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 selfharm.

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 selfharm
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 sociocultural 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