PSYCHIATRY FOR GIMDr. Vishal Maheshwar ST5

25/01/18

CONCEPT OF RISK:SUICIDE AND DELIBERATE SELF-HARM

What I will cover before break

• Introduction to risk

• Suicide

• Deliberate Self Harm

• Epidemiology

• Clinical Variables

• History Taking

General Principles of Risk

• Risk cannot be eliminated

• It can be rigorously assessed and managed

• Risk is dynamic

• (Therefore risk assessment needs to be frequently reviewed !)

Risk to Self

• Suicide

• A fatal act of self injury, undertaken with more or less

conscious self-destructive intent, however vague and

ambiguous

• Para-suicide

• Similar to suicide – but for whatever reason the victim

survived the attempt

• Deliberate self harm

• An act of self harm where the action was not with the

intention of death, but to cause harm

Suicide – ONS 2016

• Around three-quarters of all suicides in 2016 in Great Britain

were male. (Usually rate of male:female 3:1)

• In Great Britain, there were 3.4% fewer suicides registered in

2016 than in 2015; this equates to 5,668 in 2016, a decrease

from 5,870 deaths in 2015.

• For deaths registered in 2016 in Great Britain, persons aged 40

to 44 had the highest age-specific suicide rate at 15.1 per

100,000 – this age group also had the highest rate among

males at 23.7 per 100,000; the age group with the highest rate

for females was 50 to 54 at 8.1 per 100,000.

• The most common suicide method in Great Britain in 2016 was

hanging.

Contact with service prior (2002 review)

• 75% of suicide victims had contact with GP within year of

suicide

• 33% of suicide victims had contact with mental health services

• 20% of suicide victims had contact with mental health services within 1 month

• 45% of suicide victims had contact with GP within 1 month

Epidemiology (U.K)

• Risk highest during inpatient stay (1 in 1000/1 in 500)

and 14 days post-discharge.

• Inpatient suicides-risk increased with forensic history,

previous suicidal behaviour, violence to property, recent

bereavement and presence of delusions.

• Post discharge-unplanned discharge, lack of continuity

of care, unemployment, suicidal behaviour prior to

admission.

• Identified risk factors?

• being male, living alone, unemployment, drug and

alcohol misuse, mental illness, past self harm

Clinical Variables for Suicide

Mood disorders e.g. Depression

• Main correlates includeGreater severity of illnessSelf neglectHopelessnessAlcohol abuseHistory of suicidal behaviour

About one in three people with bipolar disorder will attempt suicide at least once. People with bipolar disorder are 20 times more likely to attempt suicide than the general population.

Schizophrenia

• Main correlates:

• Positive psychotic symptoms

• Post psychotic depression

• Young and male

• First decade of illness

• Relapsing pattern of illness

• Recent discharge from hospital

• Social isolation

• Good insight into illness

It's estimated that one in 20 people with schizophrenia will take their own life.

Alcohol Abuse

• Main correlates

• Male sex

• Longer duration of problems

• Single/divorced/widowed

• Multiple substance abuse

• Comorbid depression

Personality Disorder

• Evidence suggests that suicides associated with PD are

nearly always associated with a depressive syndrome or

substance (alcohol) abuse

• Borderline PD at highest risk – accidental deaths.

Chronic Physical Illness

• Increased risk in patients with chronic neurological, gastro-intestinal, cardiovascular disorders, cancers.

• Severe chronic pain leads to increased risk – depression.

• Disfigurement, especially in women

• Chronic physical illness can lead to limitations including loss of job, role, family, money, etc

Peter

• 25 yr old, male

• Known to services since the age of 18

• Early years – Neglect and physical abuse

• Parents – both alcohol dependence.

• Started using drugs since 14 - cannabis and

amphetamines

• Alcohol dependence since 20 yrs old

• Multiple admissions to hospitals – psychotic symptoms,

drug misuse.

Peter

• 25 yr old, male

• Known to services since the age of 18

• Early years – Neglect and physical abuse

• Parents – both alcohol dependence.

• Started using drugs since 14 - cannabis and

amphetamines

• Alcohol dependence since 20 yrs old

• Multiple admissions to hospitals – psychotic symptoms,

drug misuse.

Contd

• Diagnosis of Paranoid Schizophrenia

• Multiple overdoses with prescribed medication with less

clear suicidal intent.

