Transcript Deliberate self Harm

DELIBERATE SELF HARM (DSH)
& VIOLENCE
Assessment and Management
Dr Javier Rodriguez
Consultant Psychiatrist
College Tutor
Dr Javier Rodriguez
DELIBERATE SELF-HARM
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“A non-fatal act in which an individual deliberately
causes self-injury or ingests a substance in excess
of any prescribed or generally recognized dosage”
(Kreitman-1977)
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“An acute non-fatal act of self-harm carried out
deliberately in the form of an acute episode of
behaviour by an individual with variable motivation”
(BMJ-Oct 2005)
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Dr Javier Rodriguez
SUICIDE
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Suicide has been defined as an act with a
fatal outcome, that is deliberately initiated
and performed by the person in the
knowledge or expectation of its fatal
outcome
(Shorter Oxford Textbook
of Psychiatry fourth edition)
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Dr Javier Rodriguez
SUICIDE
Complex phenomenon
 Multi factorial
 Rare event
 False positives
 Over-estimation and under-estimation of
suicide risk
 Assessment tools offer guidance
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Dr Javier Rodriguez
SUICIDE
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The fundamental basis of risk assessment
must involve a thorough examination of the
personal, interpersonal and social
circumstances of each individual
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It requires a degree of 'clinical judgement'
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Dr Javier Rodriguez
EPIDEMIOLOGY DSH
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In UK, current rate of DSH 3/1000 per year
In UK over 100,000 hospital admissions each year
following DSH
In UK, 90% of DSH involve drug overdose.
Most of them present no serious threat to life
Common drugs: paracetamol and aspirin
About 40% of DSH take alcohol in the six hours before
the act (Hawton et al. 1989)
1/6th will repeat self-harm within 1 year
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Dr Javier Rodriguez
EPIDEMIOLOGY
DSH-SUICIDE
30 fold increase in risk of suicide compared to
gen population
 1% DSH commit suicide in the first year
 Greatest risk in the first six months, risk
remains high for 5 years
 10% of DSH attempters ultimately commit
suicide
 40-60% of suicides have history of DSH
 25% of suicides did DSH in the year before
suicide
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Dr Javier Rodriguez
WHY DO PEOPLE SELF-HARM?
Attempt to kill themselves
 Attempt to communicate with others
 Obtain help/care
 Obtain relief from overwhelming situation or
emotion; frustration, anger
 In the context of a life event i.e. break-up of
relationship, financial, physical illness,…
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Dr Javier Rodriguez
PSYCHOLOGICAL ASPECTS
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Relief from stressful situation
“Cry for help”
To change the behavior of others
To escape from a situation
To show desperation to others
To get back at other people, to make them feel guilty
Actively suicidal
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Dr Javier Rodriguez
FACTORS ASSOCIATED WITH DSH
Socio-economic disadvantage
 Poor social support
 Alcohol/drug misuse
 Domestic violence
 Psychiatric diagnosis >1/3
 Poor physical health
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Dr Javier Rodriguez
MENTAL DISORDERS
ASSOCIATED WITH DSH
Adjustment disorder
 Depression – 2/3 have depressive
symptoms but few have full depressive
picture
 Substance misuse/dependency
 Personality disorder (Borderline, Dissocial)
 Psychotic disorders – small percentage of
total but high risk
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Dr Javier Rodriguez
ASSESSMENT AND MANAGEMENT
Psychosocial assessment
 Information from other sources imperative
 Seriousness of attempt and immediate risks
of suicide
 Subsequent risks of further DSH
 Current medical or social problems
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RISK ASSESSMENT
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We need to look at circumstances around
the act of self harm and,
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Circumstances around the person’s life –
sociodemographic factors
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Dr Javier Rodriguez
ASSESSMENT OF THE ACT ITSELF
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What were the patient’s intentions at the time of DSH?
Act planned or impulsive?
Precautions taken against being found out?
Did the patient seek help?
Was the method thought to be dangerous?
Was there a final act (e.g. suicide note, will )?
Does the patient still want to die or regret failing to die?
What are the current problems ?
Is there a psychiatric disorder?
What are the patient’s resources? Any protective or modifiable
factors ?
