Assessment and management of self-harm Nicky Rourke GPST1 January 24th 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, nonsuicidal 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 1519yrs F, and 20-24 M. More common in women. • Highest rates of self harm among young Black and South Asian women. • A&E – 80% self poisoned, remainder self injuredcutting. • 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 deathnote •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;1:750-758 © The Author 2008. Published by Oxford University Press on behalf of the RCGP. All rights reserved. For permissions please e-mail: journals.permissions@oxfordjournals.org 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 2011 4 (5):278-287 • NICE 2004 Self harm in primary and secondary care. • NICE 2011. Self harm – longer term management. NCG33. • Shinear A. Self harm in Adolescence. InnoVait 2008 1(11): 750-758. THANK YOU