Self-harm in Children x Adolescents (Including Hx) Flashcards
How do you define self-harm?
SELF HARM
* Umbrella term for all non-fatal injury
* Clinically important to distinguish between potentially lethal acts of attempted suicide (eg hanging, shooting) from painful but usually non lethal methods of self harm where there is commonly no conscious intention to die
* Hope to escape intolerable situation
* Self-cutting most common type
“ Other methods: burning, bruising, self stabbing, food
restriction, overdose
What are self-reported reasons for self-harm? [4]
Sense of release for tension / pressure that has grown
- sense of relief / elation after SH
To avoid more dangerous forms of self-harm or suicide
Self punishment
May help to overcome numbness
NB: important to distinguish if is a suicide attempt or not.
What theories exist for self-harm?
- Childhood provides a ‘validating environment’ where parents take child’s experiences seriously & speak to them in way that helps them mange intense emotion
- Provides basis to ‘mentalize’ ie reflect on & process emotional experiences
*When childhood is traumatic/abusive/neglectful - little space for reflection and thought
* Emotional experiences dealt with by action - relationship between parts of self and other - in which there is unmodulated emotion which cannot be expressed in words alone
What is the clinical significance or recognising self harm? [2]
1/6 who SH will SH again
Risk of completed suicide is 50-100x greater than general population
Describe how you would take a self-harm Hx
What are good ways of asking about ‘the story now’ for a SH Hx? [4]
‘You’ve been through a lot today. It may be hard to talk about, but could you tell me what happened?’
‘What first made you think of harming yourself?’
“What was the final straw?’
‘Did you have any big problems or worries?’ (work-related, relationships, money, health…)
What are good ways of asking about ‘the act’ for a SH Hx? [1]
‘Talk me through exactly what you did’
What are good ways of asking about ‘the degree of planning’ for a SH Hx? [3]
‘How long were you planning this?’
“Tell me about the preparations.
‘Did you tell anyone you were feeling you were going to harm yourself?’
What are good ways of asking about ‘precautions’ for a SH Hx? [2]
‘Did you do anything to make sure people couldn’t interrupt you?’ eg locking doors, telling people you were somewhere else?
‘Were you alone?’
What are good ways of asking about ‘the details’ for a SH Hx? [+]
‘What did you use to harm yourself?’
‘Ever done this before’?
‘Did you want to end your life or hurt yourself’?
‘Did you take any alcohol or drugs too’?
‘Did you feel anything?” ‘Numbness’?
‘I wonder why you harmed yourself?’ (might not know)
‘What did you do exactly?’ (depth, superficial, deep, burning, scalding, bruising, head banging, scratching, hitting etc etc)
What are good ways of asking about ‘the purpose’ for a SH Hx? [2]
‘Did you hope this would kill you, or did you hope for something else?’
‘A big part of you wanted to die. I’m wondering whether there was a small part of you that wanted to live?’
What are good ways of asking about ‘the certainty’ for a SH Hx? [2]
‘At the time, how sure were you that you wanted to harm yourself rather than ending your life?’
‘Did you think that anyone would stop you if they found you?’
‘Did you tell anyone you were going to self harm?’
What are good ways of asking about ‘the discovery’ for a SH Hx? [2]
‘How did you end up coming to hospital?’ (‘It sounds as though you planned things very carefully’)
‘Were you found or did you get help yourself?’
‘How did you feel about that?’
‘What was going on immediately before you cut yourself/self harmed?’
‘What mood were you in just before you cut?’ (boredom, rejection, anger, grief, felt numb, irritable etc)
‘How did you feel immediately after you cut your self?’
What are good ways of asking about ‘the now’ for a SH Hx? [4]
‘Looking back, how do you feel about harming yourself?’
‘Do you regret harming yourself?’
‘Do you regret failing to kill yourself?’
‘How do you feel about being alive?’
‘Do you wish you were dead?’
‘Has anything changed, or are your problems still as bad as before?’
What are good ways of asking about ‘the future’ for a SH Hx? [4]
‘How do you see the future?’
‘Do you have any plans to harm or kill yourself?’ (assessment)
‘Can you think of anything that would make life easier for
you?’
‘What will you do if (stressor) happens (or happens again)?’
What other parts of the Hx would you need to ask about? [3]
Which risk factors do you need to ask about in SH? [2]
Do you have friends/ family you can talk to about your worries?’
Screen for:
- Current depression (see later)
- Current use of drugs/alcohol
Problems with relationships, work, recent losses, physical ill health
What do you need to screen for in a SH Hx? [1]
How? [+]
Describe how you would conduct risk management for SH [+]
- Assessment of possible suicide, future self-harm
-
Immediate and longer term risks
Low, medium, high? Not necessarily accurate - be more specific - Think how risk can be decreased through management including distraction techniques, using self harm app, MH website support
- Most important - are they safe to go home now? Or stay in hospital?
- Home with HTT or Crisis team?
- Always get senior input on decision
Therapeutic input -
* ‘Next time what could you do instead of reaching
* for pills, cutting/burning/head banging etc?’
What can you suggest for a safety plan for a SH patient? [+]
Which follow up therapies could you suggest for someone w SH? [4]
Longer term therapies - shown to decrease DSH
* Cognitive Behavioural Therapy (CBT)
* Dialectical behaviour therapy (DBT)
* Mentalization-based treatment (in day hospital)
- Transference-Focused Psychotherapy
TBL
Which of the following has the most evidence for SH?
- Cognitive Behavioural Therapy (CBT)
- Dialectical behaviour therapy (DBT)
- Mentalization-based treatment (in day hospital)
- Transference-Focused Psychotherapy
Dialectical behaviour therapy (DBT)
How would you follow up patients who have self-harmed? [3]
NICE guidelines state that if have SH, suicide acts or ideations - need to admit to paediatric ward.
- Can then make a safe plan for discharge - will be seen by community mental health team within a week of discharge
Underlying disorders - such as depression must be treated
- SSRIs are safest if used in overdose
- Keep prescriptions short and review regularly to avoid stockpiling & OD.
If high risk of suicide - may need admission to MH IP for assessment of underlying condition and treatment
Describe what is meant by dialectical behaviour therapy [1]
Derived from principles of CBT, but used for people who struggle to regulate their emotions
- Often group therapy
- Because in SH theres a lot of isolating shame, being in a group helps, also makes accountability
- Learn skills to deal with epidsodes of extreme distress
