🩺 Self Harm

Self-harm is defined as any intentional act of self-injury or self-poisoning, regardless of the motivation or degree of suicidal intent. It is a major public health concern in the UK, with some of the highest rates in Europe, particularly among young people. Presentations range from superficial cutting to life-threatening overdoses. Management in the UK follows NICE guidelines, which emphasise compassion, risk assessment, and the immediate treatment of physical injuries followed by a comprehensive psychosocial assessment by a mental health professional.

The history should be taken in a private, non-judgmental environment. Explore the events leading up to the act, the method used, and the patient's intent (specifically inquiring if they intended to die). Ask about 'final acts' such as writing a will or a suicide note. It is crucial to identify triggers, such as relationship breakdowns or financial stress, and to assess protective factors like children or religious beliefs. A history of previous self-harm or suicide attempts must be documented.

Primary focus is on the physical assessment and stabilisation of injuries, such as suturing lacerations or managing the toxic effects of an overdose according to TOXBASE. On Mental State Examination (MSE), look for signs of current suicidal intent, hopelessness, and the presence of underlying mental health disorders like depression or borderline personality disorder. The physical exam should also look for old scars, indicating a chronic pattern of self-harm. Always perform a thorough assessment of the patient's capacity to refuse treatment for their injuries.

Suicide attempt (high intent), Self-harm with low suicidal intent (emotional regulation), Accidental self-injury, Substance misuse, Borderline Personality Disorder, Major Depressive Disorder.

Use of high-lethality methods (hanging, carbon monoxide, firearms). Steps taken to avoid discovery (e.g., timing the act when family are away). Leaving a suicide note or making final arrangements. Regret at surviving the attempt. Persistent hopelessness or 'refusal to engage' with mental health services.

For self-poisoning (overdose), investigations are guided by the substance ingested. For paracetamol, a serum paracetamol level is required at 4 hours post-ingestion (or immediately if presenting later). Baseline bloods include FBC, U&Es, LFTs, Clotting screen, and an ECG. A salicylate level and blood glucose should also be checked in unknown overdoses. For physical trauma, X-rays or bedside imaging may be needed. Psychiatric assessment tools like the SAD PERSONS scale are discouraged in modern UK practice in favour of clinical judgement.

Self-harm is the strongest predictor of future completed suicide. Clinical assessment should focus on the intent and the psychological function of the self-harm (e.g., emotional regulation vs. ending life). Avoid 'contracts for safety' as they are not evidence-based and may provide false reassurance; focus instead on collaborative safety planning. Patients who have used 'violent' methods or have taken steps to avoid discovery are at much higher risk of further serious harm.

Aligned with the 'Mental Health' Emergencies and 'A&E' maps. Note the importance of the Paracetamol Overdose Nomogram (though now simplified in many UK trusts to a single treatment line). Understand the legal framework for treating patients who have self-harmed but refuse life-saving treatment (Mental Capacity Act vs. Mental Health Act).