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Dr Javier Rodriguez
SOCIO-DEMOGRAPHIC
RISK FACTORS
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Male
Under 45 years, over 70
years
Living alone, social
isolation
Unmarried men,
divorced or widowed
women
Unemployment
Drugs/alcohol misuse
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Previous attempts, using
violent methods
Chronic physical illness
Chronic mental health
problems
Little sense of control
over life
First degree relative
suicide
Adverse childhood
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experiences
Dr Javier Rodriguez
THINGS TO REMEMBER!
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All patients with deliberate self-harm should have a psychosocial assessment
Acts of deliberate self harm occur at times of crisis
Where a patient feels heard and understood, this helps defuse
the crisis
The process of assessing risk is also a Therapeutic
Intervention, a way of managing risk
Not always easy to offer this empathy, be aware of your
attitudes
If patient is intoxified psychiatric assessment is not possible so
patient should remain in A&E until fit to be seen
Patients should be medically stable before assessing
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Dr Javier Rodriguez
ROLE OF A&E TRIAGE NURSE
Nature of self harm
 Willingness to remain
 Levels of distress
 Mental capacity
 Presence of mental illness
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Dr Javier Rodriguez
PHYSICAL TREATMENT
Attend to physical needs
 Explain interventions
 If refuse one form of treatment, do not withhold
other
 Always use analgesia/anaesthesia if painful
intervention
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Dr Javier Rodriguez
Patient wants to leave
before Psychosocial Assessment
No high risk
Capacity
Inform GP
Mental Health Team
ASAP
High risk
No capacity
Prevent from leaving
Mental Capacity Act
Refer for urgent
mental health assessment
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Dr Javier Rodriguez
DISCHARGE IS THE
MOST LIKELY OUTCOME
Follow-up
No severe
mental illness
No high risk
Severe
mental illness
No high risk
Severe
mental illness
High risk
Primary care follow-up
Community
Mental Health Team
CRHT / Admission
A&E Liaison
for up to
3 sessions
If in doubt discuss assessment with Band 6 or/and senior
staff.
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ASSESSING
POTENTIAL VIOLENCE
It is impossible for any clinician to be
able to assess with one hundred
percent accuracy the likelihood of rare
events such as serious violence
Dr Javier Rodriguez
VARIABLES ASSOCIATED WITH
POTENTIAL VIOLENCE
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A history of violence (the single strongest predictor)
Being male
Moving house frequently
Being unemployed
Living or growing up in a violent subculture
Abuse of drugs or alcohol
Low intelligence
Coming from a violent family
Having weapons available
Having victims available
History of poor impulse control
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Dr Javier Rodriguez
ASK ABOUT MOTIVES
Are you thinking about hurting anyone?
If yes,
 Who are you angry at, or thinking about hurting?
 When do you think you might hurt (the person mentioned)
 Where will you do this?
 How long have you been thinking this way?
 Are you able to control these thoughts about hurting (the person
mentioned)?
 Do you think you would be able to stop yourself from hurting (the
person mentioned) if you wanted to?
 For how long do you think you can control your thoughts about
hurting (the person mentioned)?
 Have you every purposely hurt someone in the past or come
close to it?
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Dr Javier Rodriguez
RELEVANT FACTORS
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The individual’s history of violence (fights, hurting others,
trouble with the police)
Factors that may weaken self-control (e.g. psychotic illness,
paranoid thinking, organic personality disorder such as a
frontal lobe syndrome or a limbic epilepsy syndrome, drug
or alcohol abuse)
History of impulsive behaviour. In addition to violence, drug
abuse, or alcohol abuse, also consider stealing, shoplifting,
sexual indiscretions, binge eating, suicide attempts or
threats
Assess the level of intent, specific intent stated in the active
voice is more serious than a general threat in the passive
voice
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Dr Javier Rodriguez
OTHER FACTORS
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Recent severe stress particularly loss events
Recent discontinuation of medication
Access to potential victims especially if specific
threats have been made
Threat/control override symptoms
Persecutory delusions
Delusions of passivity
Violent emotions, irritability, anger, hostility,
suspiciousness
Then consider management plan
to best reduce risk
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This is to certify that:
.........................................
Has reviewed/completed
..........Deliberate Self Harm.................
Date
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