Psychiatric and personality disorders in deliberate self-harm patients

BACKGROUND: Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide. AIMS: To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients. METHOD: A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12-16 months later. RESULTS: ICD-10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%. CONCLUSIONS: Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.     

Suicide after deliberate self-harm: a 4-year cohort study

OBJECTIVE: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort. METHOD: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox's proportional hazards models. RESULTS: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide rates were highest within the first 6 months after the index self-harm episode. The independent predictors of subsequent suicide were avoiding discovery at the time of self-harm, not living with a close relative, previous psychiatric treatment, self-mutilation, alcohol misuse, and physical health problems. CONCLUSIONS: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm. Treatment should include attention to physical illness, alcohol problems, and living circumstances. Self-harm appears to confer a particularly high risk of suicide in female patients.     

Suicide and deliberate self-harm in Oxford University students over a 30-year period

Purpose  

To determine whether rates of suicide and self-harm in university students differ from those in other young people.     

Ethnicity and adolescent deliberate self-harm

The characteristics of all adolescents referred to the psychiatric service of a tertiary hospital following an episode of deliberate self-harm (DSH) were studied. Of 100 adolescents selected over a 3-year period, 64 White and 28 Black adolescents were compared to identify factors associated with DSH in Black adolescents. The main findings were: (1) the referral rate for Black adolescents was in proportion to the community composition; (2) the characteristics of Black and White adolescents referred following DSH were similar for background socio-demographic variables, psychiatric symptoms, circumstances of the attempt and outcome. However, more social stress was reported in the Black group.     

Cognitive-behavioural intervention in deliberate self-harm.

OBJECTIVE: The objective of the study was to find the efficacy of cognitive behaviour therapy (CBT) in the management of deliberate self-harm (DSH) patients. METHOD: The experimental group (n=20) was given 10 sessions of CBT. CBT included cognitive methods, behavioural methods, problem-solving skills training and behavioural counselling to significant others. The control group (n=20) was given routine medical treatment. Post-assessment was done for both groups at the end of 3 months. RESULTS: The analysis of pre-post-assessment revealed that only the experimental group showed significant improvement on all the variables, except on impulsivity. CONCLUSION: CBT was effective in the management of DSH patients.     

Pubertal stage and deliberate self-harm in adolescents

OBJECTIVE: To ascertain the association between pubertal stage and deliberate self-harm. METHOD: Cross-sectional survey of 12- to 15-year-olds in 300 secondary schools in the U.S. state of Washington in February-April 2002 and the Australian state of Victoria in June-August 2002. A total of 3,332 students in grades 7 and 9 provided complete data on episodes of deliberate self-harm in the previous 12 months and pubertal stage. Pubertal stage was assessed with the Pubertal Development Scale. RESULTS: The prevalence of deliberate self-harm was 3.7% with a more than twofold higher rate in females. Late puberty was associated with a more than fourfold higher rate of self-harm (odds ratio 4.6, 95% confidence interval 1.5-14) after adjustment for age and school grade level. In contrast age had a protective association (odds ratio 0.7, confidence interval 0.4-1.0). The sharpest rises in prevalence across puberty were for self-laceration and self-poisoning in females. Higher rates of depressive symptoms, frequent alcohol use, and initiation of sexual activity largely accounted for the association between self-harm and pubertal stage in multivariate models. CONCLUSIONS: Puberty is associated with changes in the form and frequency of self-harm. For adolescents with a gap between puberty and brain development, risk factors such as early sexual activity and substance abuse may be particularly potent.     

Violent deliberate self-harm amongst adolescent refugees

Investigation of frequency and characteristics of violent deliberate self-harm (DSH) amongst adolescents. Study was retrospective, over 3-year period, based on records of attendees at child and adolescent mental health clinics in North West London. Nine adolescents showed violent self-harm out of 982 DSH cases (frequency 0.92%). The nine cases included five female asylum seekers, who experienced war related events, were significantly more likely to have affective disorders and post-traumatic stress disorder (PTSD), compared with the four males (none asylum seekers), who were significantly more likely to have conduct and substance misuse disorders.     

A literature review of deliberate self-harm

PURPOSE: Despite agreement across disciplines regarding the significance of deliberate self-harm (DSH), there continues to be a lack of consensus regarding what DSH is and is not. The purpose of this literature review was to determine the current state of understanding of this complex phenomenon. CONCLUSIONS: There remains a problem of definitional ambiguity regarding DSH, and a definition derived from the literature is offered. Using Rodger's framework for the evolutionary approach to concept analysis, the attributes, antecedents, and consequences of DSH are developed. PRACTICE IMPLICATIONS: Therapeutic approaches that are based on open-minded, non-judgmental listening and on harm minimization rather than abstinence may be more effective than current treatment approaches that forbid any form of DSH.     

Staff knowledge and attitudes towards deliberate self-harm in adolescents

This study investigates knowledge, attitudes and training needs concerning deliberate self-harm (DSH) in adolescents, amongst a variety of professionals involved in the assessment and management of adolescence who self-harm. A questionnaire survey was completed by 126 health professionals working with adolescents who harm themselves. The main outcome measures were a knowledge measure and three attitude measures (generated using factor analysis). The mean percentage of correctly answered knowledge questions, across all professional groups, was 60%. With regard to knowledge, over three-quarters of participants were unaware that homosexual young men and those who had been sexually abused are at greater risk of DSH, whilst one third of staff were unaware that adolescents who self-harm are at increased risk of suicide. Staff who felt more effective felt less negative towards this group of patients (B=-0.21, p=0.03). Forty-two per cent of the participants wanted further training in DSH amongst adolescents.     

