Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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self-harm and manipulation
- Brian F. Walker (24 May 2002)
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Self harm and suicide
- Rajesh Moholkar, LU5 0FB (25 May 2002)
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Study doesn't address motivation
- Simon Smith (25 May 2002)
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Could intervention aggravate self harm?
- Prof Chris J Hawley, Howlands, Wlewyn Garden City AL7 4HQ (25 May 2002)
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Helping GPs Deal with the Complex Problem of Deliberate Self-Harm
- Alex J Mitchell (26 May 2002)
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Is the bias explaining the lack of benefit in the intervention group?
- Grazyna T Adamiak (26 May 2002)
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Motivation is also a chemical issue
- Lisa C Blakemore-Brown (26 May 2002)
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Intentional Self-Injury Patterns and Interventions
- Aliceann Carlton (27 May 2002)
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Self-injury pictures misrepresent trial
- Allan House, David Owens and Judith Horrocks (30 May 2002)
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Brian F. Walker, GP Hong Kong
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In my experience both at the receiving end as a casualty SHO as well as psychiatry SHO, and finally in varied GP settings, self-harm is one feature common to a group of behavioural issues, including major psychiatric illness. Excluding those cases of major psychiatric illness (which are of course a medical emergency) in my experience self-harm is used almost exclusively to achieve two outcomes; firstly to express dissatisfaction in visible form, and secondly to manipulate carers to undertake an action they would not normally have done. Classically the self-harmer wishes to obtain a short-term admission to a hospital ward. Guidelines in dealing with this problem are then to be perceived as an attempt to change the rules by which the patient should abide. From our perspective they may make sense, but if the self-harmer fails to obtain the desired outcome, then they will revert to a pattern of behaviour they know to be effective. If this is the case, then the results are indeed unsurprising. I found the following approach to be more productive when dealing with such cases. Having excluded major depressive illness and similar pathology, I made clear to the patient that their survival was a matter of indifference to me. As they were mentally fit to make a choice, and as suicide is not illegal as such, they were free to kill themselves. Therefore they were not to be referred to me via casualty, but rather after appropriate treatment they were to make an appointment with the duty nurse for examination the following morning in my office. This achieved the following objectives: the game rules were changed from their plan to my plan, the predicted outcome they assumed was regularly not achieved requiring them to rethink their strategy, it became essential for them to consider new options. At this point we could begin to address the issues at the root of their problems, and not deal with the parasuicide smokescreen. As long as we reinforce the shock value of self-harm by acting promptly - on command - to the patients actions, we will tacitly validate their actions, and slow real help in addressing the root causes. I would suggest modifying the current guidelines to take account of this, and then repeat the study to assess any success. |
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Rajesh Moholkar, SHO Psychiatry Orchard Unit, Calnwood road, Luton, LU5 0FB
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Having worked in psychiatry for six years, I am no stranger to patients harming themselves and in some unfortunate cases, commiting suicide either delibaretly or as a result of self harm attempt accidently causing death. Olive Bennewith et al throw some light on this issue of self harm and hence suicide prevention.There have been very limited trials concerining strategies about self harm and suicide prediction and prevention. Unfortunately, the psychiatrist and related professionals have to go trough a painful and sometimes humiliating enquiries following suicides of their patients. Self harm in my opinion is much more of a cultural phenomenon. Now a days, the stigma that was once associated with self harm attempts has got diluted and it has become an acceptable way of seeking retribution or asking for help. The fact is that we as a society are getting more ane more uncomfortable at being unhappy. The tolerance towards unhappiness and frustration has gone down. Somehow, we seem to be under an illusion that life should be a perfect and happy thing and unhappiness is unacceptable. Of course, the dream doesnt last and the rude shock causes the self harming behaviour. In my opinion, doctors have a very limited role to play in the prevention of self harming behaviour. Their role will be to treat the underlying psychiatric disorder if any. Majority of self harmers donot suffer from a treatable mental illness. In these, the solution in a social and cultural change towards self harm in particular and life in general if we are to reduce the rising incidence of self harm. References 1.General practice based interventions to prevent repeat episodes of deliberate self harm:cluster randomised controlled trial; Olive Bennewith et al; BMJ 2002, 324:1254-1257 |
