Deliberate Self Harm and Risk Assessment

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Deliberate Self Harm and Risk Assessment

• Dr S Bahia

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Overview of Presentation

• Definition of DSH
• Epidemiology
• Case Scenario
• Assessment of DSH
• Function of Self Harm
• Assessing Risk
• Other Risks

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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.

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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

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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?

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Assessment

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

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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
• Didnt expect mother to come round
• Wanted to die but now not sure
• No suicide note
• Similar episode 3 years ago

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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

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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

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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

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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

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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

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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

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Assessment

• Dont
• 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

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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

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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 2005162(2)297-303
  

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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

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Risk Assessment

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

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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

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Assessing other Risks

• Vulnerability
• Social factors
• Abuse
• Disinhibition
• Poor impulse control
• Self Care
• Level of functioning
• Social circumstances