de and Self-Harm
Introduction and definitions:
Suicide is a form of deliberate self harm (nowadays the term self harm has replaced DSH, parasuicide, attempted suicide. In this lecture the term DSH will still be used) which end up with the individual being expired.
There are no figures here to indicate the percentage of suicide as a cause of death. On average suicide is taken on average as 1% as a death cause, however this is oversimplification and the figure will change from one country to the next, depending on many factors.
DSH ends without death and is far much more common than suicide. In the next section a comparison a between suicide (i.e. ends with death) and DSH (i.e. ends with no death) will be given in the two boxes below:
Suicide
Older (age>40years) Male Violent method Planned 90% mentally ill
Deliberate Self Harm (DSH)
Young Female Overdose Impulsive Mental illness rare
Aetiology:
Mental illness is by far the most important cause of suicide, present in 90% of cases. In 70%of suicide the mental illness is depressive disorder. It is important to be aware that the early stage of recovery from depression is a vulnerable time (this can be used as a rule for almost all severe mental illnesses especially after hospitalization), as energy and motivation may return before the mood lifts, so that the patient is more able to act on continuing suicidal ideas.
Up to 15% of people with severe mood disorders will die by suicide. As schizophrenia is relatively uncommon compared to depression, suicide present 2-3% of all cases (but the rate in schizophrenia is still high, up to 10%).
A number of social and medical factors are associated with suicide. They are extremely important to recognize and will be listed below:
Factors associated with suicide:
Male gender Older age - the greatest risk is in men over 75 Previous attempts (past history of DSH) - up to 30% of people who commit suicide have attempted suicide before. Mental illness-present in 90%, mainly depressive disorders (70%) Divorced, single or widowed Bereavement - in particular loss of spouse Social isolation Living in urban environment (i.e. cities) Physical ill-health- chronic, painful and life-threatening illnesses Unemployment - the rate increases with duration of unemployment and is also raised in the wives of unemployed men.
The above are not necessarily causes of suicide and are not present in all cases, but it is useful to bear them in mind when assessing a patient who may be at risk of committing suicide.
The causes and motivation for DSH vary enormously. Three groups may be identified; although three there is considerable overlap:
Failed suicide attempt. These individuals are likely to be similar to those who succeed in the attempt but fail to die. They are at high risk of repeating the attempt, with fatal results. They are likely to have a mental illness. Impulsive self harm, with ambivalence about the wish to die. Often an overdose is taken immediately after a stressful event, with no advance planning and help is sought quickly. There may be a genuine wish to die at the time of the act or lack of concern about the outcome. Often there is no real suicidal intent at all, but instead an attempt to cope with difficult situation by gaining attention, self punishment or manipulation of others. The characteristic of such individuals are quite different from those with serious suicide intent. They are unlikely to be mentally ill and tend to be young and females (see above box - DSH). Repeated self harm with no suicide intent. There are a small group of individuals who repeatedly act on impulses to harm themselves, most often by cutting their arms (see later) superficially or taking small overdoses. This behaviour is usually due to a severe personality disorder.
Assessing suicide risk:
Suicide risk is not easily quantifiable and can fluctuate. Risk is not an all or nothing phenomenon, it is dynamic. Bio-psycho-social factors play an interactive role; saying that; all doctors should be able to carry on a suicide risk.
Some patients will describe suicidal thoughts, accompanied by a plan to put the thoughts into action, and a definite intention to act on the plan. They clearly have high risk of committing suicide and urgent action is required. However, it is not usually this clear cut. Thoughts of suicide may be resisted because of an awareness of the impact of suicide on family or because of religious beliefs. This resistance will vary with changes in severity of the mental illness. For examples, with worsening of the depressive disorder a mother may move from resisting suicide for the sake of her children to feeling that they would be better off without her. Similar example could be applied to religious individuals. It is therefore important to reassess suicide risk in vulnerable patients at frequent intervals (taking full psychiatric and physical history, psychiatric (scales) and physical investigations, looking for risk factors)
Asking about suicide:
Asking about suicide is a skill that requires practice and professionalism. It has to be in a sensitive way without raising the anxiety in both patient and doctor. In general asking about suicide does not make the patient suicidal or increase the risk.
There are many ways of asking about suicide, and one should find a form of questioning that feel comfortable with and then use it routinely, with modification depending on the circumstances.
Assessment following DSH:
The aim here is to assess the suicidal risk following the DSH, determine whether a mental illness is present and develop a management plan that will ensure the patient's safety.
The following ‘common sense' approach is useful considering whether the DSH was a serious attempt at suicide. The questions should include:
Ø Events preceding the act (before the attempt):e.g. why did they harm themselves? Was there a single incident or a buildup of stressors? Was the attempt planned? How much details were put to the plan? etc. Ø The act itself (during the attempt):e.g. what method was used? Did they intend to die? did they write a suicide note? Did they try to avoid being found? etc. Ø Current thoughts about suicide (after the attempt):e.g. what is their view about the attempt now? Do they wish they had succeeded? What has the reaction of friends and family? Do they think they might repeat the act? etc.
Management:
When the suicide risk assessment has been completed, a management plan can be developed (Bio-Psycho-Social approach). The priority must be to ensure the patient's safety.
Medical treatment may be needed before starting psychiatric treatment. The place of treatment should be carefully considered. Patients with high risk are likely to need admission to the safe environment of a psychiatric unit under close supervision ( level 4 in Rashid hospital). General medical ward are not safe for high risk patient, it is essential that if this was the case a constant nursing care be present.
Special group of DSH ‘multiple self-cutters':
This group of individuals raises lots of attention especially due to media attention and the nature of the act. Although ‘cutters' are heterogeneous group (i.e. they cut for different reasons). The next discussion will involve grouping these individual together.
The ‘cutter' cause great anxiety to health professionals and family alike. The characteristic of multiple self-cutters are:
Young Single Female Often with a medical or nursing background or family Personality problems or personality disorders (usually borderline) Background social problems are common Current eating disorder or abnormal eating habits. Sexual problems
The attempt is made in response to threats or loss, and the following clinical features are evident:
Increasingly intolerable feeling of depersonalization and escalating tension precede the attempt Multiple superficial cuts are made on writs or arms (but could be any part in the body) No pain is felt during the act, and there is often none for several hours The drawing of blood is important, and the sight of it is described as giving relieve from tension.
The complete anesthesia accompanying the cutting is one index of an extremely unusual of consciousness (flat polygraph during the episode).
Self cutters are rarely suicidal, and it has been argued the cutting is in many ways the obverse of suicide. Attempting as it does to bring the sufferer back to connection with reality from which they have found themselves uncomfortably removed. However, one should remember that serious injury and death are always a possibility.
References:
1. Stevens L, Rodin I, Psychiatry: An illustrated colour text, Churchill Livingstone 2001
2. Smith G et al. Key topics in Psychiatry. Bios scientific publisher limited, 1996.
Prof. Saoud Al Mualla (M.B, MSC, M.D, Dip, MRCPsych)
