Suicide and Self-Harm Flashcards
Define suicide
A fatal act of self injury, undertaken with conscious self-destructive intent.
Define para-suicide
A conscious act of self-destruction, with fatal intent. However, this differs from suicide as the victim manages to survive the attempt.
Define deliberate self harm
An act of self harm without the intention of death.
Outline the worldwide epidemiology of suicide
1 million people commit suicide worldwide each year.
It is among the top 10 causes of death in most countries.
Which demographic is at highest risk of suicide?
Male (3:1), especially aged 45-59.
When in regards to healthcare services, are mental health patients at highest risk of suicide?
Inpatient stay
14-day post-discharge
List 4 risk factors for suicide
Male sex (3:1) Increasing age Unemployment or social isolation Divorced or widowed Hx of mental illness (especially depression, schizophrenia) Hx of deliberate self harm Alcohol or drug misuse
Name 3 factors associated with risk of suicide following deliberate self harm
Efforts to avoid discovery Planning Written note Final acts Violent method
What factors increase the risk of inpatient suicide?
Forensic Hx Previous suicidal behaviour Violence to property Recent bereavement Delusions
What factors increase the risk of post-discharge suicide?
Unplanned discharge
Lack of continuity of care
Unemployment
Previous suicidal behaviour
What is the impact of depression on lifetime risk of suicide?
Increase by 15%
What aspects of depression increase the risk of suicide?
Greater severity of depression Self neglect Hopelessness Alcohol abuse Impaired concentration History of suicidal behaviour
What is the impact of schizophrenia on lifetime risk of suicide?
Increase by 10-15%
What aspects of schizophrenia increase the risk of suicide?
Psychotic symptoms Post-psychotic depression Young male First decade of illness Relapsing illness pattern Good insight
What is the impact of alcohol abuse on lifetime risk of suicide?
Increase by 2-4%
What aspects of alcohol abuse increase the risk of suicide?
Male sex Longer duration of issues Single, divorced, widowed Multiple substance abuse Comorbid depression
What is the impact of personality disorders on lifetime risk of suicide?
<10% increase
EUPD has highest risk, commonly manifesting as accidental death.
How are suicide and chronic physical illness associated?
Increased risk in chronic neurological, GI, CV disorders, and cancer.
Severe chronic pain increases risk of depression.
Disfigurement, especially in women.
Effect on job, role, family, and finance.
What are the 2 main types of deliberate self-harm?
Self-poisoning
Self-injury
Outline the epidemiology of deliberate self-harm in the UK
150,000 new attendances at A&E per year
Higher rate in females
Peak age 15-44
What is the impact of deliberate self-harm on risk of suicide?
40-60% increase in risk of suicide
What is the risk of suicide within one year of deliberate self-harm?
- 7%
- 1% if male
- 5% if female
Name 3 risk factors for repeated self-harm
Previous self harm Psychiatric Hx Unemployment, low SE Hx trauma or abuse Forensic Hx or violence Single, divorced, separated Family Hx - 4x risk
List motives for acts of deliberate self-harm
Wish to die
Cry for help
Communication
Unbearable symptoms
What psychological characteristics contribute to deliberate self-harm?
Impulsivity
Cognitive rigidity
Problem-solving deficits
Hopelessness
Describe the association between substance abuse and deliberate self-harm
Substance abuse occurs commonly at the time or before DSH.
Alcohol can increase the dangers of overdose. It also increases the toxicity of psychotropic drugs,
Intoxication may result in unconsciousness and delayed treatment.
Outline the risk assessment of suicide
Risk factors: dynamic, static, modifiable
Specific suicide inquiry
Protective factors
What should be included in the specific suicide inquiry?
Triggers
Preparation:
planning, final acts
Circumstance:
precaution against discovery, alcohol, the suicide act, pt thought and desires of outcome
After act:
Sought help?, regret, intent, future plans
What risk management options exist regarding suicide?
Treat any underlying psychiatric disorders
Inpatient: closer supervision, Tx adherence, staff training, safer environment
Outline the association between psychiatric disorder and homicide (risk to others)
Delayed sleep phase disorder, substance misuse, and schizophrenia cause a small increase risk to others.
Mood disorders have no increased risk to others.
Psychotic disorders increase the risk to others by persecutory psychosis and command auditory hallucinations.
What information is required if child protection may be involved in psychiatry?
Child’s name, DOB, residence, relationship
What are the stages involved in management of self harm?
1 Acute management - suture wound, antidotes 2 Assess risk - consider MHA section 2 3 Treat psychiatric issue 4 Resolve social issues 5 Future planning
What can be given acutely for self-poisoning?
Activated charcoal - if within 1 hour of ingestion - reduce absorption
What is the antidote for paracetamol OD?
N-Acetylcysteine
What is the antidote for Opiate OD?
Naloxone
What is the antidote for Benzodiazepine OD? Why is it never actually given in practice?
Flumazenil
Patients over take a mixed OD with TCAs and the benzodiazepines prevent TCA related seizures occurring. Therefore if you reverse the benzodiazepines the patient is likely to seize
What is the antidote for beta blocker OD?
Glucagon
What is the antidote for tricyclic antidepressant OD?
