Transcript Self Harm 5th October 2012 D F Akerele

Self Harm
&
Risk Assessment
Definitions
• Self Harm - self-poisoning or injury, irrespective of the
apparent purpose of the act (NICE 2004)
• DSH - A deliberate non-fatal act, whether physical, drug
over dosage or poisoning, done in the knowledge that it
was potentially harmful, and in the case of drug over
dosage, that the amount taken was excessive’( Morgan
1979)
Definitions
• Parasuicide: ‘any act deliberately undertaken by a
patient which mimics the act of suicide but which does
not result in a fatal outcome’ ( Kreitman 1988)
• Attempted suicide : ‘an act of self damage inflicted
with the intention of self destruction’
Self Harm
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cutting
burning
scalding
banging or scratching one’s own body
breaking bones
hair pulling
ingesting toxic substances or objects.
Scale of problem
• DSH among top 5 causes of hospital admission in
the UK
• Most common reason for medical admission of
females (Hawton 2007)
• Suicide is the most common cause of death in
men <35
• Suicide rate highest in 45-74yr age group
• DSH commoner in younger age and women
Prevalence (YP)
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1 in 15 of young people self harm
Maybe 1 in 10 (Hawton et al 2003)
Self cutting is most common type of DSH
F:M = 4-6.5 : 1
Asian females (15-35) 2-3x more likely to SH
Suicide is very rare under the age of 12 yrs
Suicide in 10-14yrs = 0.9/100,000
in 15-19yrs = 6.9/100,000
Risk factors
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Girls
Psychiatric disorder
Hx of abuse
School, home or work problems
Alcohol & drug misuse
Lack of supportive family relationships
Parental mental illness
Management …NICE 2004
• The management of DSH in young people is a joint
endeavour between A and E, Paediatrics and CAMHS
• Joint Royal College ( Paediatrics and Psychiatry)
recommendations
• Admit all cases overnight irrespective of apparent
seriousness of attempt
• Next working day assessment
• Local joint working protocols
• Protocols to be NICE compliant
Special issues for those under 16
• Triage, assess and treat in
separate area
• Nurses trained in
assessment and early
management of young
people who have self
harmed
• All should be admitted
overnight to Paediatric
ward and assessed the next
day
• Admit to a ward for
adolescents if over 14
• Paediatrician should have
overall responsibility for
those admitted
• Obtain parental consent for
mental health assessment
• Staff to be trained in the
particular issues related to
consent and capacity in this
age group
• Special attention to
confidentiality, consent,
capacity, parental consent,
mental health act and
children act
• CAMHS should undertake
assessment and provide
consultation to family and
other agencies/staff groups
as appropriate
Particular focus on adolescence
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Untreated depression
Limited repertoire of strategies of coping
Impulsive traits
Substance Misuse
Access to irreversible methods
• Together these factors are a potent and risky
combination
Risk factors for repeat attempt and for suicide
completion
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Male gender
Increasing age
Living alone
Steps to avoid detection
Past attempts
Mood disorder
Substance Misuse (particularly males over 16)
Depression, hopelessness
Remember
• SH is not the core problem – it is a sign & symptom of
an underlying emotional difficulty/pain
• not usually triggered by one isolated event but rather a
set of circumstances
“I don’t really like school and nick off as much as I can. There’s
always arguments at home so I go out and hang around with a
group of lads and lasses. We all drink a bit; sometimes I cut my
arm with a bit of broken glass. It feels good, but then I regret it
the next day when I see the scar.” (Dimmock, 2008:45)
Risk Assessment
Risk
Originally a sailing term from Portuguese
'sailing into uncharted waters'.
Risk
‘the possibility of beneficial and harmful outcomes and the likelihood of
their outcome in a stated timescale
danger vs risk
Danger is the damage or harm that may occur from an event
Risk is the likelihood of the event
Risk is not static, it is dynamic.
Risk assessment is a cross-sectional view but may take
changing factors into consideration
We are not proficient at quantifying risk( one study
suggests we're wrong 95% of the time‘
Thankfully wrong by overstimation in the main
Types of adverse outcome
•Harm to self
Self-mutilation
Suicidal acts
Self neglect and starvation
•Harm to others
Emotional abuse and violence
Physical abuse and violence
•Harm from others
Emotional abuse and exploitation
Physical
Sexual
•Harm from healthcare system
•Harm to staff in the work
Overdose Assessment
Separate up into groups and take 10 minutes
Perform a risk assessment and devise a management
plan
16 year old girl
Overdose of 10 paracetamol
Did not know about potential lethality
Taken when angry
Immediately told mother
Came to hospital without resistance
Regrets action
No major history of emotional disturbance
But hx of SH & 2 previous OD after relationship break
Parental support
Are you worried
Would you let her home
What advice would you give her and her mother
Risk assessment psychol
16 year old girl
Overdose 90 paracetamol
Taken with the intention of dying. Planned for 2 weeks
Church in the evening, quietly made her peace with
friends
Went home
Mother drunk
Went upstairs, took the tablets alone and sober
No direct trigger
Knew mother would not disturb her until the Tuesday
(college day)
Mother found her unconscious on Tuesday
Phoned ambulance, only got into it for her mother
Are you worried
Will you send her home
What might steer you to allow her home
Remember
We cannot read the future
Human nature is impossibly complex
Risk assessment is highly inexact
Risk management does not equal risk elimination
Responsibility is not a binary issue