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Simon Smith, Consultant Psychiatrist South Shropshire CMHT, 25 Corve Street, Ludlow, Shropshire SY8 1DA
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Bennewith and colleagues should be applauded for their complex and detailed look at the effectiveness of primary care based interventions in deliberate self harm. However, I am unsurprised that their intervention was ineffective. Self harm is so common and has so many different motivations that any sort of guideline brief enough to be used in a primary care setting will have shortcomings. The guideline also failed to identify or address the needs of those who harm themselves, without suicidal intent, as a coping strategy. These individuals make up, at least amongst the population I see, the majority of those who repeatedly self harm. In medical terms many would be labelled as "emotionally unstable personality disorder" of "borderline" or "impulsive" type. Such individuals often have problems resulting from abuse histories and stopping them harming themselves in the short term, before they have developed other coping strategies, can be more dangerous (in terms of provoking real suicide attempts) than leaving alone. Even secondary care services can struggle to meet the needs of such individuals although a tactic of harm minimisation rather than stopping self harming can reduce risks, if not the incidence of self harm itself. Psychotherapy or therapeutic communities may help in the long term. If the rate of deliberate self harm can be seen as an indicator of the the completed suicide rate the study also raises questions about the government's target for suicide reduction. Not that such a target shouldn't be aspired to, just that it will be far more difficult to achieve than is anticipated. Simon Smith |
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Prof Chris J Hawley, Consultant Psychiatrist Queen Elizabeth II Hospital, Howlands, Wlewyn Garden City AL7 4HQ
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From a public-health perspective it would be highly desirable to know of strategies that would serve to minimise and contain repeated self- harming - a societal phenomonon that continues to be of epidemic proportions. However, it is a serious consideration that at least some forms of intervention in this group of patients might serve to aggravate, rather than attenuate, the propensity to self harm. In Bennewith et al it is therefore notable that the rate of self harm in the intervention group exceeded that in the control group by one-third. Although this difference (p=0.16) falls short of conventional statistical significance, within a Baysean framework the probabilities shift toward the intervention as harmful rather than helpful. Many clinicians are of the view that over-solicitous repsonses to self harm can be positively unhelpful. The direction of findings in Bennewith et al suggests that such views may not be without foundation. One suggests that studies in this difficult area should be designed and powered sufficient to detect worsening as well as improvement. |
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Alex J Mitchell, Lecturer in Psychiatry University of Leeds
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Bennewith and colleagues have attempted to examine the ability of general practitioners to prevent repeated deliberate self-harm (DSH). The results are not encouraging, particularly as patients without a previous self-harm history appeared to be more likely to harm themselves when treated by GPs who offered to see the patient soon after hospital discharge. On the other side of the coin, a beneficial effect was detected in the 14% who were repeated self-harmers but the number of outcome events in this subgroup would have been very small and, confusingly, the results appear to conflict with the previous Bristol Green Card studies. Whilst disappointing, the negative results are not surprising. No intervention, psychological, social or biological, has been shown to be definitively effective in reducing future DSH even when conducted by motivated and skilled researchers. This is likely to be because of the difficulty in influencing the ongoing and unpredictable future adverse circumstances and suboptimal problem solving skills that are a feature of many individuals who self-harm. In other words a powerful intervention would be necessary in order to demonstrate a significant difference in a real-world modestly sized RCT. The intervention suggested in this study is essentially an “offer of contact” and an educational handout. This type of intervention was not associated with appreciable benefits in 11 previous studies.1 Further, we do not know from this study whether the guideline document was actually used or even whether it was thought to be useful by the GPs concerned. We do know, however, that approximately the same number of patients visited their GP within six weeks regardless of whether they were invited or not. In fact, on close reading, significantly more patients in the control group visited their GP early after the index episode. What