438 Psychiatric Emergencies
DELIBERATE SELF-HARM
DIAGNOSIS
1 The most common met hod of deliberate self-harm is by acute poisoning.
(i) This may be admitted freely, or may be evident from finding an
empty bottle beside the patient or a suicide note.
(ii) The possibility should also be remembered in any unconscious
or confused patient, or in patients with unexplained metabolic,
respiratory or cardiac problems (see p. 24).
2 Other more violent methods of self-harm include cutting the wrists or
throat, shooting, hanging, suffocation, gassing, jumping from a height and
drowning.
(i) These are more common in completed suicide.
3 Perform a formal psychiatric assessment when the patient has made a full
recovery, is alert and orientated, and all necessary medical therapy is com-
pleted. This will help plan the further management of the patient with the
psychiatric team.
(i) Assessment of current suicidal intent. Enquire specifically about:
(a) present suicidal thoughts
(b) previous deliberate self-harm
(c) evidence of a pre-meditated act without the intention of
being found.
(ii) Determine other high-risk factors for completed suicide:
(a) mental illness including depression and schizophrenia; severe
anxiety
(b) violent self-harm attempt, such as jumping, hanging or
shooting
(c) previous self-harm attempt
(d) chronic alcohol abuse, drug dependence, unemployment,
homelessness
(e) older, single, urban, lonely male
(f) chronic, painful or terminal physical illness
(g) puerperium.
(iii) Record a general mental state examination:
(a) general appearance, behaviour, attitudes
(b) speech including pressure of speech, neologisms
(c) mood and affect, appropriateness
(d) thought processes for content and form
(e) perception including delusions and hallucinations (especially
auditory)