Transcript Self-harm - Dual Diagnosis

Krista Nilsen
Mental health liaison nurse
Self-harm team
 Clients aged between 18 and 64 years old with an
episode of self-harm admitted to the medical wards at
St James’ hospital and Leeds General Infirmary.
 An injury must have occurred
 One off assessments and then refer on to other
services.
What is self-harm?
 Not straightforward given the different motives and
meaning for the individual and the varying types.
 ‘Self-poisoning or self-injury, irrespective of the
apparent purpose of the act’
NICE guidelines, National
Collaborating Centre for Mental Health, 2004
 Self-harm is not a disorder.
 ‘Self injury is frequently the least possible amount of
damage and represents extreme restraint’
Harm Network, 1998
National Self-
Types of self-harm
Cutting
Burning
Scalding
Inflicting blows on or banging the body
Scratching
Biting
Scraping
Inserting sharp objects under the skin or into body orifices
Interfering with wounds
Tying ligatures
Pulling out hairs
Scrubbing away the surface of the skin
Swallowing sharp objects or harmful substances
 Substance misuse through excessive alcohol or drug
consumption, eating disorders, physical risk taking,
sexual risk taking, self neglect, misuse of prescribed
medication are sometimes called indirect self-harm
 People may switch methods of self-harm
 When deliberate self-harm behaviours are overcome
other self-damaging problems may emerge, such as
eating disorders.
Suicide
 In Britain suicide is the third largest contributor to




premature mortality (WHO, 2000).
Men are five times more likely to die by suicide than
women.
Of people in UK who die by suicide 25% were in contact
with mental health services in the preceding 12 months
Suicide rate has decreased. In 2007 still 7.9 suicides per
100,000
In some studies the rate of diagnosed mental illness in
those who killed themselves has been found to be more
than 80%
Self-harm
 UK has one of the highest self-harm rates in Europe. Self-
harm is one of the top 5 presentations to acute hospitals.
Many do not attend hospital.
 Younger people are more likely to self-harm
 Presentations to hospital, 2/3 are under the age of 35 and
2/3 of this group are female.
 People who self-harm repeatedly are at a high and
persistent risk of suicide (Hawton et al, 2003).
Approximately a 30 fold increase in risk of suicide in
comparison to the general population. Suicide rates were
highest within first six months after index self-harm
episode (Cooper et al, 2005).
Self-harm and mental illness
 The assessor must conduct a proper psychiatric history and
biopsychosocial and diagnostic assessment. It is important
to assess risk and future management.
 Difficult feelings
 For those who have more fundamental disorders of
personality or formal psychiatric illness the treatment may
require medication, psychotherapies, assistance with
arrangements for living, containment and protection.
Strong links with borderline personality disorder, major
depression, anxiety, substance misuse, eating disorders,
post traumatic stress disorder, schizophrenia and other
personality disorders.
Drug and alcohol issues
 People who have or are recovering from drug and
alcohol problems are at a significantly greater risk of
self-harm and suicide than the general population.
 Self-medication
 Risk increases in the short term when people begin to
address their substance problem. There are
implications for the assessment, treatment and
management of the withdrawal process.
 Untreated withdrawal
Motives









Suicide
Ambivalence
Accidental harm
A coping mechanism or distraction. A form of self-preservation. Helps them
function better. Assurance they are still alive. Self-punishment. Comfort and
validation
It’s often a secret activity until circumstances change. There can be a fear of
disclosure as it may mean relinquishing responsibility.
It may indicate transient distress rather than severe pathology. Reasons incluce
escape from a terrible state of mind, punishment, demonstration of
desperation, wanting to find out if someone loved them, wanting to frighten
someone, wanting to get back at someone.
Motives can evolve over time, confused and not known to them.
Much self harm is repeated, can become habitual, addictive and contagious
Can be viewed as ‘challenging behaviour’
Assessing self-harm
 Presenting complaint, including nature of act of self-
harm. Events leading up the act. What occurred after
the incident and how did they come to your attention.
Was there a time gap? What is the reason for the time
gap.
 Personal history
 Mental state examination
Shortened version of Beck’s suicide
intent scale
Consider
 Isolation
 Timing
 Any precautions against discovery and/or intervention
 Acting to gain help during or after attempt
 Final acts in anticipation of death
 Suicide note (including if it was torn up)
 Clients statement of lethality (did they think it would kill them)
 Stated intent
 Premeditation
 Reaction to the act
 Would death have occurred without medical intervention.
Some things to consider in Mental
State examination and risk
assessment
Thoughts of hopelessness for the future.
Fleeting or persistent thoughts life is not worth living
Fleeting thoughts of suicide. Are they soon dismissed?
Frequent suicidal ideas. Methods, definite plans, access
to means of suicide, degree of planning.
Demographic risk factors














Social class 1 and 5
Personality disorder
Forensic history
Substance misuse
Older age
Male gender
Divorced
Widowed
Single
Unemployed/retired
Past deliberate self-harm
Physical illness
Mental illness
Family history of mental illness, particularly suicide
Harm reduction
 Address and minimize the risks inherent to different
types of injuries. For example, many people who
overdose are unaware that there is no way to predict
the outcome and therefore cause irreversible damage.
 Aftercare and wound treatment. This promotes
physical wellbeing and reduces the risk of unintended
consequences
Harm reduction in Self-injury.
Controversial?
 Contracts
 User led resources, information leaflets, books, online
forums.
 Promotion of safer injuries, reducing the risk of
infection. Safe kits.
SUPERVISION
Clinical scenario 1
 46 year old gentleman, known to be alcohol
dependent, presented to A&E department with an
alleged overdose of 30 paracetamol. He smelled
strongly of alcohol and refused treatment and stated
he wanted to leave the department. He has a history
of presenting intoxicated and alleging overdoses, for
which there is very little clinical evidence.
 Can he be forced to stay in the department? Should
he?
 Can he have a mental health assessment?
Clinical scenario 2
 Jennifer is 23 years old, a diagnosis of borderline
personality disorder and lower end of normal range of
intelligence. She has presented 3 times in 4 weeks with an
overdose of her boyfriend’s insulin. She overdoses on a
long-acting medication and she is usually admitted to the
medical wards for several days on each occasion. She states
she understands the risks involved in overdosing on
insulin, to her boyfriend and to herself and now regrets it.
She gives a clear account that when she is angry with her
boyfriend she takes his medication and at the time she
intends to die.
 What safeguarding issues should you consider?