does this imply about the risk of people who do not subsequently consult their GP? A useful study by Crawford and Wessely (2000) showed that in these circumstances, non-attending patients may not be at higher risk than attending patients.2 I think there are two important lessons that can be learnt from this study. The first is that the majority of patients visit their GP soon after discharge from A&E with DSH and this remains an important target for secondary prevention. One modifying variable in this equation is the efficiency of communication between hospital staff and general practitioners. At the point of contact, the GP is faced with the awkward situation that the patient’s recent history may not be known, and the patient is as likely to present with physical symptoms as mental health symptoms.2 Whereas if the patient’s history is known, then a clinician can have a high index of suspicion for mood disorder or emotionally unstable (borderline) personality disorder. The second lesson is that more than printed material is required to help GPs manage this complex and heterogeneous group of patients. One practical suggestion is more joint work between primary and secondary care for difficult cases – as this helps inform each party about the pressures and limitations of the other. The evidence for education programs was mentioned but dismissed because DSH is too rare to attract GPs interest. This misses the point that DSH is not an illness but a behaviour which is a symptom of many disorders, of which depression is probably the most important reversible medical cause.3 Many patients may experience significant distress following initial DSH but never re-present with further DSH. For this reason future studies should examine the effects of intervention upon patient’s mood as well as their behaviour. Viewed in this broader context there is much more reason to believe GPs would be interested in an intervention package (teaching, mentoring or outreach) which aims to improve skills as well as knowledge. 1 Freemantle, N. Harvey, EL. Wolf, F. Grimshaw, JM. Grilli, R. Bero, LA. Printed educational materials: effects on professional practice and health care outcomes. [Systematic Review] Cochrane Effective Practice and Organisation of Care Group Cochrane Database of Systematic Reviews. Issue Issue 1, 2002. 2 Crawford MJ, Wessely S. The management of patients following deliberate self-harm – what happens to those discharged from hospital to GP care? Primary Care Psychiatry 2000; 6:61-65. 3 Beautrais AL, Jorce PR, Mulder RT, Ferguson DM, Deavol DJ, Nightingale SK. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study. Am J Psychiatr 1996; 153:1009-1014. |
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Grazyna T Adamiak, PhD Student HSR, Uppsala University, Uppsala science Park, 751 85 UPPSALA
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Authors are arguing that the majority of previous intervention on patients committing self-harm have been based in secondary care and that the described intervention is entirely based in primary care practice. This is a contradictory statement while they concomitantly provide information that the recruitment of patients was actually based on the records from the hospitals' accident and emergency departments, i.e. secondary care settings.” Audits showed that around 95% of all patients in the intervention and control groups who were subsequently admitted as inpatients (about half the total) were identified and recruited.” The inclusion was thus entirely based on secondary care data while the exclusion comprised the episodes of deliberate self-harm managed entirely in primary care. The data collected in the aim to study the management process were collected from secondary care and addressed communication with hospitals and referrals in the following 12 months. Thus, the intervention did appear neither to exclusively be held in primary care practices nor to be possible to be implemented without support from the emergency departments at hospitals. The outcomes were repeated episodes of self-harm, obviously identified by hospitals too. Also 40% of the patients in the control group as compared to in the intervention group were referred for psychiatric or community mental health team care or for counselling in the 12 months after the index episode [1]. It suggests that the mode of management considerably differed between the intervention and control groups, and could contribute to the negative results obtained in the trial. It is some kind of illusion the study is mediating of isolated interventions within primary care, without any contributions from other caregivers, even more specialised services. However, the discussion is lacking of these facts. The Authors are stating the uniqueness of the intervention as it were performed on “the island of primary care”. They believe that the trial was the largest of “deliberate self harm carried out and the only study based completely in primary care”. The reason to the lack of improvement in the intervention group, as it is discussed in the article, could depend on the characteristics of the participating practices, not on the fact that a much larger proportion of patients in the control group in fact were treated by specialised services. The argument and fact that many of the practices in the intervention group were larger and provided