Self-harm

1. Self-harm Krista Nilsen Mental health liaison nurse

2. 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.

3. 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.

4. ‘Self injury is frequently the least possible amount of damage and represents extreme restraint’ National Self-Harm Network, 1998

5. 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

6. 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.

7. 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%

8. 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).

9. 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.

10. 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

11. 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’

12. 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

13. 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.

14. 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.

15. 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

16. 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

17. 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.

18. SUPERVISION

19. 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?

20. 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?