Self-harm & Suicide

Dr Joanna Bennett

Self harm / Self injury/Self mutilation

Deliberate self-cutting, burning, poisoning, with or without the intention of committing suicide

No DSM or ICD diagnosis A symptom for diagnosing other mental

disorders Borderline personality disorder

‘recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 

Self harm / Self injury/Self mutilation

self-harm behavior is seen in patients with many mental disorders

Occurs without any apparent disease and can persist after other symptoms of a particular psychological disorder have subsided

Call for a separate diagnosis

Prevalence

Prevalence is 3-5% of the population in Europe & US

Risks are higher in:– women– young adults– socially isolated or deprived – psychiatric and personality disorders

Around one-quarter will repeat self harm in 4 years– Younger adults repeat non-fatal self-harm– Adults (>45yrs) more likely to commit suicide

Prevalence - Caribbean

On the rise Ingestion of tablets – females Strong chemicals – men Self- mutilation/cutting – adolescents and

young adults Trinidad – 3 people daily deliberate self

harm (Hickling & Sorel)

Aetiology

Biological - familial, genetic Psychosocial

Other suggested personality traits:– impulsive, aggressive, inflexible– impaired decision making and problem solving

Self-harm & suicide

30-fold increase in risk of suicide, compared with the general population

Long-term suicide risk 3-7%

Suicide rates are highest within the first 6-12 months after the index self-harm episode.

Self-harm & suicide

Predictors of subsequent suicide include:– avoiding discovery at the time of self-harm– not living with a close relative– previous psychiatric treatment– self-mutilation– alcohol misuse – physical health problems.

Management: self harm

No drug treatment shown to be of benefit in reducing recurrent self harm – Flupentixol depot injections may reduce

the recurrence of self-harm, but with associated adverse effects.

– Paroxetine has not been shown to reduce the risks of repeated deliberate self-harm but may increase suicidal ideation

Psychological interventions

Problem-solving therapy may reduce depression and anxiety, but may not be effective in preventing recurrence of self-harm.

Intensive follow up plus outreach , nurse led management or hospital admission have not been shown to reduce recurrent self-harm compared with usual care.

Psychological interventions

Cognitive therapy plus usual care reduces the incidence of deliberate self-harm in adults with a recent history of self-harm compared with usual care

problem-solving approaches, dynamic psychotherapy, short-term counselling, does not reduce rates of repetition at 1 year compared with usual treatment

Psychological interventions

Cognitive therapy plus usual care more effective at 6–18 months than usual care

– reducing suicide attempts and severity of depression

– reducing hopelessness– no more effective at reducing suicidal ideation

Management: self harm

Aims of interventions– reduce repetition of deliberate self-harm– reduce desire to self-harm– prevent suicide– improve social functioning and quality of

life

Self harm: Patient’s views

Patients with a history of deliberate self harm lack of control over their lives, through: – alcohol dependence– untreated depression– uncertainty within their family relationships.

Accident and emergency staff's perceptions of deliberate self-harm

89 A&E medical and nursing staff. rate attributions for the cause of the deliberate self-

harm their emotional responses, optimism for change, willingness to help change the behaviour. general attitudes towards deliberate self-harm

patients perceived needs for training in the care of these

patients were also assessed

Accident and emergency staff's perceptions of deliberate self-harm

The greater attributions of controllability, the greater the negative affect of staff towards the person, and the less the propensity to help.

Male staff and medical staff had more negative attitudes, and medical staff saw less need for further training.

Suicide

WHO: each year approximately one million people die from

suicide. A global mortality rate of 16 per 100,000. One death every 40 seconds

In the last 45 years suicide rates have increased by 60% worldwide.

Suicide is now among the three leading causes of death among those aged 15-44 (both sexes).

Suicide attempts are up to 20 times more frequent than completed suicides.

Suicide

suicide rates among young people have been increasing - they are now the group at highest risk in a third of all countries.

Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide.

Suicide

suicide results from many complex socio-cultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis

In many cases, swift, decisive intervention can prevent suicide. Recognizing risk and taking action if the potential arises is critical.

Assessment: suicide risk

Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide.

Any plans for suicidal acts - more specific plans indicate greater danger: purchased a gun, has ammunition, has made out a will

Assessment: suicide risk

– Determine whether they have a weapon or access to it.

– Determine what the patient believes suicide would achieve - suggests how seriously the person has been considering suicide and the reason for death

– Potential for homicide

Assessment: suicide risk

– Any family members or friends who have killed themselves.

– Symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse

Assessment: suicide risk

The clinician's gut feeling- clinician's reaction counts and should be considered in the intervention.

Use of rating scales – e.g. Beck depression Inventory

Management: Suicide risk

Close observation - individual must not be left alone

Remove anything that the patient may use to hurt or kill him or herself

Some Nursing Diagnoses

Risk for self-directed violence Hopelessness Ineffective individual coping