Suicide risk and suicide method in patients with personality disorders

ObjectiveThe influence of psychopathology on suicide method has revealed different distributions among different psychiatric disorders. However, evidence is still scarce. We hypothesized that having a diagnosis of personality disorder (PD) affect the suicide method, and that different PD clusters would influence the suicide method in different ways. In addition, we hypothesized that the presence of psychiatric and somatic co-morbidity also affects the suicide method.MethodWe examined 25,217 individuals aged 15–64 who had been hospitalized in Sweden with a main diagnosis of PD the years 1987–2013 (N = 25,217). The patients were followed from the date of first discharge until death or until the end of the follow-up period, i.e. December 31, 2013, for a total of 323,508.8 person-years, with a mean follow up time of 11.7 years. The SMR, i.e. the ratio between the observed number of suicides and the expected number of suicides, was used as a measure of risk.ResultsOverall PD, different PD-clusters, and comorbidity influenced the suicide method. Hanging evidenced highest SMR in female PD patients (SMR 34.2 (95% CI: 29.3–39.8)), as compared to non-PD patients and jumping among male PD patients (SMR 24.8 (95% CI: 18.3–33.6)), as compared to non PD-patients. Furthermore, the elevated suicide risk was related to both psychiatric and somatic comorbidity.ConclusionThe increased suicide risk was unevenly distributed with respect to suicide method and type of PD. However, these differences were only moderate and greatly overshadowed by the overall excess suicide risk in having PD. Any attempt from society to decrease the suicide rate in persons with PD must take these characteristics into account.     

Pain and deliberate self-harm: an important association

OBJECTIVE: The aim of this study was to establish how often pain was a factor contributing to an episode of deliberate self-harm. METHOD: Retrospective case note examination of all deliberate self-harm patients with concurrent medical problems admitted to a general hospital over 2 years. RESULTS: Pain was considered to be a contributory factor in the episode of deliberate self-harm in 75 (4%) of the total number of episodes of deliberate self-harm (1665) over the 2-year period. These patients were older and had higher suicide intent scores, but lower rates of previous psychiatric illness or alcohol or drug misuse than did the deliberate self-harm patients with medical problems but no pain. Although 60% had experienced pain for more than 6 months only, 8 (12%) were attending the local Pain Clinic at the time of the deliberate self-harm. CONCLUSION: We propose closer collaboration between general hospital services and local pain clinics for deliberate self-harm patients with painful disorders. Clinicians need to assess suicidal ideation and risk of self-harm when prescribing for this population.     

Alcohol dependence, excessive drinking and deliberate self-harm

BACKGROUND: Problems relating to alcohol use are very common among deliberate self-harm (DSH) patients, and alcohol abuse increases the risk of both DSH and suicide. In the UK, per capita consumption of alcohol has risen by 50% since 1970. The proportion of women (but not men) drinking in excess of government-recommended limits has also increased. We investigate trends, by gender and age group, in alcohol problems and usage among DSH patients. METHOD: Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine trends in alcohol disorders and alcohol consumption shortly before, or at, the time of self-harm by patients aged 15 years or over between 1989 and 2002. RESULTS: Data were available on 10,414 patients who were involved in 17,511 episodes of DSH. The annual numbers of both male and female DSH patients rose progressively over the study period. Although rates of alcohol disorders and consumption remained higher in males than females, substantial increases were seen in females of all ages in rates of alcohol problems, excessive drinking and consumption of alcohol within 6 h of DSH and as part of the act of DSH. Rates for males largely remained unchanged. CONCLUSIONS: There has been a significant increase in excessive drinking and consumption of alcohol around the time of DSH by females but not males. These changes may relate to increases in the affordability and availability of alcohol and to social changes in drinking patterns. They have implications for services for DSH patients and may have an impact on future patterns of suicidal behaviour.     

Interventions to reduce repetition of deliberate self-harm

Abstract

At least 25–30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.     

Rates of deliberate self-harm in Asians: findings and models

The average prevalence rate of non-psychotic postpartum depression based on the results of a large number of studies is 13%. Prevalence estimates are affected by the nature of the assessment method (larger estimates in studies using self-report measures) and by the length of the postpartum period under evaluation (longer periods predict high prevalences). A meta-analysis was undertaken to determine the sizes of the effects of a number of putative risk factors, measured during pregnancy, for postpartum depression. The strongest predictors of postpartum depression were past history of psychopathology and psychological disturbance during pregnancy, poor marital relationship and low social support, and stressful life events. Finally, indicators of low social status showed a small but significant predictive relation to postpartum depression. In sum, these findings generally mirror the conclusions from earlier qualitative reviews of postpartum depression risk factors.     

Repetition of deliberate self-harm as seen in Uganda.

Described is the presentation of repetition of deliberate self-harm (DSH) as seen in an African population in urban Uganda. A Luganda version (local language in study area) of the modified European Parasuicide Interview Schedule I (EPSIS I) was used to collect the data. An univariate analysis was conducted. Results indicated that repeaters of DSH differed significantly from non-repeaters on several dimensions. The factors included were: more often single, less often had children, staying alone or with their parents, reported sexual problems as a precipitant of current DSH event, more negative life events in childhood and less negative life events in the last year. Furthermore, a multivariate analysis was conducted resulting in only sexual problems and the psychological factor of trait anger, which retained statistical significance. The significance of these findings is discussed.     

The challenge of deliberate self-harm by young adolescents

This paper describes a model of crisis intervention to families of adolescents below the age of 16 who deliberately harm themselves and summarizes the premises which guide our practice. The adolescent's "overdose" is understood as an attempt to resolve relationship conflicts and so the initial interview aims to explore the predicament for the adolescent and the family and decide what further help may be required. Verbatim extracts from one session illustrate this process.