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Practical aspects of risk assessment in self harm
1. Practical Aspects of Risk
Assessment in Self Harm
The Evidence Base and Real Life Clinical Scenarios
Yasir Hameed (MRCPsych)
Psychiatrist and Honorary Lecturer
UEA
22.5.2015
2. Outline
Discuss the basics of risk assessment
Explore risk of self harm in more details
Special focus on young people
What interventions work
MCQs
Clinical scenarios and videos
3. Learning Objectives
Describe a structure for assessing the level of risk the patient
poses to themselves or others.
Describe the demographic and other relevant features which
underpin an assessment of risk (e.g. age, sex, substance use etc).
Debate key concepts associated with risk such as “right to die”,
deliberate self harm and when and why people do this,
confidentiality and when one can break this, safe prescribing in
deliberate self harm, and public health measures aimed at
reducing suicide and DSH.
5. Risk Assessment
The process of assessing whether or not , and
in what circumstances, a person may harm
themselves or others (or be harmed).
It is about assessing the likely occurrence of a
future event , the likely impact of that event,
upon whom or what and with what
consequences.
Risk assessment is a dynamic process.
Inner London Probation Service,1997
6. Risk Factors
Is any personal quality or circumstance that is
associated with a negative event through
causation or facilitation.
Knowing the risk factors of the individual person
can help to predict the risk.
Risk factors are static and dynamic.
7. ‘Self-harm is not an illness, but is
more or less dangerous behaviour
that should alert us to an underlying
problem, difficulty or disorder.’
National Collaborating Centre for Mental Health, 2004: p. 16
8. ‘Suicide risk among self-harm
patients is hundreds of times higher
than the general population’.
Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm:
systematic review. Br J Psychiatry 2002;181:193–9.
9. Self harm is often repeated
For any young person with self harm:
Around half will have a history of prior harm
18% will repeat the behaviour within a year (and present to
hospital) again.
40–60% of those who die by suicide having self-
harmed in the past
In one study, 80% of young people who died by
suicide had self-harmed in the preceding year
10. 1 in 25 patients presenting to
hospital emergency departments
for self-harm will die by suicide in
the following 5 years
Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-
fatal repetition: systematic review and meta-analysis. PLoS ONE 2014:e89944.
11. Risk of completed suicide
Higher in:
Young people who self harm by cutting
Male
Received treatment for psychiatric disorder
Substance misuse
Negative psycho-social factors
12. Why do people self-harm?
Many theories, but limited evidence
The coping and emotion regulation functions
“Escape function” of the behaviour and the complex bio-psycho-
social factors
Psychological mechanisms (self-esteem, impulsivity,
hopelessness)
Negative life events
Knowing someone who has self harmed
13. Patients’ perspective
‘I don’t see it as a prelude to suicide; I see it as a survival thing.’
‘In some ways it gave me control over the pain I felt, rather than
having it inflicted on me by someone else, somehow inflicting
harm on myself as I say, got me through the other afflictions […] it
was just helping me through life in general.’
‘After a while it just feels like routine and a way to keep your mind
in check.’
15. Main findings
1 in 10 young people report self-harm
Self harm is the strongest clinical predictor of death by
suicide
Compared with those who had never self-harmed,
adolescents who engaged in ‘non-suicidal self-injury’
(NSSI) had a greater than twofold increase in the odds of
depression and anxiety at age 18 years.
Suicidal self-harm was associated with a fivefold increase
in the odds of both depression and anxiety at age 18
years.
16. NSSI experienced a greater than twofold increase in
the odds of problematic cannabis use at age 18
years.
Suicidal self-harm was associated with a greater than
sixfold increase in problematic cannabis use at age
18 years.
The odds of harmful alcohol use at age 18 years was
more than doubled for both non-suicidal and suicidal
self-harm.
17. Self-harm with suicidal intent was associated with a
doubling in the odds of not being in education,
employment or training at age 19 years.
Other longitudinal research indicates that the majority
will cease self-harming yet the behaviour may still
signal an underlying vulnerability to serious difficulties
in later adult life.