• 3 Significant episodes of suicide, last one 10/12 ago –

“tortured by voices”, lying on the train track, note for sister.

Seen and alerted by railway worker.

• On oral antipsychotic but poor adherence – sometimes

missing doses.

• On-going suspected drug and alcohol misuse, but not

regular.

Contd

• Diagnosis of Paranoid Schizophrenia

• Multiple overdoses with prescribed medication with less

clear suicidal intent.

• 3 Significant attempts of suicide, last one 10/12 ago –

“tortured by voices”, lying on the train track, note for sister.

Seen and alerted by railway worker.

• On oral antipsychotic but poor adherence – sometimes

missing doses.

• On-going suspected drug and alcohol misuse, but not

regular.

• Limited social network and no friends

• Recent MSE: ….persecutory delusions of men trying to

kill him, chronic fleeting suicidal thoughts but no active

plans or intent…..

• He clearly states that he doesn’t wish to die.

• Considered by the team to be relatively stable in his

mental health

• Limited social network and no friends

• Recent MSE: ….persecutory delusions of men trying to

kill him, chronic fleeting suicidal thoughts but no active

plans or intent…..

• He clearly states that he doesn’t wish to die.

• Considered by the team to be relatively stable in his

mental health

• What is the risk of suicide? Low/moderate/high

• What is the imminent risk of suicide?

• Can you predict when the suicide may occur?

• What interventions could you put in place, or how would

you manage this?

Chronic high risk

Romeo (and Juliet)

• No childhood adversity

• No contact with mental health services

• No financial worries

• Good physical health

• No disordered personality

• No previous mental health diagnoses

• Occasional use of drugs/alcohol

Contd

• Acute life-changing event – fall in love

• Fear of losing Juliet

• Future plans of escape with Juliet, as he believes there is

no life without her.

Rapid onset of dynamic risk factors

Static Risk factors

• History of self-harm

• Seriousness of previous suicidality

• Previous hospitalisation

• History of mental disorder

• History of substance use disorder

• Personality disorder/traits

• Childhood adversity

• Family history of suicide

• Age, gender and marital status

Dynamic risk factors

• Suicidal ideation, communication and intent

• Hopelessness

• Active psychological symptoms

• Treatment adherence

• Substance use

• Psychiatric admission and discharge

• Psychosocial stress

• Problem-solving deficits

• In Peter’s case – the fact of suicide occurring may not be

surprising but the circumstances and timing may be…

• Multiple risk factors may not always be present in high-

risk individuals.

• Risks may escalate rapidly over a very short period.

• Predicting suicide is challenging.

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

DELIBERATE SELF

HARM

Deliberate Self Harm

• The behaviour is self-initiated

• harm is intended (intention to kill is low)

• results in injury or harm

• Two main types:

• self-poisoning

• self-injury

Epidemiology

• 150,000 new attendances at A+E per year in E+W

• Higher rates in females

• Peak age 15-44 yrs

• Increased risk of suicide: 40-60% h/o DSH

• Risk of suicide within one year of DSH: 0.7%: males 1.1% and females 0.5%

• Methods: cutting, burning, scratching, banging, wound healing interference, hair pulling, ingestion of toxins

Associations with repeated self-harm?

• Previous self-harm/ psychiatric contact

• Alcohol / Drug misuse

• Unemployment/ Social class V

• H/o trauma, sexual or physical abuse

• Criminal record/ history of violence

• Single / divorced / separated

• Family history- 4 fold increase risk, twin and adoption

studies

• Motives Underlying DSH

Wish to die, cry for help, communication with others, unbearable symptoms

• Psychological characteristics Impulsivity, cognitive rigidity, problem-solving deficits, hopelessness

• Coping mechanism

Temporary relief of anxiety, stress, emotional numbness, sense of failure

Substance Abuse and DSH

• Extensive use at time of DSH or just before DSH : 40-75% males & 12-50% females.

• Use of alcohol can add to the potential dangers of an OD

• Alcohol increases the toxicity of psychotropic drugs

• Alcohol alone can lead to unconsciousness and therefore delay time to treatment.