Sodium bicarbonate
What is the antidote for organophosphate poisoning?
Atropine
What are the protective factors against suicide?
Supportive family
Children
Religious belief
How can you try to prevent suicide?
Public education Reduce access to means to suicide - safe prescribing Rapid access to care - samaritans Decrease societal stressors Reduce substance misuse National suicide prevention lifeline
What in a history would make you think suicide was an attempt at killing oneself vs a cry for help?
Tried to avoid discovery
Planned rather than spontaneous
Wrote a note
Sorted out affairs like finances, pet care
What are the risk factors for deliberate self harm?
Divorced, single, living alone Severe life stressors Harmful drug/alcohol use Less than 35 Chronic physical health problems Violence - domestic or childhood maltreatment Socioeconomic disadvantage Psychiatric illness e.g. depression or psychosis
What motives should be asked about in deliberate self harm?
DRIPS
Death wish - genuine wish to die
Relief - seeking unconsciousness or pain as a means of temp relief and escape from problems
Influencing others - trying to influence another person to change their views or behaviour
Punishment
Seeking attention
What is seen on mental state exam in deliberate self harm?
Obvious self inflicted injuries
Patient may be tearful or exhibit signs of neglect
Behaviour may reflect an underlying mental disorder
Thoughts may include feelings of guilt, worthlessness or helplessness.
Hallucinations may be present in cases of schizophrenia and depression with psychosis
DSH may be triggered by command hallucinations
Concentration impaired
Insight varies
What are the investigations for DSH?
Bloods Paracetamol levels Salicylate levels if suspected overdose U&Es for renal function LFTs and clotting - synthetic hepatic function
CT head if an intracranial cause for altered consciousness suspected, in self-poisoning
Lumbar puncture if intracranial infection e.g. meningitis, suspected in self-poisoning
What are the differentials for self-poisoning?
Head trauma, intracranial haemorrhage, intracranial infection e.g. meningitis
Metabolic abnormalities
Liver disease
What are the differentials for self-injury?
Clotting disorders causing significant bruising or bleeding
Not investigations and differentials are dependent on the method of self harm
What is the biopsychosocial model of management for deliberate self-harm?
Biological
Treat any overdose with appropriate antidote
Suturing and anti tetanus if appropriate for deep lacerations
Psychological
Counselling
CBT for underlying illness
Psychodynamic psychotherapy if personality disorder
Social
Social services input, voluntary organisations e.g. samaritans, mind
What are the general points of management of deliberate self harm?
Acute management - antidotes, suturing, any surgical input
Manage high risk suicide - complete full risk assessment, consider inpatient psychiatric assessment
Treat any psychiatric disorder
Enable patient to resolve any difficulties that led to act e.g. refer to drug and alcohol services, offer financial and occupational rehabilitation
Enable patient to manage future crises - offer info, arrange follow up, remove access to means of DSH e.g. prescribe limited amount of meds
What is the mnemonic for suicide risk factors?
IM A SAD PERSON
Institutionalised
Mental health disorders
Alone
Sex - male
Age - middle aged
Depression
Previous attempts Ethanol use Rational thinking lost Sickness Occupation No job - unemployed
What are the clinical features of someone who is attempting suicide?
Preoccupation with death - thoughts, fantasies, ruminations
Sense of isolation and withdrawal from society
Emotional distance from others
Distraction and lack of pleasure, in their own world and suffer from anhedonia
Focus on past, dwell on past losses and defeats, anticipate no future - Beck’s triad
Feelings of hopelessness and helplessness
How can the risk of suicide following DSH be determined?
Note left behind, written Planned attempt of suicide Attempts to avoid discovery Afterwards no help sought Violent method Final acts - sorting out finances, writing a will
What is investigated in a risk assessment?
Explore suicidal ideation
Explore suicide intent - was it planned, method, note left, any other preparation, intoxicated, alone
did they try to avoid discovery, did they seek help afterwards, how do they feel about being found
Exploring risk factors - anything makes you feel this way, previous attempts, insight into illness, any family history of attempt
Perform mental state examination
Explore protective factors - anything that would stop you, positive things in life, anyone to confide in, live with anyone, social support
Explore risk to others including children and risk from others
Ever thought about harming others, do you have a close contact with children
ever feel threatened or at risk from others
Formulate management plan
What is the general management following suicide attempt?
Ensure safety, remove means for suicide, ensure safety of patient and others
Patients who have attempted and failed should be medically stabilised e.g. management of drug overdose or treatment of physical injury
Risk assessment
Admission to hospital or observation in safe place, MHA may be needed
Referral to secondary care
Psychiatric treatment
Involvement of crisis revolution and home treatment team
Outpatient and community treatment if chronic suicidal ideation but no history of previous suicide attempts, need a strong support network and easy access to outpatient
What individual suicide prevention strategies are available?
Detect and treat psychiatric disorders
Urgent hospitalisation under MHA
Involvement of Crisis Resolution and home treatment team
What population level suicide prevention strategies are available?
Public education and discussion Reducing access to means of suicide Easy, rapid access to psychiatric care Decreasing societal stressors Reducing substance misuse