training is also surprising, while it is used as proof of better care in the intervention group, despite the final negative outcomes. In which way this “could have limited the capacity of the intervention to produce an improvement in outcome” is difficult to understand. On the contrary, training suggests up to date methods and specialised education among the general practitioners and other personnel working at these units. The Authors describe that the events of self-harm are relatively uncommon or rare in general practice. “The mean annual number of patients recruited per general practitioner was about three” in the study area. It is likely the fact known from other areas of the medicine, that outcomes of care might differ due to skills and training, which are affected by the volume of performed procedures or treatments per physician or unit, which may explain the various outcomes of aftercare in the intervention and control groups. The repeated self-harm is primarily an indices of the outcome of psychiatric therapeutic interventions in primary care. It would probably more appropriate to consider system-redesign, i.e. centralisation of aftercare provided in general practice to a smaller number of practices, which could allow for more effective services to this small group of patients as well for subsequent specialisation of physicians in psychiatric care. I am suggesting that the quality of psychiatric interventions would probably improve through centralisation. It is also interesting how the hospitals selected patients for further referrals to mental services and counselling. The conclusion that “the question is open on the most effective management in general practice of patients with self-harm” is not entirely justified. It would be interesting if the Authors could consider collaboration and integration with caregivers at hospitals and other providers, while it seems that not all patients repeating self-harm are contacting their general practitioners despite letters or remainders [1]. Another weakness is that the study did not consider such characteristics of relevance for patients’ propensity for suicide, such as socio-economic circumstances and the amount of support from proxies or relatives, which also could significantly differ between the two patient groups [2]. References 1. John W Williams, Jr (commentator). Feedback to physicians plus telephone care management improved outcomes in primary care patients with depression. Evid Based Ment Health 2000 3: 124 2. Ashok M. Schizophrenia and disorders with psychotic features . Evidence -Based Mental Health 2000; 3:120. (Regarding: Positive family interaction was associated with fewer relapses in patients admitted to hospital for psychotic disorder by Halford WK, Steindl S, Varghese FN, et al. “Observed family interaction and outcome in patients with first-admission psychoses”. Behavior Therapy 1999 Winter/Fall;30:555–80). |
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Lisa C Blakemore-Brown, Independent Psychologist UK
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The considerable increase in Autistic Spectrum and ADHD disorders over the last decade, implicating, for example, the frontal lobes and the neurotransmission system, must also be related to the increase in self harming. Amongst those who I have assessed with this problem, some have told me that they self harm to actually be able to FEEL something, as there is impairment of sensory perception ( including pain ) in association with social perceptual impairment. Then the effect on brain chemistry of self harming can become a highly reinforcing experience, and the act an obsession, however it is interpreted. The young autistic/ADHD child may impulsively head bang involuntarily, the pre teen may head bang to `make my brain work`, whilst the adolescent may be seeking out similar sensations, but the purposeful self cutting behaviour seems to emerge from the insight into their difference, social isolation and deep confusion in those I have seen. |
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Aliceann Carlton, Licensed Clinical Therapist Eastern Montana Community Mental Health Center USA 59301
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This study speaks to the frustrations and very real risks of patients presenting at hospital EDs with intentional self-injury. What is interesting to me as a community based clinician are the study population exclusions noted below: "Exclusions We excluded cases of alcohol (taken alone) and illicit drug overdose, except where the casualty officer felt that the purpose of the act was self harm or suicide. We excluded patients who were under 16, of no fixed abode, or imprisoned; who had requested that nobody was to be informed of the episode or had harmed themselves deliberately in response to a psychotic hallucination or delusion; or whose episode of deliberate self harm was managed entirely in primary care." While this study protocol make efforts to eliminate uncontrollable variables that influence impulsivity, cognition, and lifestyle, it eliminates the bulk of the self-harming population who repeat these behaviors and represent at EDs in varying frequencies and levels of injury. It is the bulk of folks who are the highest risk, repeat event admissions who cost EDs and health care tremendously in personnel, treatment costs and stress. The