Self-Harm
Definition and Types
Self-harm is defined as intentional self-poisoning or injury, regardless of the apparent purpose of the act
Self-harm can be broadly divided into:
- Self-poisoning
- Intentional ingestion of medication, e.g. paracetamol overdose
- Intentional ingestion of other harmful substances
- Self-injury
- Cutting
- Burning
- Hitting or otherwise deliberately injuring oneself
Self-harm and suicidal intent
- Self-harm may occur with or without suicidal intent
- Therefore, self-harm should not automatically be assumed to represent a suicide attempt
- However, every presentation with self-harm should prompt assessment for suicidal thoughts, intent and immediate safety concerns
Risk Factors and Association
| Category | Specific factors |
|---|---|
| Previous self-harm / suicidal behaviour |
|
| Concurrent mental health conditions |
|
| Psychological and social factors |
|
| Trauma and adverse experiences |
|
| Physical health |
|
| Demographic / vulnerability factors | Increasing age following self-harm is associated with greater subsequent suicide risk
|
Learning aid: SAD PERSONS mnemonic for factors historically associated with suicide risk: [Ref]
| Letter | Corresponding factor |
|---|---|
| S | Sex: male |
| A | Age: <19 or >45 y/o |
| D | Depression or hopelessness |
| P | Previous attempts or psychiatric care |
| E | Excess alcohol or substance use |
| R | Rational thinking loss (e.g. psychosis) |
| S | Separated (single or divorced or widowed) |
| O | Organised or serious attempt |
| N | No social support |
| S | Stated future intent |
Important: the SAD PERSONS is traditionally used as a suicide risk-assessment scoring system. However, it has poor evidence as a predictive tool. NICE explicitly recommends not using risk-assessment tools or scales to predict future suicide or repeat self-harm, determine treatment or discharge, or classify patients as low, medium or high risk. Instead, use an individualised psychosocial assessment and risk formulation.
Initial Assessment and Management
Key concept: identify and treat any immediate life-threatening physical problems → psychosocial assessment as soon as the patient can participate, alongside ongoing physical care
Management components:
| Assess and manage immediate physical health needs |
|
| Assess immediate mental health and safety |
|
| Arrange psychosocial assessment |
|
Do NOT use risk-assessment tools or scales (e.g. SAD PERSONS) to predict future suicide or repeat self-harm, determine treatment or discharge, or classify patients as low, medium or high risk.
Admission and Discharge Criteria
Consider hospital admission after a self-harm episode if ANY of the following:
- Active physical safety concerns (e.g. at risk of violence, abuse, exploitation) and a psychiatric admission is not indicated
- Safeguarding planning needs to be completed
- Inability to engage in a psychosocial assessment (e.g. highly distressed, intoxicated)
Prior to discharge, the following must be performed:
- Psychosocial assessment
- MDT discharge planning
- Clear management plan that is co-created with the patient
- Communicated aftercare management to the primary care team
Interventions and Management
Psychological interventions:
- Adults: CBT-informed psychological intervention
- Children and young people who experience significant emotional dysregulation difficulties: consider dialectical behavioural therapy adapted for adolescents
Other management components:
| Component | Description |
|---|---|
| Safety planning |
|
| Harm minimisation |
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| Therapeutic risk taking |
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Do NOT offer drug treatment as an intervention to reduce self-harm.
Drug treatment should only be used to treat underlying or concurrent mental health conditions (e.g. depression, bipolar disorder, schizophrenia, borderline personality disorder)