Risk Assessment

Psychiatric Examination

Risk Factors

Dynamic/Static

Protective

Factors

Specific Suicide

Inquiry

Modifiable Risk

Factors

Risk Level:

Low, Med., High

Taking a History e.g. OD

• Triggers

• Preparation

• Planning in advance, final acts

• Circumstances

• Alone, precautions against discovery, alcohol, the act itself, what did they think would happen? What did they want to happen?

• After the act

• Didn’t seek help, regret failure, intent

Taking a History

e.g. OD

What lead up to it?

• Depression?

• Schizophrenia?

• Personality disorder?

What about now?

• Ideation

• Intent

• Plans

Taking a History

• Rest of Mental State Examination e.g. psychosis,

depression, anxiety etc.

• Rest of a full psychiatric history: past psychiatric

history (including past DSH), past medical history,

medication, drugs and alcohol, social history, forensic

history, family history, personal history

• COLLATERAL

What management options are there?

Risk management• Treat the psychiatric disorder

• As an inpatient? closer supervision, adherence to

treatment, staffing numbers, better staffing training, safer

environment e.g. ligature points

Any questions about risk to self?

• Part 1: Alcohol and substance misuse

1. Alcohol

2. Opiates

• Part 2: Medically unexplained symptoms

1. Diagnosis

2. Differences

Part 1: Alcohol

Assessment

• Medical and Psych hx

• Collateral hx

• Physical and psych dependence

• Effects of alcohol – Physical, psych & social

• Complications

Management plan

• Managing the aggressive patient

• Capacity

• Initial management

• Investigations

• Referrals – Gastroenterology, psychiatry

• Aftercare – GP, Substance misuse services

• Social – homelessness…

Medical and psych hx

• HPC: focus on alcohol hx

• Elicit features of dependence

• Co-morbid medical conditions – Liver disease

• Co-morbid psych conditions – Psychosis, OCD, Anxiety,

Depression

• Co-morbid substance use – Opiate, Benzodiazepine

dependence

• Complications – DT, Wernicke’s, Korsakoff

• RISKS

Substance use

• What drug(s)

• Last time consumed

• How long

• How much

• Money

• How often

• Withdrawal

Dependence

ICD 10 diagnosis:

• Intoxication – transient phenomenon

• Harmful use: Physical or mental harm(not social)

• Dependence: 3 or more within the past12 months

Dependence features

• Craving

• Loss of control

• Persistent use despite

harm

Dependence features

• Strong desire (psychological) or sense of

compulsion

• Loss of control – onset, termination or level of use

• Tolerance

• Neglect of alternative pleasures or

interests(salience)

• Persistent use despite overt harm

• Withdrawals(physiological)

• *Same pattern of use regardless of social

constraints (drinking at work, drink driving…)

Pain

• Opioid drugs for relief

of pain

• Withdrawals when

stopped including

pain

• Lack of desire to

continue taking drugs.

Alcohol withdrawal

- From Maudsley Prescribing guidelines

Alcohol withdrawal

Somatic symptoms

• Agitation

• Tremor

• Nausea/retching/vomiting

• Sweating

• Tachycardia

• Headache, malaise, insomnia

Seizures

• Rule out organic cause/epilepsy

• Long acting BDZ – Diazepam

• Carbamezepine loading during detox

• Phenytoin – does not prevent alcohol withdrawal seizures

• 30% develop DT’s.

Delirium Tremens

•Neuroadaptation to high BAC

•Low BAC � hyper excited brain.

•Toxic confusional state

Delirium Tremens

Risk factors

• Severe dependence

• Past DT

• Alcohol-related seizure

• Older patient

• Acute physical illness

Features

• Tremors

• Clouding of

consciousness/confusion

• Hallucinations

• Delusions

• Agitation

• Autonomic hyperactivity

Management: Benzodiazepines – Oral or IM

Lorazepam /+ Haloperidol.

Wernicke’s encephalopathy

Thiamine deficiency

• Only 10% with triad

• Confusion

• Ataxia

• Ophthalmoplegia/nystagmus

• MRI – High specificity 93%

(sens – 53%)

• Risks

• Dependent drinker(heavy 30

Units)

• Malnourishment

Treatment

• Presumptive diagnosis

• Parenteral Pabrinex

• Suspected/established

diagnosis - 2 pairs IV TDS

for 3-5 days

• Prophylaxis – for all in-

patient detox: 1 pair IM

OD for 3-5 days

Korsakoff’s syndrome

• 80% recovering from WE

develop KS

• Intact sensorium

• Marked deficits in

anterograde and some

retrograde episodic

memory

• Intact procedural and

working memory

• Apathy, confabulation

Screening

• AUDIT – Alcohol use disorders identification test (83%

males, 65% females)

• FAST – Fast alcohol screening test

• CAGE (62% males, 54% females)

Treatment of alcohol withdrawal

• Severity of alcohol dependence/withdrawals

• Dependence: SADQ – 20 item: Mod 16 – 30, severe >30

• Withdrawals: CIWA – Ar – 10 item:

10-20 – Mod, >20 –severe.

