Self Harm

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Self HarmRisk Assessment
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Definitions

• Self Harm - self-poisoning or injury,
  irrespective of the apparent purpose of the act
  (NICE 2004)
• 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)

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Definitions

• 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

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Self Harm

• cutting
• burning
• scalding
• banging or scratching ones own body
• breaking bones
• hair pulling
• ingesting toxic substances or objects.

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Scale of problem

• DSH among top 5 causes of hospital admission in
  the UK
• Most common reason for medical admission of
  females (Hawton 2007)
• Suicide is the most common cause of death in men
  lt35
• Suicide rate highest in 45-74yr age group
• DSH commoner in younger age and women

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Prevalence (YP)

• 1 in 15 of young people self harm
• Maybe 1 in 10 (Hawton et al 2003)
• Self cutting is most common type of DSH
• FM 4-6.5 1
• Asian females (15-35) 2-3x more likely to SH
• Suicide is very rare under the age of 12 yrs
• Suicide in 10-14yrs 0.9/100,000
• in 15-19yrs 6.9/100,000

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Risk factors

• Girls
• Psychiatric disorder
• Hx of abuse
• School, home or work problems
• Alcohol drug misuse
• Lack of supportive family relationships
• Parental mental illness

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Management NICE 2004

• 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

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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

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• 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

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• 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

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Remember

• SH is not the core problem it is a sign
  symptom of an underlying emotional
  difficulty/pain
• not usually triggered by one isolated event but
  rather a set of circumstances
• I dont really like school and nick off as
  much as I can. Theres always arguments at home
  so I go out and hang around with a group of lads
  and lasses. We all drink a bit sometimes I cut
  my arm with a bit of broken glass. It feels good,
  but then I regret it the next day when I see the
  scar. (Dimmock, 200845)

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Risk Assessment

• Risk
• Originally a sailing term from Portuguese
  'sailing into uncharted waters'.

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• Risk
• the possibility of beneficial and harmful
  outcomes and the likelihood of their outcome in a
  stated timescale
• danger vs risk
• Danger is the damage or harm that may occur from
  an event
• Risk is the likelihood of the event

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• Risk is not static, it is dynamic.
• Risk assessment is a cross-sectional view but may
  take changing factors into consideration
• We are not proficient at quantifying risk( one
  study suggests we're wrong 95 of the time
• Thankfully wrong by overstimation in the main

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• Types of adverse outcome
• Harm to self Self-mutilation
• Suicidal acts
• Self neglect and starvation
• Harm to others Emotional abuse and violence
• Physical abuse and violence
• Harm from others Emotional abuse and exploitation
• Physical
• Sexual
• Harm from healthcare system
• Harm to staff in the work

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• Overdose Assessment
• Separate up into groups and take 10 minutes
• Perform a risk assessment and devise a management
  plan

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16 year old girl Overdose of 10 paracetamol Did
not know about potential lethality Taken when
angry Immediately told mother Came to hospital
without resistance Regrets action No major
history of emotional disturbance But hx of SH 2
previous OD after relationship break Parental
support
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• Are you worried
• Would you let her home
• What advice would you give her and her mother

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Risk assessment psychol

• 16 year old girl
• Overdose 90 paracetamol
• Taken with the intention of dying. Planned for 2
  weeks
• Church in the evening, quietly made her peace
  with friends
• Went home
• Mother drunk
• Went upstairs, took the tablets alone and sober
• No direct trigger
• Knew mother would not disturb her until the
  Tuesday (college day)
• Mother found her unconscious on Tuesday
• Phoned ambulance, only got into it for her mother

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• Are you worried
• Will you send her home
• What might steer you to allow her home

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• Remember
• We cannot read the future
• Human nature is impossibly complex
• Risk assessment is highly inexact
• Risk management does not equal risk elimination
• Responsibility is not a binary issue