Self Harm

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.¹

Deliberate self harm is defined as an act with a non-fatal outcome in which an individual deliberately did one or more of the following:

• A behaviour (e.g. 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, e.g. bullying, abuse, or academic or work pressure. Self harm is usually done in private and hidden from anyone else.

• Self-harm is most common in children over the age of 11 and increases in frequency with age during adolescence. A survey of 15-16 year olds at school in Australia found that approximately 7% had harmed themselves.²
• It is uncommon in younger children.
• A study carried out in schools in 2002 found that 11% of girls and 3% of boys aged 15 and 16 said they had harmed themselves in the previous year.³
• In the same study, the factors identified by females included self harm by friends or by family members, drug misuse, depression, anxiety, impulsivity and low self esteem.
• In males the factors were suicidal behaviour in friends and family members, drug use and low self-esteem.
• Other risk factors include victims of domestic violence,⁴ socioeconomic disadvantage⁵ and those with eating disorders.⁶ There is an increased risk in South Asian women.⁷

• In most circumstances, people who have self-poisoned and present to primary care should be urgently referred 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. The phone number for the NPIS are available here.⁸

Drugs

• For the majority of drugs taken in overdose, activated charcoal given as early as possible, preferably within 1 hour of ingestion, can prevent or reduce absorption of the drug. Activated charcoal should be immediately available for rapid and appropriate use by ambulance and emergency department staff.
• 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.

• 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 are properly assessed by local psychiatry services and appropriately managed and supported by all health professionals involved in their care.
• 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.¹
• 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.¹
• Psychological, psychosocial and pharmacological interventions: Following psychosocial assessment for people who have self-harmed, the decision about referral for further treatment and help should be based upon a comprehensive psychiatric, psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed.¹
• Assessment after self-harm includes careful consideration of the patient's intent and beliefs about the lethality of the method used.
• Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk.⁵
• 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.⁵

• Risk of repetition of self-harm and of later suicide is high. More than 5% of people who have been seen at a hospital after self-harm will have committed suicide within 9 years.⁵
• 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.
• A history of deliberate self harm increases the risk of suicide.⁹

• For any person considered at risk, it is essential to assess the risk of self harm.
• 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.¹⁰
• 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.