Transcript Self Harm - The Cambridge MRCPsych Course
Self Harm (SH)
Divik Seth [email protected]
ST6 Child & Adolescent Psychiatry
Epidemiology Terminology Aetiology Impact Assessment Management
EPIDEMIOLOGY
Epidemiology
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
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
Suicide prevalence Male 6.5/100000 Female M>F 2.25/100000 except very young
TERMINOLOGY
Definition
‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’
(NICE July 2004)
Terminology
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
‘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
No formal classification Self-injury behavior is seen in connection with a number of diagnosis • 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 factors parental 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?
feel better To communicate To cope To punish self or others
Its complex!!
Common Misconceptions
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”
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” !!!!!!!!!
How people who self-harm experience services (NICE 2004)
Service users describe contact with health services as often difficult, characterized by ignorance, negative attitudes and, sometimes, punitive behavior by professionals towards people who self harm.
“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
•
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
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
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
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
Aim towards engagement Treat with empathy, care & respect Privacy Involve family Promote involvement in decision making
Assessment
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
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
Assessment of needs
A good mental state Maltreatment (potential child protection issues) Family functioning and support Friendships School Protective factors
MANAGEMENT
Management
Risk management Treating underlying Psychiatric Illness
Management
• 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
Ice Cube Therapy Line Therapy 15-minute Contract
15-Minute Contract
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
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
Often depends on the availability and training of staff and individual needs.
CBT,DBT, Family therapy, medication as needed.
Hospitalization