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Deliberate Self Harm and Risk Assessment
Dr S Bahia
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Overview of Presentation
Definition of DSH Epidemiology Case Scenario Assessment of DSH Function of Self Harm Assessing Risk Other Risks
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Definition Deliberate Self Harm:
Acute non-fatal act of self harm carried out deliberately in the form of an acute episode of behaviour by individual with variable motivation. Gelder M., Shorter Oxford Textbook of Psychiatry 2001.
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Epidemiology DSH 250-300 per 100,000 popn. per year
Suicide rate 1% in 12mths after hosp attendance 2-3 per 100,000 of popn die by suicide within 1 year of attending hospital Overall suicide rate 11 per 100,000 per year 30 fold increase in risk of suicide compared to gen population Office for National Statistics 2000: 2% men and 3% women admitted to self harm 5% in young people to 0.2% age 65-74
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Case Scenario Called by A/E to see a 28 year old female who has presented after ingesting 25 paracetamol and 20 fluoxetine after the break up of a relationship. Used to be a regular attender with self harm a few years ago. You are requested to do a psychosocial assessment. What are you going to do?
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Assessment Collateral information Physical Assessment
DSH/ Suicide Risk Mental Illness
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Case Scenario Had the tablets at home Boyfriend left her that day
Thinking about it for a few hours Drank half a bottle of vodka Took the tablets but vomited afterwards Didn’t expect mother to come round Wanted to die but now not sure No suicide note Similar episode 3 years ago
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Assessment Suicidal Intent Method Premeditated Suicide note
Wanted to die at time of attempt Tried to avoid discovery Alcohol/ Drug use Precipitant of self harm Previous self harm
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Case Scenario Feeling low since birth of baby 10weeks ago
Previous postnatal depression with overdose Has symptoms of depression Alcohol 10units/week, amphetamine at weekends Lives in 2 bed council flat with 2 children 3yrs and 10weeks Mother supportive Used to self lacerate between ages of 14 and 24 Mother had depression, regularly put into care Feels hopeless, has thoughts of wanting to end it all, no immediate intent or plans, children and mother protective factors No psychotic symptoms
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Assessment History Taking and Mental State Examination
Past psychiatric history Current symptoms of mental illness Alcohol/ Drug use Social Circumstances Medical History Hallucinations/ Delusions Hopelessness Suicidal thoughts and intent Insight and engagement
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Meaning and Functions of DSH
A way of surviving relationships A form of communication An expression of rage A form of punishment of self and others A way of dissociating A way of feeling real Emotional Control Incomplete suicide
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Assessment Can be difficult due to strong emotions aroused in all the people involved Resist instant moral/ ethical judgments Can be complex Resist falling into behavioural traps
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Assessment Do Respond sensitively and with empathy Explore reasons
Accept that self harm may continue Support the person Seek support for self Understand behaviour underpinned by mechanism to manage difficulties Examine associated problems
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Assessment Don’t Accuse person of being manipulative or attention seeking Criticise the person Conclude that it is a lost cause Expect too much of yourself Put pressure on person to reveal all Threaten to take away support
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Risk Assessment Psych history, previous self harm and increased age
Predictive value of all risk factors poor for suicide 3 important areas to consider for risk of suicide: suicidal intent at time of self harm, MSE social support Protective factors
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Risk Assessment Independent predictors of subsequent suicide
Avoiding discovery at time of self harm Not living with close relative Previous psychiatric treatment Alcohol misuse Self mutilation Physical health problems Cooper et al Am. J. Psychiatry 2005;162(2):
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Risk Assessment Expressing Risk Is there risk
What sort of risk and degree How likely is it Immediacy How long will it last Factors that increase risk How can factors be modified or managed
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Risk Assessment Risks change with time and circumstances
Risk Assessment is an ongoing process and requires regular review
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Assessing other Risks Assessment of Risk of Violence History
Previous history of violence Poor compliance Substance misuse Social rootlessness Forensic history Mental State Persecutory delusions Delusions of passivity Threats./ thoughts of violence Emotional state Behaviour
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Assessing other Risks Vulnerability Social factors Abuse Disinhibition
Poor impulse control Self Care Level of functioning Social circumstances
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