Self Harm&

Risk Assessment

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)

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’

Self Harm

• cutting

• burning

• scalding

• banging or scratching one’s own body

• breaking bones

• hair pulling

• ingesting toxic substances or objects.

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 <35

• Suicide rate highest in 45-74yr age group• DSH commoner in younger age and

women

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• F:M = 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

Risk factors

• Girls

• Psychiatric disorder

• Hx of abuse

• School, home or work problems

• Alcohol & drug misuse

• Lack of supportive family relationships

• Parental mental illness

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

• 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

Special issues for those under 16Special issues for those under 16

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

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

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 don’t really like school and nick off as much as I can. There’s 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, 2008:45)

Risk Assessment

RiskRisk

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

RiskRisk

‘‘the possibility of beneficial and harmful outcomes and the likelihood of the possibility of beneficial and harmful outcomes and the likelihood of their outcome in a stated timescaletheir outcome in a stated timescale

danger vs riskdanger vs risk

Danger is the damage or harm that may occur from an eventDanger is the damage or harm that may occur from an event

Risk is the likelihood of the eventRisk is the likelihood of the event

Risk is not static, it is dynamic.Risk is not static, it is dynamic.

Risk assessment is a cross-sectional view but may take Risk assessment is a cross-sectional view but may take changing factors into considerationchanging factors into consideration

We are not proficient at quantifying risk( one study We are not proficient at quantifying risk( one study suggests we're wrong 95% of the time‘suggests we're wrong 95% of the time‘

Thankfully wrong by overstimation in the mainThankfully wrong by overstimation in the main

Types of adverse outcomeTypes of adverse outcome

•Harm to selfHarm to self Self-mutilationSelf-mutilationSuicidal actsSuicidal acts

Self neglect and starvationSelf neglect and starvation

•Harm to othersHarm to others Emotional abuse and violenceEmotional abuse and violencePhysical abuse and violencePhysical abuse and violence

•Harm from othersHarm from others Emotional abuse and exploitationEmotional abuse and exploitationPhysicalPhysicalSexualSexual

•Harm from healthcare system Harm from healthcare system

•Harm to staff in the workHarm to staff in the work

Overdose AssessmentOverdose Assessment

Separate up into groups and take 10 minutesSeparate up into groups and take 10 minutes

Perform a risk assessment and devise a management Perform a risk assessment and devise a management planplan

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

Are you worriedAre you worried

Would you let her homeWould you let her home

What advice would you give her and her motherWhat advice would you give her and her mother

16 year old girl16 year old girl

Overdose 90 paracetamolOverdose 90 paracetamolTaken with the intention of dying. Planned for 2 weeksTaken with the intention of dying. Planned for 2 weeks

Church in the evening, quietly made her peace with Church in the evening, quietly made her peace with friendsfriends

Went homeWent homeMother drunkMother drunk

Went upstairs, took the tablets alone and soberWent upstairs, took the tablets alone and soberNo direct triggerNo direct trigger

Knew mother would not disturb her until the Tuesday Knew mother would not disturb her until the Tuesday (college day)(college day)

Mother found her unconscious on TuesdayMother found her unconscious on TuesdayPhoned ambulance, only got into it for her motherPhoned ambulance, only got into it for her mother

Risk assessment psycholRisk assessment psychol

Are you worriedAre you worried

Will you send her homeWill you send her home

What might steer you to allow her homeWhat might steer you to allow her home

RememberRemember

We cannot read the futureWe cannot read the future

Human nature is impossibly complexHuman nature is impossibly complex

Risk assessment is highly inexactRisk assessment is highly inexact

Risk management does not equal risk eliminationRisk management does not equal risk elimination

Responsibility is not a binary issueResponsibility is not a binary issue