Transcript Self Harm and Risk Assessment

Deliberate Self Harm and
Risk Assessment
Dr S Bahia
Overview of Presentation
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Definition of DSH
Epidemiology
Case Scenario
Assessment of DSH
Function of Self Harm
Assessing Risk
Other Risks
Definition
Deliberate Self Harm:
Acute non-fatal act of self harm carried out deliberately
in the form of an acute episode of behaviour by
individual with variable motivation.
Gelder M., Shorter Oxford Textbook of Psychiatry 2001.
Epidemiology
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DSH 250-300 per 100,000 popn. per year
Suicide rate 1% in 12mths after hosp attendance
2-3 per 100,000 of popn die by suicide within 1 year
of attending hospital
Overall suicide rate 11 per 100,000 per year
30 fold increase in risk of suicide compared to gen
population
Office for National Statistics 2000:
2% men and 3% women admitted to self harm
5% in young people to 0.2% age 65-74
Case Scenario
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Called by A/E to see a 28 year old female who has
presented after ingesting 25 paracetamol and 20
fluoxetine after the break up of a relationship. Used to
be a regular attender with self harm a few years ago.
You are requested to do a psychosocial assessment.
What are you going to do?
Assessment
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Collateral information
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Physical Assessment
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DSH/ Suicide Risk
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Mental Illness
Case Scenario
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Had the tablets at home
Boyfriend left her that day
Thinking about it for a few hours
Drank half a bottle of vodka
Took the tablets but vomited afterwards
Didn’t expect mother to come round
Wanted to die but now not sure
No suicide note
Similar episode 3 years ago
Assessment
Suicidal Intent
 Method
 Premeditated
 Suicide note
 Wanted to die at time of attempt
 Tried to avoid discovery
 Alcohol/ Drug use
 Precipitant of self harm
 Previous self harm
Case Scenario
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Feeling low since birth of baby 10weeks ago
Previous postnatal depression with overdose
Has symptoms of depression
Alcohol 10units/week, amphetamine at weekends
Lives in 2 bed council flat with 2 children 3yrs and 10weeks
Mother supportive
Used to self lacerate between ages of 14 and 24
Mother had depression, regularly put into care
Feels hopeless, has thoughts of wanting to end it all, no
immediate intent or plans, children and mother protective factors
No psychotic symptoms
Assessment
History Taking and Mental State Examination
 Past psychiatric history
 Current symptoms of mental illness
 Alcohol/ Drug use
 Social Circumstances
 Medical History
 Hallucinations/ Delusions
 Hopelessness
 Suicidal thoughts and intent
 Insight and engagement
Meaning and Functions of DSH
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A way of surviving relationships
A form of communication
An expression of rage
A form of punishment of self and others
A way of dissociating
A way of feeling real
Emotional Control
Incomplete suicide
Assessment
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Can be difficult due to strong emotions aroused in all
the people involved
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Resist instant moral/ ethical judgments
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Can be complex
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Resist falling into behavioural traps
Assessment
Do
 Respond sensitively and with empathy
 Explore reasons
 Accept that self harm may continue
 Support the person
 Seek support for self
 Understand behaviour underpinned by mechanism to
manage difficulties
 Examine associated problems
Assessment
Don’t
 Accuse person of being manipulative or attention
seeking
 Criticise the person
 Conclude that it is a lost cause
 Expect too much of yourself
 Put pressure on person to reveal all
 Threaten to take away support
Risk Assessment
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Psych history, previous self harm and increased age
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Predictive value of all risk factors poor for suicide
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3 important areas to consider for risk of suicide:
suicidal intent at time of self harm, MSE
social support
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Protective factors
Risk Assessment
Independent predictors of subsequent suicide
 Avoiding discovery at time of self harm
 Not living with close relative
 Previous psychiatric treatment
 Alcohol misuse
 Self mutilation
 Physical health problems
Cooper et al Am. J. Psychiatry 2005;162(2):297-303
Risk Assessment
Expressing Risk
 Is there risk
 What sort of risk and degree
 How likely is it
 Immediacy
 How long will it last
 Factors that increase risk
 How can factors be modified or managed
Risk Assessment
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Risks change with time and circumstances
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Risk Assessment is an ongoing process and requires
regular review
Assessing other Risks
Assessment of Risk of Violence
History
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Previous history of violence
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Poor compliance
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Substance misuse
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Social rootlessness
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Forensic history
Mental State
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Persecutory delusions
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Delusions of passivity
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Threats./ thoughts of violence
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Emotional state
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Behaviour
Assessing other Risks
Vulnerability
 Social factors
 Abuse
 Disinhibition
 Poor impulse control
Self Care
 Level of functioning
 Social circumstances