Assessment and management of self-harm

Assessment and management of
Nicky Rourke
January 24th 2012
Risk factors associated with self-harm
Assessment of self-harm
GP curriculum
Statement 1: Being a GP
Statement 5: Healthy people
Statement 7: Care of acutely ill people
Statement 13: Care of people with mental
health problems
55 yr male
Background hx alcohol problems, PD
Frequent attender A&E following binge
Self harm – usually bilateral wrists
Self discharges/abscound,threatens suicide
• “any act of self poisoning or self injury carried out
by an individual irrespective of motivation”
- NICE 2011 Self-harm: longer term management.
• DSH – no longer used – judgemental
• Self- harm accepted terminology
• Other popular terms- direct self harm, nonsuicidal self injury, self poisoning, indirect self
How common is self-harm?
• More prevalent in UK compared with Europe
• May account for over 200,000 hospital attendances
in England every year.
• More common in the young, incidence peaking 1519yrs F, and 20-24 M. More common in women.
• Highest rates of self harm among young Black and
South Asian women.
• A&E – 80% self poisoned, remainder self injuredcutting.
• SH most common reasons for women to be admitted
to medical wards
• Reported to be more common among people
who are socioeconomically disadvantaged,
single, divorced, live alone, single parents, lack
of social support (Meltzer et al 2002).
• Most acts of self-harm do not result in
presentation, real term figures not known
• Half of those seen in A&E following self harm have
seen GP in the previous month
• Similar proportion will visit GP within 2/12
of attending A&E.
Associations and special groups
• Association between self-harm and mental
disorder - > 2/3 will be diagnosed as having
• Certain types of mental disorder – more likely to
self harm (Skegg 2005)- schizophrenia, phobic,
psychotic disorders.
• Certain psychological characteristics more
common - half who present to A&E meet criteria
for PD. Labelling.
• Alcohol and drug use.
• Child abuse and domestic violence
• Older people – high suicide intent, follow up
20 years high suicide rates (NICE 2009)
- More prevalent in males, ?marriage a
protective factor.
- high proportion (69%) depressed, isolated
lifestyle and poor physical health
• Learning disabilities
Repetition and suicide
• 1 in 5 who attend A&E following SH will harm
themselves again in the following year
• Those who harm themselves by cutting less
likely to die by suicide than other ways
• Rate of suicide increases to between 50 and
100 times the rate of suicide in general
• Suicide risk increases with age (both genders)
• Men who SH more likely to die by suicide
Methods of self harm
• Divided into 2 broad groups:
• self-poisoning;
- analgesics/antidepressants, small no of illicit
• Self injury;
-cutting most common method. Less common –
burning, hanging, stabbing, swallowing,
drowning, jumping from heights/in front of
Reasons for self harm
• assumptions should not be based on previous
patterns, different reasons for motives/intent.
• expression of personal distress
• inability to cope with emotional/physical pain
• desperation
• trauma/abuse
• guilt/isolation
• increase control
• to "feel real"
Qin et al 2009
Reasons for self-harm
• coping mechanism to resist acting upon
chronic thoughts of suicide
Risk factors (Bolger et al.2004)
socio-economic class
minority groups
illness- physical/mental
emotional and behavioural
social isolation
relationship instability
recent bereavement
young carer
childhood abuse
domestic violence
family history
Non-disclosure of self-harm
• Stigma
• Negative attitudes of professionals
• Clinicians ill prepared – therefore do not ask
the question
• “...normal empathy deserts them..”
• Challenging professionally – reflective practice
Risk assessment
• Person centred bio-psychosocial approach
• Risk assessment- include identification of
main risk factors associated with risk of
further self harm/suicide
• Also include key psychological characteristics
associated with risk- depression, hopelessness
and continuing suicidal intent.
• Assessing risk of self harm – coping strategy
Features that
suggest high
suicidal intent
• conducted in
•Tried to avoid
•Did not alert others
•Preparation of deathnote
•Told others about
thoughts of suicide
•Act pre-planned
Assessing self harm
• Explore events leading up to SH- current
situation, recent events/problems, post event
• Wade and Cole-King mnemonic for GPs “SOS”
• Severity – in-house treatment, medical
treatment, A&E, severity of distress
• Outcome – intended outcome, planning and
preparation, call for help, regret?
• Support system – social network of family and
friends, isolation
Assessment of patients who have deliberately self-harmed, threatened or attempted suicide.
Shiner A InnovAiT 2008;1:750-758
© The Author 2008. Published by Oxford University Press on behalf of the RCGP. All rights
reserved. For permissions please e-mail: [email protected]
Mitigating self harm/ treatment
• Establishing suicidal intent – suicide risk
assessment, keeping safe
• Engage individual in seeking and accepting help
• Psychological therapies – distraction therapies,
CBT, problem solving therapy
• Patient to identify a personal resource
• Voluntary organisations – self help groups
• Don’t forget family
• Self help
•Get connected
•Young people &
self harm website
•Association for
young peoples
•National self-help
harm network.
Challenging area for GPs
Non-judgemental, negotiate
Ensure careful history taking
Explore factors leading to self-harm
Risk assessment
Engagement of individual, referral
Training issues for GPs
STORM training
Connecting people with self harm
Royal College of Psychiatrists College Education and
Training Centre
• Cole-King A, Green G, Wadman S. Therapeutic
assessment of patients following self harm. Innovait
2011 4 (5):278-287
• NICE 2004 Self harm in primary and secondary care.
• NICE 2011. Self harm – longer term management.
• Shinear A. Self harm in Adolescence. InnoVait 2008
1(11): 750-758.

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