Practical aspects of risk assessment in self harm

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

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

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.

Ever wondered whether their deaths
could have been prevented?

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

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.

‘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

‘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.

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

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.

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

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

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.’

Adolescent self-harm and mental
health status in young adulthood

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.

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.

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.

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.

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

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

Limited evidence for interventions
Group-based psychotherapy versus treatment as usual
(equivocal)
Individual psychotherapy (CBT, Mentalisation-based
therapy)
Home-based family therapy

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.

MCQs: Courtesy of Birmingham
MRCPsych Course ®

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

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

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

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

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

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

Practical aspects of risk assessment in self harm

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