Transcript Self Harm - The Cambridge MRCPsych Course

Self Harm
(SH)
Divik Seth
[email protected]
ST6
Child & Adolescent Psychiatry
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Epidemiology
Terminology
Aetiology
Impact
Assessment
Management
EPIDEMIOLOGY
Epidemiology
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SI>SH>Suicide
1 in 5 had thoughts about suicide in
previous year.
7%-14% of adolescents will self harm at
some time in their life (Hawton, 2005)
Since many acts of self-harm do not come
to the attention of healthcare services,
hospital attendance rates do not reflect
the true scale of the problem (Hawton et
al., 2002a; Meltzer et al., 2002b).
Epidemiology
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Self-harm is one of the top five
causes of acute medical admission in
the UK (Hawton & Fagg, 1992;
Gunnell et al., 1996).
Risk of repeat (10-15% in the
following year) versus risk of suicide
(0.5-1%)
Epidemiology
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Suicide prevalence
Male6.5/100000
Female2.25/100000
M>F
except very young
TERMINOLOGY
Definition
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‘self-poisoning or
self-injury,
irrespective of the
apparent
purpose of the act’
(NICE July 2004)
Terminology
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Self-harm
DSH
Intentional self harm
Para suicide
Attempted Suicide
Changes UK (1) Prefix “intentional”
dropped from NICE Guidelines
'Many service users object to these terms
[deliberate and intentional], especially
those who harm themselves during
dissociative states, afterwards being
unaware of any conscious intent to have
harmed themselves.’
National Collaborating Centre for Mental Health
(2004).
Self-harm: The short-term physical and
psychological
management and secondary prevention of
self-harm in primary and secondary care.
London: Gaskell & BPS
(2) Prefix “deliberate” dropped from Royal
College of Psychiatrists’ report
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‘The use of the adjective "deliberate"
has not been acceptable to all and
some service users fear it might be
of itself stigmatising. For this reason
we have dropped the term
“deliberate” from the title of this
report.’
Royal College of Psychiatrists (2004).
Assessment following self-harm in adults
Council Report CR122.
London: Royal College of Psychiatrists
DSM IV-TR
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No formal classification
Self-injury behavior is seen in connection
with a number of diagnosis
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Borderline Personality Disorder
Depression
Eating Disorders (anorexia and bulimia)
Obsessive-Compulsive Disorders (OCD)
Post-Traumatic Stress Disorder (PTSD)
Dissociative Disorders
Anxiety and Panic Disorders
Impulse Disorder Not Otherwise Specified
ETIOLOGY
Etiological Factors that are
associated with self-harm
 Genetics and Neurobiological
 MZ(12%)>DZ(2%)
 5HIAA
• CognitiveHopelessness,
dichotomous thinking
External locus of control
Etiological Factors that are
associated with self-harm
• Psychiatric – Mood disorder, Substance abuse,
anxiety, psychosis eating disorder.
 Family factorsparental psychiatric disorder,
FH of suicidal behaviour
abuse
Broken homes (separation, divorce, or death of
parents)
Etiological Factors that are
associated with self-harm
• Peers-
influence of peer suicidal behaviour
Bullying
Group membership – EMO
• Media and internet
• Physical ill health
• Sexual orientation
• Proximal risk factors/ Life stress
What are the intents in self harm?
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feel better
To communicate
To cope
To punish self or others
Its complex!!
Common Misconceptions
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Attention seeking behaviour ?
SI tends to be done in private
Those who engage in SI tend to conceal their
wounds
Superficial So Not Serious
Risk of repeat -10-15% in the following year
Risk of suicide -0.5-1%
Borderline Personality Disorder
Untreatable
Invalidating Statements
“You’re not trying hard enough”
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All of us receive statements like these but for children
raised in invalidating environments, the messages are
constant.
Chronic invalidation can lead to self-invalidation, and
feelings that one never mattered.
Could it be a call for help an “expression of maladaptive
distress” “a way of communication”
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How people who self-harm
experience services (NICE 2004)
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Service users describe contact with health
services as often difficult, characterized by
ignorance, negative attitudes and,
sometimes, punitive behavior by
professionals towards people who selfharm.
“People who have self harmed should be
treated with the same care, respect and
privacy as any patient” NICE 2004
The consequences of self-harm
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Repetition and suicide
Following an act of self-harm the rate of suicide
increases to between 50 and 100 times the rate
of suicide in the general population (Hawton et
al., 2003b; Owens et al., 2002).
About one in six people who attend an
emergency department following self-harm will
self-harm again in the following year (Owens et
al., 2002); a small minority of people will do so
repeatedly.
The consequences of self-harm
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Physical health
self-harm can result in long-lasting ill
health or disability.
Paracetamol poisoning is a major cause of
acute liver failure requiring liver
transplantation.
Self cutting can result in permanent
damage to tendons and nerves and
scarring leading to disfigurement.
More violent forms of self-injury often lead
to permanent disability and/or
hospitalization.
The consequences of self-harm
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Economic cost of self-harm
Direct cost- 150,000–170,000
attendances at an emergency
department each year and the
subsequent medical and psychiatric
care (Yeo, 1993).
Indirect costs of self-harm are
unknown but, given its prevalence,
are likely to be substantial,
particularly in terms of days lost
from work.
ASSESSMENT
Assessment
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For children and young people, the
consensus is that admission to a
pediatric ward for time to ‘cool off’,
to undertake assessment of the child
and family, and to address child
protection issues, should these arise,
should be the normal course of
events (Royal College of
Psychiatrists, 1998).
General principles
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Aim towards engagement
Treat with empathy, care & respect
Privacy
Involve family
Promote involvement in decision
making
Assessment
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Medical Management.
Assessment of the attempt and risk
Assessment of the underlying
conditions
All patients who have self harmed
should be offered a preliminary
psychosocial assessment (NICE,
2004)
Assessment of attempt and risk
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Method
Intent
Precipitants
Planning- suicide note
Feeling now
Other areas of risk e.g. child
protection, risks to others - violence
, suicide pacts.
Assessment of underlying
conditions
Family history
 Past mental health history (in
particular a history of previous
attempts)
 Past Medical history
 Personal history
 Social network (friends, confidants)
 Drug and alcohol history
 Current mental state
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Assessment of needs
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A good mental state
Maltreatment (potential child
protection issues)
Family functioning and support
Friendships
School
Protective factors
MANAGEMENT
Management
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Risk management
Treating underlying Psychiatric
Illness
Management
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Risk management –
involve the parents and other
agencies as required
Provide emergency contact details.
Thinking of safer ways to vent
feelings/alternatives to self harm.
Keeping medications in safe etc.
Arrange follow up
Specific Alternatives to SI
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Ice Cube Therapy
Line Therapy
15-minute Contract
15-Minute Contract
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Contract (with self or others) to wait
15-minutes before self-injuring
Utilize pre-made list of diversional
and tension-reducing activities
At end of 15-minutes, praise self
If impulse/urge persists, new
contract
Call crisis line or other support if
believe cannot make the 15-minutes
Other Alternatives
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Go to the mall or restaurant
Call a friend or therapist
Read a book
Exercise
Watch a funny movie
Paint or draw
Cook or do chores
Specific Treatments
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Often depends on the availability and
training of staff and individual needs.
CBT,DBT, Family therapy, medication
as needed.
Hospitalization
QUESTIONS ?
THANK YOU