Deliberate Self Harm and Risk Assessment

1. Deliberate Self Harm and Risk Assessment Dr S Bahia

2. Overview of Presentation • Definition of DSH • Epidemiology • Case Scenario • Assessment of DSH • Function of Self Harm • Assessing Risk • Other Risks

3. 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.

4. Epidemiology • 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

5. Case Scenario • 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?

6. Assessment • Collateral information • Physical Assessment • DSH/ Suicide Risk • Mental Illness

7. Case Scenario • 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

8. 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

9. Case Scenario • 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

10. 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

11. Meaning and Functions of DSH • 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

12. Assessment • Can be difficult due to strong emotions aroused in all the people involved • Resist instant moral/ ethical judgments • Can be complex • Resist falling into behavioural traps

13. 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

14. 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

15. Risk Assessment • Psych history, previous self harm and increased age • Predictive value of all risk factors poor for suicide • 3 important areas to consider for risk of suicide: suicidal intent at time of self harm, MSE social support • Protective factors

16. 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

17. 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

18. Risk Assessment • Risks change with time and circumstances • Risk Assessment is an ongoing process and requires regular review

19. Assessing other Risks Assessment of Risk of Violence History • Previous history of violence • Poor compliance • Substance misuse • Social rootlessness • Forensic history Mental State • Persecutory delusions • Delusions of passivity • Threats./ thoughts of violence • Emotional state • Behaviour

20. Assessing other Risks Vulnerability • Social factors • Abuse • Disinhibition • Poor impulse control Self Care • Level of functioning • Social circumstances