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Deliberate Self Harm: Overview
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Deliberate Self Harm (DSH) can be defined as a self-initiated act in which the patient injures themself, or takes a substance in greater quantities than the therapeutic dose or the level which they are habituated to, that does not result in death.
DSH patients are clearly a heterogeneous group comprising those who have ‘failed’ to complete suicide, those with rather ambivalent feeling about death, and those whose intention is not to die. The evidence for this is as much as anything the striking difference in the epidemiology of DSH from suicide. There are extremely high rates with up to 1 in 100 young women being admitted at least once with DSH, and it is the commonest single cause of acute medical admission to hospital for women, and second only to ischaemic heart disease in men.
Around 90% of DSH acts are drug overdoses, most commonly with NSAIDs, anxiolytics, and antidepressants (in that order). Around 80% use prescription drugs (70% their own, 10% other people’s). 50% of men and 25-45% of women have taken alcohol within the last 6 hours. Of non-overdose DSH, self-laceration is the most common, otherwise it tends to comprise failed violent suicide attempts.
Self-laceration
This can be of three forms:
- Deep and dangerous wound with high suicidal intent.
- Self-mutilation e.g. by schizophrenic in response to psychotic symptomatology.
- Superficial wounds. This third group is the most common, and represent an important subgroup of DSH that can be extremely difficult to manage. They are mostly young women with severe personality disorders characterised by low self-esteem, impulsivity, unstable moods, difficulty with interpersonal relationships, and a tendency to abuse alcohol and drugs. They sometimes fit the criteria for borderline personality disorder. High rates of childhood sexual abuse have also been reported. Multiple lacerations seem to relieve increasing tension, appear to be associated with little pain, and are followed by feelings of shame and guilt. The behaviour can occur as an imitation of others in psychiatric in-patients.
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Deliberate Self Harm: Epidemiology
Rates of DSH appeared to increase substantially in the 1960’s and 70’s, although they may have been stabilising or falling since then.
Age & Sex
DSH is more common in the young than the old. Peak age for men is between 20 and 24, and for women between 15 and 19. Women > men (c.f. suicide) up to around 50 years of age, and then similar rates between the sexes are seen.
Marital Status
Divorced, and single people, plus those who married young are more at likely to self-harm.
Social Class
DSH increases dramatically with decreasing social class (c.f. suicide).
Employment
Unemployed rates are much higher than for the employed.
Psychiatric Illness
15-20% of DSH is in those with psychiatric illness (c.f. suicide). Of these 50% depression, 30% personality disorders, 15% alcoholism.
Other Correlates
The majority of those who self-harm have experienced major life events, also disruption in interpersonal relationships, broken homes, criminal records, suffered child abuse, social isolation, anxiety over job/ housing etc. (c.f. suicide).
Motivation
Most commonly DSH is impulsive following a situational crisis. Serious suicidal intent is present in 5-15% of those who self-harm. Reasons given include:
- ‘cry for help’
- ‘escape from intolerable situation’
- ‘relief from state of mind’
- ‘attempt to influence others’
- ‘testing the benevolence of fate’.
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Deliberate Self Harm: Assessment
Because of the considerable overlap between DSH and suicide, plus the significant rates of psychiatric illness in DSH patients, DSH should never be underestimated. 1 to 2% of DSH kill themselves within 1 to 2 years. An episode of DSH increases the risk of death in that person by 50 to 100 times.
Following an episode of DSH the first task is to assess the degree of suicidal intent. This may be suggested by:
- A clear intention to die, and remorse for having failed.
- Planning of the episode in advance.
- Steps taken to avoid discovery.
- No attempt made to obtain help afterwards.
- Using violent methods.
- Undertaking ‘final acts’ e.g. leaving a note, paying off bills, writing will.
This then needs to be followed by a general psychiatric assessment and an assessment of suicidal risk. Note that there is no correlation between the medical seriousness of the DSH and the risk of suicide in the future.
The overall risk of repetition of DSH is 15 to 25% in the year following the episode. The best predictors of DSH repetition include:
- Previous history of DSH.
- Psychiatric treatment.
- Criminal record.
- Personality disorder.
Other predictors include being separated, low social class, drug or alcohol problems, early separation from mother, the episode not being precipitated by a situational crisis.
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Deliberate Self Harm: Prevention and Management
It is worthwhile noting that 1/3 of all patients who self-harm attend their GP for relief of emotional symptoms and 1/4 are recurrent psychiatric attendees. This implies that prevention should in theory be possible, and entails treatment of any psychiatric illness, social intervention , and family and individual counselling.
Following an episode, precedence should be given to medical treatment of the episode . Management may then follow the lines described previously for suicide.
First ever episodes respond best to intervention.
There are high rates of default from psychiatric clinics in DSH patients that are referred.
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