Suicide and Self-harm Flashcards
Definition of self-harm
Any act intentionally causing physical injury to the body, but not resulting in death
Definition of suicide
An act that deliberately brings about one’s own death
How (and by how much) do psychiatric illnesses increase the risk of self-harm. What proportion of people who die by suicide have psychiatric illnesses at the time?
The risk of self-harm is increased in people with depression, anxiety disorder, BPAD, conduct disorder, PD, ASD and substance use disorders. 9 out of 10 people who die by suicide have a psychiatric illness at the time.
- Depression: 15% lifetime risk of suicide (80% associated with depression)
- BPAD: 15% die by suicide, 20% attempt suicide
- Personality disorder: present in 50% of people who die by suicideà Dissocial, disinhibited and borderline traits
- Substance use disorders: intoxication can increase distress and impulsivity (50% associated with alcohol use within 6 hours)
What is mentalisation
Traumatic, abuse or neglectful childhoods give little scope for reflection (mentalizing) leading to learned behaviours which are used to manage mood or ventilate emotions (e.g self-harm) (mentalisation theory is one explaining self-harm/suicide)
Another theory is self-presevation, whereby self-harm is seen as a coping strategy (harming part of the body preserves the whole.)
Factors which we need to consider in a self-harm/suicide risk assessment?
- Social circumstances and stressors
- Strengths and coping strategies
- Intention to perform future self-harm or attempted suicide
- Risk and protective factors for future self-harm and completed suicide (sex, age (middle aged and elderly more at risk) marital status, employment, accommodation, PPH, self-harm details)
- Details of current or previous self-harm including:
How should a self-harm history be taken? What details are important to gather?
BEFORE, DURING, AFTER
Before:
- Preparation: duration and attention to detail: self-harm may be impulsive or planned in detail, over days, weeks, months. In depth preparation poses a higher risk of completed suicide
- Method: need to explore location, timing, precautions taken against discover (e.g locking doors, turning off phones), suicide notes and drugs and alcohol. Violent or medically dangerous methods elevate the risk of completed suicide (may not reflect distress.)
- Function: The function of self-harm is not always suicide- need to explore the patient’s view of its lethality (may not always be correct)
- Discovery: A person coming to hospital or calling a friend is less worrying than being found
During:
- Were they intoxicated at the time? Did they vomit or pass out?
After:
- How did they arrive in hospital? Who found them? How do they feel about the suicide attempt now? What are the physical manifestations?
When can patients be managed at home after a suicide attempt
If supportive friends/family who are willing to take preventative actions (removing medication etc.) and no intention to die.
Need to involve crisis team
Antidote for paracetamol overdose and its MoA
N-Acetylcysteine (NAC)- (almost 100% effective in preventing liver damage by replenishing glutathione when given within 8 hours IV),
Antidote for benzodiazepine overdose
Flumazenil
Antidote for insulin overdose
Glucagon
Antidote for opiate overdose
Naloxone
Antidote for digoxin and iron salt overdose
Digoxin= Digoxin-specific antibody fragments (Digibind), Iron salts= Deferoxamine mesylate
Other possible steps needed to manage an overdose (after giving an antidote)
- Activated charcoal binds to many poisons, preventing absorption from the gut into the blood
- Active elimination can deal with poisons- haemodialysis (lithium, salicylates), urine alkalinization (salicylates) or repeated activated charcoal (carbamazepine)
- Gastric lavage- must be done within 1 hour of overdose but rarely done and never for corrosive substances.
Management of patients with ongoing suicidality/ high risk
Risk management can be achieved using a problem-solving approach to address stressors and RFs. People at immediate risk should be admitted to psychiatric hospital for further assessment and tx: 1:1 nursing, restricted leave and treatment of any underlying mental illness. Brief CBT (3-12 sessions) can effectively reduce risk of future self-harm
Before discharge a follow up plan should be agreed (follow up within 1 week) to generate future coping strategies and access to CRISIS teams. Follow up can be dome by CMHTs (CRISIS/HTT), at outpatient clinic, by GP or therapist.
Coping strategies which can be used as an alternative to self-harm
- Prevention- Keep tablets and sharp objects out of reach and sight, Avoid self-harm triggering images, Stay in public places or with supportive people, Call a friend or support line, Avoid drugs and alcohol
- Alternatives to painful, damaging self harmà Squeeze ice cubes, Snap a rubber band around the wrist, Bite into something strongly flavoured e.g. lemon
- Alternatives to drawing bloodà Put red food dye on dull side of knife and draw across the skin, Use a washable red pen to mark the skin instead of cutting it