• Moderate regime : Chlordiazepoxide 20mg QDS (20

Units daily), tapered over 5-7 days.

• Severe – Chlordiazepoxide 40mg QDS tapered over 7-10

days.

• Significant hepatic impairment – Lorazepam/Oxazepam.

Management of behaviour

• Aggressive

• Agitated

• Check – adequately treated withdrawals(objective signs –

use CIWA - Ar)

• Balance – over treating vs undertreating.

• DO NOT START TREATMENT IN AN INTOXICATED

PATIENT

• Be vigilant of drug-seeking(objective signs).

• Same principles of management of aggressive/agitated

patient.

• Liaise with Addiction consultant/services.

Relapse prevention

• Alcoholics anonymous

• Group work

• 12 – step programme

• Acamprosate

• Disulfiram

• Naltrexone

* Nalmefene

Opioid dependence

• Street Heroin• Codeine• Dihydrocodeine• Oramorph• Poppy seeds/flowers

• Methadone 1mg/ml liquid• Buprenorphine S/L tabs• Prescribed by drug and alcohol services

• DO NOT PRESCRIBE AND SEND THEM BACK TO DAAS.

• Especially unless presenting in opiate withdrawals and plan for them to stay in General Hospital.

• Before prescribing liaise with “keyworker”.

Licensed for Opioid dependence

Methadone 1mg/ml

• Full agonist

• Starting dose – 20-30ml

• Titrated usually to

>60mg/day

• T ½ >24hrs (once daily

dosing)

• Other opioids can be

prescribed and cumulative

effect

Buprenorphine

• Partial agonist

• Starting dose – 4mg

• Titrated usually to 16mg/day

• T ½ >24 hrs (once daily dosing)

• Concurrent opioid prescriptions can cause “precipitated opiate withdrawals”

Any questions?

Part 2: Medically Unexplained Symptoms

Hypochondriasis

Somatisation disorder

Factitious disorder

Dissociative disorder

• Some patients have difficulty expressing emotions, sorrow, have chronic difficulties in relationships

• Mental/psychological conflict

• Conflict is then converted to a physical or mental symptom

• Need to take a thorough personal and social history to aid diagnosis.

Somatisation Disorder• At least 2 years of multiple and variable unexplained

physical symptoms

• Persistent refusal to accept advice or reassurance from

several doctors

• Some impairment of family and social functioning

Hypochondriacal Disorder• Persistent belief in the presence of atleast one serious

physical illness, even though repeated investigations are

normal.

• Persistent refusal to accept the advice and reassurance

of several doctors.

Dissociative (Conversion) disorders

∗ No evidence of physical disorder.

∗ Evidence for psychological cause

∗ Clear temporal relationship

• Amnesia

• Fugue

• Trance and possession disorders

• Motor disorders- paralysis, ataxia, aphonia

• Pseudo-seizures

• Anaesthesia and sensory loss

• Ganser’s syndrome

• Multiple personality disorder

Contd..

• Mental effects of a conflict

• Eg Amnesia, loss of identity, change in personality

• Physical effects of a conflict

• Eg Blindness, seizures, paralysis…

Dissociation Conversion

• Diagnosis

• “disease” – eg brain

tumour

• GI most common

• Symptoms

• “cure”

• Musculoskeletal

Hypochondriasis Somatisation

Contd..

• Production of symptom

• GIT, musculoskeletal

• Polysymptomatic

• Loss of function

• Neurological

• Monosymptomatic

Somatoform Conversion

Factitious disorders

• Intentional feigning of symptoms or disabilities either physical/ psychological

• Motivation obscure; disorder of illness behaviour and the sick role

• Includes Munchausen's syndrome and hospital hopper syndrome

Thank you