Non fatal deliberate self harm ( DSH)

1

• Non fatal deliberate self harm ( 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)

2

• Synonyms
• 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

3

• 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

4

• NICE 2004
• Guidelines re Deliberate Self Harm
• Focussed on respect, understanding, privacy
• Choice in their care
• Triage screening for and identifying physical and
  mental health needs
• Offering comprehensive psychosocial assessment to
  all

5
NICE guidelines DSH

• 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

6
NICE guidelines DSH

• Special issues for those under 16

• CAMH professionals should
• Be trained specifically to work with children and
  YP after self harm
• Be skilled in the assessment of risk
• Have regular supervision
• Have access to consultation with senior colleagues

7
NICE guidelines DSH

• Special issues for those under 16

• Initial Management should include advising carers
  about removal of all means of self harm including
  medication.
• If repeated self harm consider developmental
  group psychotherapy for at least 6 sessions

8

• Risk factors for repeat attempt and for suicide
  completion
• Male gender
• Increasing age
• Living alone
• Steps to avoid detection
• Past attempts
• Mood disorder
• Substance Misuse (particularly males over 16)
• Depression, hopelessness
• Agitation

9

• Particular focus on adolescence
• 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

10

• Adolescence associated psychosocial problems
• Conduct Disorder
• Depressive Disorder
• Psychosis
• Multi-impulsive Bulimia
• Incipient family breakdown
• Undisclosed abuse of all types
• Reaction to parental mental illness

11

• In young people think about it as an event with
  meaning
• Particularly social or relational meaning
• Usually people who use DSH remain in contact with
  others, and there is an element of warning, or
  appeal for help from another
• Whether taken in context around others or not,
  there is always symbolic meaning to be made
  cutting the bad out of me

12

• Assessment
• Screening history and mental state for known
  factors associated with risk of repetition and
  completion
• At the same time asking the salient questionwhat
  is the significance of this person presenting to
  me, in this way, at this point in their life

13

• Intent
• In the context of the assessment you have just
  made, what is your assessment of intention
• Assessment of intention in young people
  particularly important.
• It informs risk assessment
• Intention around the original act and ongoing
  intention
• What do they say about intention and what do
  their actions suggest