were there precautions taken to avoid discovery (e.g. they waited until the house
was empty, locked doors, timed so that intervention would be highly unlikely)?
Did the patient think that they were certain to die even if they received medical
attention?
What was the degree of premeditation? How long had they been contemplating
suicide for? What plans had they made before acting?
Did the patient seek help after the attempt or were they found and brought in by
someone else?
How does the patient feel about it now? Do they regret it or do they wish that they
had succeeded?
How do they feel about being found? Are they relieved or are they angry?

Question 37

Questions to explore RFs for suicide

Answer 37

‘Is there anything in particular that is making you feel this way?’, ‘Can you tell me
about it?’ (stress)
‘Have you ever tried anything like this before?’, ‘Can you tell me about it?’ (previous
suicide attempts)
‘Are you aware if you are suffering from any mental health illness?’ (psychiatric
illness)
‘Do you have any health problems that are bothering you at the moment?’ (medical
illness)
‘Is there any family history of suicide, attempted suicide or self-harm?’ (family
history)

Question 38

Questions for MSE in suicide risk

Answer 38

‘Is there anything in particular that is making you feel this way?’, ‘Can you tell me
about it?’ (stress)
‘Have you ever tried anything like this before?’, ‘Can you tell me about it?’ (previous
suicide attempts)
‘Are you aware if you are suffering from any mental health illness?’ (psychiatric
illness)
‘Do you have any health problems that are bothering you at the moment?’ (medical
illness)
‘Is there any family history of suicide, attempted suicide or self-harm?’ (family
history)

Question 39

Questions to explore protective factors

Answer 39

‘Is there anything that would stop you from carrying out this act?’ What are the
positive things in their life? (general protective factors)
‘Do you have someone to confide in, close family or friends?’, ‘Who do you live
with?’, ‘Do you have company at home?’ (establishing social support or lack of)

Question 40

Explore risk to others questions

Answer 40

‘Do you ever have thoughts of harming others?’
Patients may have children/relatives that are in danger: ‘Do you have close contact
with any children?’ Document the child’s name, DOB, place of residence and
enquire as to the nature of the relationship.
‘Do you ever feel threatened or at risk from others?’

Question 41

Formulate management plan questions

Answer 41

Determine whether the patient is low, medium or high risk and formulate a
management plan accordingly, depending on the degree of planning, severity of the
attempt and ongoing concerns about risk

Question 42

Investigations for Suicide

Answer 42

Medical investigations according to the method, e.g. drug levels (see Section 9.1,
Deliberate self-harm).
Questionnaires - Tool for Assessment of Suicide Risk (TASR), Beck Suicide Intent
Scale.
Suicide can be confirmed by post-mortem

Question 43

DDs for suicide

Answer 43

Self-harm (for attempted suicide)

Question 44

Key facts: Self harm vs suicide

Answer 44

Suicide:
More common in males
Risk increases with age
Act may be planned meticulously
Act is more often violent
Physical and psychiatric illness is common
Self-harm:
More common in females
More common in young people
Act is impulsive
Usually in form of overdose or cutting
Physical and psychiatric illness is less common

Question 45

Management for suicide

Answer 45

Ensure safety: Immediate action should include removing means for suicide and ensuring
the safety of the patient and others.
Patients who have attempted suicide and failed, should be medically stabilized, e.g.
management of drug overdose or treatment of physical injury.
Risk assessment: The risk of further suicide should then be assessed. People with a high
degree of suicidal intent, specific plans, or chosen methods (particularly if lethal) should be
assigned a higher level of risk (see OSCE tips 3).
Admission to hospital (or observation in a safe place) is generally indicated if individuals
pose a high and immediate risk of suicide. The Mental Health Act might be required if the
patient refuses help and there is evidence of a mental illness.
Referral to secondary care (see OSCE tips 4).
Psychiatric treatment: Depression or psychosis should be detected and treated accordingly.
Involvement of the Crisis Resolution and Home Treatment team to provide support
immediately following discharge can be instrumental.
Outpatient and community treatment may be more suitable for patients with chronic suicidal
ideation but no history of previous significant suicide attempts. For this to succeed, a strong
support network and easy access to outpatient and community facilities are required.
Prevention strategies

Question 46

MGMT for young people with suicidal ideation

Answer 46

Manage immediate risk
Plan for young people to tell parents if have further thoughts
Manage any underlying mental health condition eg Depression
If too severe – hospital/intensive home treatment
If parents unable to work to protect young person – consider social care

Question 47

Individual suicide prevention strategies

Answer 47

Detect and treat psychiatric disorders
Urgent hospitalisation under the Mental Health Act
Involvement of the Crisis resolution and Home treatment team

Question 48

Population-level suicide prevention strategies

Answer 48

Public education and discussion
Reducing access to means of suicide
Easy, rapid access to psychiatric care
Decreasing societal stressors
Reducing substance misuese

Question 49

When to refer to secondary care for patient at risk of suicide

Answer 49

(SUSPicious)
(1) Suicidal ideation clearly stated; (2) Underlying psychiatric illness is
severe; (3) Social support (lack of); (4) Presentation change for an individual who has repeatedly self-harmed.

Question 50

Biological basis of depression

Answer 50

Low levels of blood tryptophan (source of serotonin)
Low serotonin levels in brain and low receptor
HPA dysregulation & elevated blood cortisol levels
Low serotonin and 5HIAA (serotonin metabolite) in the CSF of suicide victims