Assessment and management of self-harm Nicky Rourke GPST1 January 24 th 2012

AIMS Terminology Demographics Risk factors associated with self-harm Assessment of self-harm Management Training

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

Case 55 yr male Background hx alcohol problems, PD Frequent attender A&E following binge Self harm – usually bilateral wrists Self discharges/abscound,threatens suicide

Terminology “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, non- suicidal self injury, self poisoning, indirect self harm

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 yrs F, and M. More common in women. Highest rates of self harm among young Black and South Asian women. A&E – 80% self poisoned, remainder self injured- cutting. 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 depression. 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 population. 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 drugs Self injury; -cutting most common method. Less common – burning, hanging, stabbing, swallowing, drowning, jumping from heights/in front of vehicles.

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) adolescence gender socio-economic class minority groups illness- physical/mental unemployment emotional and behavioural factors social isolation relationship instability recent bereavement young carer childhood abuse domestic violence family history Alcohol/drugs

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 isolation Tried to avoid discovery Did not alert others Preparation of death- note 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: © The Author Published by Oxford University Press on behalf of the RCGP. All rights reserved. For permissions please

Mitigating self harm/ treatment strategies 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 Samaritans Selfinjury.org.uk Young people & self harm website Association for young peoples health. National self-help harm network.

Summary 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

REFERENCES Cole-King A, Green G, Wadman S. Therapeutic assessment of patients following self harm. Innovait (5): NICE 2004 Self harm in primary and secondary care. NICE Self harm – longer term management. NCG33. Shinear A. Self harm in Adolescence. InnoVait (11):

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