pattern of self-harm beginning in adolescence frequently leads to concommitant and comorbid factors such as homelessness or drifting, alcohol and drug use which disinhibit and/or are acts of self-medication, and frequent hallucinatory (non-drug) or delusional experiences arising from previous trauma which is the substratum for a substantial number of repeat self-harm cases. There also are frequent problems with law enforcement as during episodes of derealization/depersonalization/loss of impulse control, self-harming individuals often are arrested and detained for legal infractions. In my 20 years' experience the intervention offered in this study of: a letter to the primary physician, an invitation to receive follow-up care and a copy of guidelines would not be seen as "helpful" by most self-injuring patients. The balance of cases which are included in the study are usually situationally reactive in nature and also not likely to follow up. Those more dependent in personality might follow-up if this was done by a phone outreach so that they would feel more of a caring connection. In the US, most EDs and primary care providers follow a protocol of a mandated mental health assessment as soon as medical stabilization is achieved. All cases of self-harm are seen as high risk and/or suicidal so that for those who refuse a voluntary assessment, an involuntary assessment at the ED will be sought (or in hospital if admission has been required). It is following this consult that a determination will be made regarding intervention and treatment. The medical/mental health collaboration is seen as an essential part of risk management. Also, the link is established between the patient and mental health provider/system that strengthens liklihood of followup within days. Medications, if indicated and accepted by the patient, are begun at the ED or within a few days in most cases. In the region where I work, there are no psychiatrists for 150 miles, so primary care providers initiate and monitor medications. Medications AVOIDED include tricyclic antidepressants, benzodiazepines, and pain management opioids. Medications UTILIZED are usually SSRIs to start and often atypical antipsychotics such as risperidone if the individual enters follow-up treatment. Few primary care providers try to manage self-harming patients without mental health consult because of the risks and frustrations of repeat incidents. This relieves the tremendous burden medical providers carry in frontier areas such as Easterm Montana where the distances from medical center access are in the hundreds of miles. In most cases, the effects of interventions support the collaboration and decrease the anger and frustrations of the providers thus maintaining compassionate patient care for individuals who challenge the patience of even the most experienced medical providers. It does not seem to make much of a deterrent in patients struggling with the addiction to self-injury to relieve psychic pain or thepatient in the throws of flashback to abuse. It would be interesting to see a study of repeat self-injury patterns including those excluded. Respectfully Submitted,
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Allan House, Professor of Liaison Psychiatry University of Leeds, David Owens and Judith Horrocks
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The trial reported by Bennewith et al (BMJ 25 May) is advertised with two striking pictures. The front cover shows the forearm of somebody who has apparently cut himself or herself on more than one occasion. The image in This Week in the BMJ is more artificial - depicting somebody posed as if about to cut his or her wrist - but is still about self-injury. There is an irony in these choices. First, self-injury (as opposed to self-poisoning) was almost certainly under-represented in the Bristol trial, in which 90% of subjects were recruited after self-poisoning. Our own monitoring, and that of others, suggests that 20% of hospital attendances for self-harm are due to self-injury rather than to poisoning. Second, although the authors indicate that there was no difference in outcomes according to method of self-harm, they do not indicate whether there was differential take-up of the intervention. We know for example that people who attend A+E departments after self-injury are more likely to leave early and are less likely to receive a specialist psychosocial assessment. Their contacts with health professionals are marked by dissatisfaction on both sides, and it would be unsurprising if their uptake of the intervention were particularly low. Self-laceration induces a certain sort of fascination (as evidenced by the lurid photographs) but not always much sympathy (as evidenced in at least one of the rapid responses to this paper). And yet those who harm themselves have characteristics - younger men with alcohol or substance misuse are over-represented - that are associated with increasing rates of suicide in the UK. What this trial shows is that general practice is not the place to treat self-injury. What current practice descriptions tell us is that mental health services are not doing well either. There is a need for new thinking in responses to self-injury, which now accounts for some 30- 40,000 hospital attendances a year in England and Wales alone. |
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