Adolescents who report self-harming behaviour
(regardless of whether or not they report suicidal
intent) should be carefully followed-up to assess their
need for support and treatment.
19. Main findings
Self-harm is strongly associated with completed suicide and
therefore needs to be treated effectively.
Very limited evidence base on what intervention works.
Hospital based statistics are “tip of the iceberg”
Suicide is the second commonest cause of death in young
people globally.
20. Standards of assessment (NICE)
Comprehensive assessment both for risk of further
episodes and clinical, social, psychosocial and physical
needs.
Assessment of depression, hopelessness and current/past
self-harm and suicidal intent
Assess the method of self-harm (cutting is a significant risk
factor for completed suicide in children and adolescents)
Use of risk assessment tools alone is not recommended
21. How you can help?
Make them feel “listened to”
Avoid being judgmental
Attitudes among clinicians towards self-harm are
negative
“Therapeutic assessment”
Offer psychosocial assessment
22. Limited evidence for interventions
Group-based psychotherapy versus treatment as usual
(equivocal)
Individual psychotherapy (CBT, Mentalisation-based
therapy)
Home-based family therapy
23. Prescribing in DSH
Careful prescribing.
Limited evidence for antipsychotic medications,
mood stabilisers and other psychotropic
medications.
Medication has to be part of a holistic approach.
25. The epidemiology of suicide reveals that in males
in the UK, the commonest method of completing
suicide is
a. CO poisoning
b. Burns
c. Hanging
d. Analgesic overdose
e. Opioid overdose
26. The epidemiology of suicide reveals that in males
in the UK, the commonest method of completing
suicide is
a. CO poisoning
b. Burns
c. Hanging
d. Analgesic overdose
e. Opioid overdose
27. The suicide rate in patients with epilepsy as
compared to general population is
a. Four fold more
b. Same
c. 25 times more
d. Five fold less
e. Difficult to compare
28. The suicide rate in patients with epilepsy as
compared to general population is
a. Four fold more
b. Same
c. 25 times more
d. Five fold less
e. Difficult to compare
29. The epidemiology of suicide reveals that in women
in the UK, the commonest method of completing
suicide is
a. Hanging
b. Drug overdose
c. Gun shot
d. CO poisoning
e. Burns
30. The epidemiology of suicide reveals that in women
in the UK, the commonest method of completing
suicide is
a. Hanging
b. Drug overdose
c. Gun shot
d. CO poisoning
e. Burns
31. Select the commonest psychiatric diagnosis in
people who have committed suicide in the UK
a. substance misuse
b. personality disorder
c. schizophrenia
d. anxiety disorder
e. mood disorder
32. Select the commonest psychiatric diagnosis in
people who have committed suicide in the UK
a. substance misuse
b. personality disorder
c. schizophrenia
d. anxiety disorder
e. mood disorder
33. The epidemiology of suicide reveals that in UK the
commonest method of attempting suicide is
a. Analgesic overdose
b. Insulin overdose
c. antipsychotic overdose
d. Opioid overdose
e. Hypnotic overdose
34. The epidemiology of suicide reveals that in UK the
commonest method of attempting suicide is
a. Analgesic overdose
b. Insulin overdose
c. antipsychotic overdose
d. Opioid overdose
e. Hypnotic overdose
35. The rate of self harm in teenagers who identify with
Goth culture is around
a. 0.1
b. 0.25
c. 0.75
d. 0.5
e. 0.15
36. The rate of self harm in teenagers who identify with
Goth culture is around
a. 0.1
b. 0.25
c. 0.75
d. 0.5
e. 0.15
Notas del editor
Avon Longitudinal Study of Parents and Children (ALSPAC): 14,000 children born between 1991-1992
This is the first population-based longitudinal study to investigate the outcomes of adolescent self-harm with and without suicidal intent.
adolescent self-harm is an important indicator of future mental health status in young adulthood.
Adolescents who report self-harming behaviour (regardless of whether or not they report suicidal intent) should be carefully followed-up to assess their need
for support and treatment. Interventions should not only focus on reducing self-harm, but should also treat the anxiety, depression and substance use
problems that may accompany self-harming behaviour