Self-harm

What is self-harm?

Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act. It is an expression of emotional distress.¹

Primary care has an important role in the assessment and treatment of people who self-harm. Careful attention to prescribing drugs to people at risk of self-harm, and their relatives, could also help in prevention. When an individual presents in primary care following an episode of self-harm, healthcare professionals should urgently establish the likely physical risk and the person's emotional and mental state.²

A survey completed by members of the Royal College of Psychiatrists found that fewer than half of the respondents felt that they or their teams had sufficient training to assess people who self-harm. The burden of care often rests with junior doctors and trainee psychiatrists because of the out-of-hours nature of many self-harm incidents. Many of those who self-harm never see a psychiatrist and are discharged from accident and emergency departments, without a psychosocial needs assessment.³

Types of self-harm

Deliberate self-harm may be caused by one or more of the following:

• A behaviour (eg, self-cutting) intended to cause self-harm.

• Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose.

• Ingesting a recreational or illicit drug that was an act that the person regarded as self-harm.

• Ingesting a non-ingestible substance or object.

Deliberate self-harm is not an attempt at suicide in the vast majority of cases. It is usually an attempt to maintain control in very stressful situations or emotional pressures - eg, bullying, abuse, academic pressure or work pressure. Self-harm is usually done in private and hidden from anyone else.

How common is self-harm? (Epidemiology)²

• Self-harm is common with lifetime prevalence estimates of at least 5-6% in the UK and USA.⁴

• Self-harm is particularly common among younger people. One survey of young people aged 15-16 years estimated that more than 10% of girls and more than 3% of boys had self-harmed in the previous year.

• Self-harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold above the rest of the population in a 12-month period.

• A wide range of psychiatric problems, such as borderline personality disorder, depression, bipolar disorder, schizophrenia, drug misuse and alcohol abuse are associated with self-harm.

• Other risk factors include victims of domestic violence, socio-economic disadvantage, and those with eating disorders. There is an increased risk in South Asian women.^{5 6 7}

One cohort study in UK primary care looking at self-harm among children and adolescents found: ⁸

• There has been a sharp rise in self-harm reported in general practices for girls aged between 13-16 years from 2011 to 2014, compared with boys of the same age.

• The rate of self-harm recorded in general practice was higher in girls (37.4 per 10,000) compared with boys (12.3 per 10,000), and rose by 68% in girls aged 13 to 16, from 45.9 per 10,000 in 2011 to 77.0 per 10,000 in 2014.

• In socially deprived areas, referrals to mental health specialist services were fewer, although self-harm rates were higher.

Whilst the research team used one of the largest primary healthcare datasets, like any routinely collected data there may be problems in identifying all cases, and a potential lack of detail, for example in recording method of self-harm.

Initial management of self-harm

See the separate Acute Poisoning - General Measures article.

• In most circumstances, people who have self-poisoned and present to primary care should be referred urgently to the nearest emergency department.

• If urgent referral to an emergency department is not considered necessary, a risk and needs assessment should be undertaken to assess the need for urgent referral to secondary mental health services.

• For information about specific poisoning, the National Poisons Information Service (NPIS) should only be contacted after accessing TOXBASE or if there is concern about the severity of poisoning.^{9 10}

Drugs

• For the majority of drugs taken in overdose, activated charcoal should be given as early as possible, preferably within one hour of ingestion, in order to prevent or reduce absorption of the drug:
  

  • Activated charcoal should be used with caution for drowsy or comatose patients because of the risk of aspiration (therefore ensure the airway is protected) or reduced gastrointestinal motility (risk of obstruction).¹¹

  • Toxins not bound to charcoal include hydrocarbons and alcohols (methanol, ethanol, ethylene glycol), metals (lithium, iron, potassium, lead, silver, mercury), malathion and corrosives.

• Emetics, including ipecac (ipecacuanha), should not be used in the management of self-poisoning.

• Gastric lavage should not be used in the management of self-poisoning unless specifically recommended by TOXBASE or NPIS.^{9 10}

Assessment and further management^{2 12}

People who self-harm should be fully involved in decision-making about their treatment and care. There should be an integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self-harm and to initiate a therapeutic relationship. Management after self-harm includes forming a trusting relationship with the patient, jointly identifying problems, ensuring support is available in a crisis and treating psychiatric illness vigorously. Family and friends may also provide support.⁶

• Self-harm is a way of expressing distress. Often people don't know why they self-harm. It is a means of communicating and has been described as expressing an inner scream. It is important that all people who have self-harmed be properly assessed by local mental health services and appropriately managed and supported by all health professionals involved in their care.

• Care plans should be agreed with the person who self-harms and should include short-term and long-term goals and a risk management plan.

• Assessment of needs: all people who have self-harmed should be offered an assessment of needs, which should include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.

• Assessment of risk: all people who have self-harmed should be assessed for risk: this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, especially depression, hopelessness and continuing suicidal intent. Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk.⁶

• NICE recommends that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, or to determine who should
  and should not be offered treatment or who should be discharged. Focus the assessment on the person's needs and how to support their immediate and long-term psychological and physical safety. Mental health professionals should undertake a risk formulation as part of every psychosocial assessment.

• Psychological intervention that is structured for people who self-harm should be offered, with the aim of reducing self-harm. The National Institute for Health and Care Excellence (NICE) recommends 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self-harm.

• Psychological, pharmacological and psychosocial interventions should be used for any associated mental health conditions.

• Dialectical behaviour therapy (DBT) is a type of talking therapy. It is based on cognitive behavioural therapy (CBT), but it's specially adapted for people who feel emotions very intensely. DBT aims to help a person understand and accept difficult feelings, learn skills to manage them, and become able to make positive life changes.¹³

• Drug treatment should not be offered as a specific intervention to reduce self-harm. A Cochrane review found low or very low quality of available evidence to make any assessment regarding pharmacological interventions for self harm.¹⁴

One review looking at the effects of interventions preventing self-harm and suicide in children and adolescents research on several recommended practices, such as local suicide plans, prevention of suicide clusters, and approaches to risk assessment, found that current evidence is inadequate to form conclusion over long term benefits.¹⁵

Prognosis

• Risk of repetition of self-harm and of later suicide is high.¹⁶ More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within nine years.⁶

• Some young people self-harm on a regular basis while others do it just once or a few times.

• For some people it is part of coping with a specific problem and they stop once the problem has resolved.

• Other people self-harm for years whenever certain kinds of pressures or feelings arise.

• There are many risk factors for repetition of self-harm but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of the index episode.¹⁷

• One review found that self-cutting as a method of self-harm in children and adolescents conveyed greater risk of suicide (and repetition) than self-poisoning, although different methods were usually used for suicide.¹⁸

• Physical health and life expectancy are severely compromised in people who self-harm.¹⁹

Prevention of self-harm

• For any person considered at risk, it is essential to assess the risk of self-harm.

• Treatments that focus on increasing protective factors, such as parent support and positive affect, as well as the promotion of alcohol and illicit drug avoidance and healthy sleep, may be beneficial with regard to the prevention of recurrent suicidal ideation, attempts, or self-harm in adolescents.²⁰

• The presence of a suicide note is an indication of a failed but serious attempt at suicide. A suicide note is one indication of a higher risk of future completed suicide than self-harm presenters who have not left a note.²¹

• For patients at risk of self-poisoning, medications prescribed should be the least dangerous in overdose and should be prescribed as a small number of tablets at any one time.

• This should also apply to prescribing for relatives who live with the person at risk because medications intended for relatives are often used in self-poisoning.