Deliberate Self Harm vs Suicidal Ideation

Deliberate Self Harm (DSH) vs Suicidal Ideation (SI)

• Deliberate self harm (DSH) is the intentional injuring of body tissue without suicidal intent
• DSH covers a range of behaviours including cutting, scratching, hitting, head banging, burning, scalding, hair pulling, and excessive use of substances.
• Although individuals engaging in DSH may not have suicidal thoughts, there is a possibility of death through misadventure.
• Suicidal ideation (SI) involves thoughts, ideas or plans about causing one's own death.
• Suicide attempt is when someone acts on their suicidal ideation.
• Suicide is when a suicide attempt is successful.

Reasons For DSH

• People engaging in DSH may not want to die; the act may be used to:
  • Manage anxiety
  • Ground themselves
  • Feel physical pain (easier than emotional pain)
  • Punish themselves
  • Gain relief
  • Feel in control
• Deliberate self-harm is described as a ‘maladaptive coping strategy’

Suicide and Self Harm Statistics

• In 2018, 3046 people completed suicide in Australia
  • More than 8 people a day
  • Accounts for 1.9% of all deaths in Australia
  • Males are 3 times more likely than females to end their life
  • Average age of death is 44 years
• In 2018, Self-Harm accounted for 10% of all ICU admissions
  • 10% of injury-related admissions for 15-19 year olds
  • Females are admitted at double the rate of males
  • Intentional self-poisoning makes up 83% of all DSH admissions

Risk Factors Related to DSH and Suicide

• Predisposing factors:
  • Social: family history of self-harm and suicide, childhood abuse, homelessness, physical illness,
  • Psychological: family history of mental illness, reduced ability to regulate emotions, poor impulse control, low self-esteem
  • Interpersonal: conflict between parents, lack of supportive relationships, poor interpersonal problem solving
• Precipitating Factors:
  • Social: entering care, parents divorcing, bereavement, unplanned pregnancy, significant financial stress, sexual assault
  • Psychological: mental illness, excessive alcohol, illicit drug use
  • Interpersonal: perceived stressful situations involving others, relationship breakdown, argument/conflict with significant other
• Perpetuating Factors:
  • Social: being bullied, unresolved housing, employment and financial problems, ready availability of potentially lethal means of self-harm
  • Psychological: Intoxication with alcohol/illicit substances, cognitive problems, believing that distress or problems are not being taken seriously
  • Interpersonal: unresolved conflict with parents, continuing negative experiences of care, ongoing difficulty communicating feelings

Mental Status Examination (MSE)

• The MSE is a standardized format for documenting observations of mental health consumers.
• It aims to uncover the subjective experience of the consumer and determine the current mental state.
• It helps professionals work collaboratively with consumers effectively and efficiently.
• It is crucial for gathering comprehensive information about a person's emotional, behavioral, cognitive, and functional well-being.
• MSEs establish a baseline of expectations around an individual's mental state.

Components of the MSE

• Appearance: Assess the individual's physical appearance, clothing, hygiene, and overall presentation.
• Behaviour: Observe the individual's demeanor, body language, gestures, eye contact, posture, and psychomotor activity.
• Mood/Affect: Assess the individual's reported mood and observable emotional expression.
• Speech: Analyze the individual's speech patterns, including quantity, quality, rate, volume, and tone.
• Thought Form: Evaluate the organization and coherence of the individual's thoughts.
• Thought Content: Examine the specific content of the individual's thoughts, including any unusual or disturbing themes.
• Perception: Assess the reliability of the individual's perception of reality.
• Cognition & Intellectual Functioning: Evaluate the individual's cognitive abilities, including orientation, memory, concentration, attention, and abstraction.
• Insight & Judgement: Evaluate the individual's awareness and understanding of their situation, the origins of their mental health issues, and the ability to make safe and sound judgements.
• Risks: Identify potential risks associated with the individual's mental state and behaviors.

Appearance

• Ascertains basic brain processes and cognitive functioning.
• Assessments include consciousness, orientation, memory, concentration, attention, capacity to read and write, visuo-spatial ability, and abstraction.

Cognition and Intellectual Functioning

• Orientation: Assess the individual's understanding of time, place, and person.
• Levels of Consciousness/Alertness: Observe the individual's level of alertness and responsiveness, including alert, clouding, fluctuating, delirium, stupor, drowsy, etc.
• Abstract Thinking: Evaluate the individual's ability to understand concepts and juggle multiple ideas simultaneously.
• Memory: Assess different types of memory including immediate, recent, and remote recall.

Insight and Judgement

• Insight: Assess the individual's awareness and understanding of their mental health problem, its origins, and its implications.
• Judgement: Evaluate the individual's ability to make safe and sound judgments in various situations, considering the potential consequences of their actions.

Risks

• Observe and document potential risks associated with the individual's mental state and behavior.
• Examples include distinctiveness features, clothing, hygiene, build, and any concerning behaviors.

Behavior

• Assess the individual's cooperation, rapport, engagement, response, and interaction with the health professional.
• Analyze body language, gestures, eye contact, posture, and psychomotor activity (hyperactivity, hypoactivity, compulsive behaviors, etc).
• Document any bizarre or unusual behaviors.

Affect & Mood

• Affect: Observe the outward expression of emotion, including facial expression, voice tone, body language, and posture.
• Mood: Determine the individual's subjective experience of their pervasive and sustained emotional state. Assess the overall emotional tone and describe it using terms like dysphoric, flat, elevated, depressed, anxious, labile, restricted, euthymic, etc.

Speech

• Assess the quantity, quality, rate, volume, and tone of the individual's speech.
• Observe factors like talkativeness, poverty of speech, slurred speech, stuttering, whispering, pressured speech, rapid speech, slow speech, loudness, quietness, and monotone speech.

Thought Form

• Assess the organization and coherence of the individual's thoughts through observation of behavior, speech, and expression of ideas.
• Evaluate and document aspects like circumstantiality, tangentiality, flight of ideas, loose associations, thought blocking, perseveration, and neologisms.