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Self-harm in adolescence
Norwich General Practice Vocational Training Scheme
E-mail: mmmr7ams{at}doctors.org.uk
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Abstract |
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TOP
Abstract
The GP curriculum and...Self-harm is a common yet frequently concealed activity among adolescents. GP trainees are likely to encounter young people who self-harm, not only in primary care, but also during placements in Accident and Emergency or general medicine. The type of self-harm seen in each situation is likely to vary and the approach to it may need to change accordingly. However, some themes remain constant and as self-harm is a prevalent phenomenon among adolescents, it is an area with which GPs should be familiar.
This article is intended to provide an overview of the subject of self-harm among adolescents, so that GPs in training are better equipped to detect and manage cases which they encounter. It focuses on self-harming behaviours such as cutting and also considers the assessment process (including suicide risk) in some depth. While it discusses a few areas of treatment, it is not intended as a guide to specific management of the various forms of self-harm.
General practitioners are front-line health care professionals who, through virtue of continuing care, are able to develop therapeutic relationships with their patients. They, or other members of the primary care team, may be the first port of call of adolescents who seek help for self-harm. They are also well placed to detect cases which have not yet been disclosed. The recognition and management of self-harm in adolescents features in a number of areas of the GP curriculum, most notably statements 13 (care of people with mental health problems), 7 (care of acutely ill people) and 8 (care of children and young people). Relevant competencies trainees are expected to acquire include:
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What is self-harm? |
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Self-harm is defined as a deliberate act in which the individual is aware that their actions will cause them harm. It does not include suicide as by definition self-harm is non-fatal. Acts may be classified into either self-injury or self-poisoning and include a wide range of activities (see Box 1). Some definitions of self-harm include engaging in harmful relationships or denying oneself basic needs, for example: misusing drugs, drinking excessive alcohol or eating disorders. This article does not address these behaviours, although they are related to many of the issues discussed.
Self-injury is the commonest form of self-harm and most frequently involves cutting of the skin. Often the cuts made are not deep but they do sometimes require medical attention. Individuals tend to have a certain area of the body that they prefer to cut. The usual places are the wrists, upper arms, inner thighs and upper chest. Less commonly people cut the face, breasts, abdomen and genitals. The instruments used include knives, glass or razor blades.
| Box 1. Types of self-harm Self-poisoning
Self-injury
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Although self-injury is more common, self-poisoning is more likely to result in an individual seeking professional help. It accounts for around 90% of known cases of deliberate self-harm and is one of the five most frequent causes of acute medical admission. Most patients who self-poison do so with over-the-counter medications. Others take medicines that have been prescribed by a doctor and a small number take a large amount of an illegal drug or poison themselves with another substance.
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How many young people self-harm? |
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In most cases, self-harm is a secretive behaviour which occurs for a long time before others are aware and individuals may never present to a health professional. Consequently, many cases are not recorded and the statistics in this area can be quite unreliable. However, it is thought that in the UK about 1 in 15 young people has self-harmed—the highest rate in Europe. One survey indicated that as many as 1 in 5–10 young people will self-harm in their teenage years. Although the incidence of completed suicide is reducing, the incidence of deliberate self-harm has risen in the UK over the last 20 years. Around 140 000 cases present to accident and emergency departments each year.
The average age of onset of self-harming is 12 years, although the range varies from young children through to adults. Around two-thirds of patients who self-harm are female. Some people only do it once or twice, but for others it becomes a regular occurrence through many years of their life.
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Why do young people self-harm? |
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Understanding adolescents' behaviour is helpful when providing health care, yet it can be challenging. Adolescents are individuals in transition from childhood to adulthood, maturing amidst a barrage of complex and interacting psychosocial factors. Their thoughts and feelings gradually adapt with their transition and although the resulting behaviour is an expression of their normal development, it may at times seem incomprehensible to others. Self-harm could be viewed as one such behaviour; paradoxically appropriate for that individual, yet most people do not understand the reasons behind it. But in order to work with self-harm, it is necessary to gain this understanding as self-harm is a symptom, not the problem. An inquiry found that many adolescents felt that their health care professional did not really examine the causes of their self-harm, which resulted in treating the symptoms but ignoring the underlying problems. The young people also felt they had not really been listened to. So, establishing the cause is vital. However, this can be a difficult task as the reasons are usually complex and multi-factorial. In addition, the nature and meaning of self-harm varies from person to person and may also vary within the same person; the reason for (and manner of) self-harm may differ on different occasions.
Most young people do not self-harm to seek attention or as a failed suicide attempt. Some may use it as a means of manipulating their social situation or asking for help, but much more commonly it is part of a coping strategy employed to deal with problems and emotional distress such as bullying or problems within the family. It acts as a form of emotional transference whereby emotional difficulties are translated into a physical experience, at a time when an individual has not yet learned other forms of coping strategies. Indeed, it should be borne in mind that because people may harm themselves as a way of coping with overwhelming situations or feelings in some cases self-harm may actually be a way of preventing suicide, even though it can only provide temporary relief and fails to deal with the underlying issues.
Some young people self-harm to release their emotions, others use it to deal with a specific problem, such as those listed in Box 2. A few people describe feeling detached from the world, and the self-harm may help to either keep them detached or in some cases bring them ‘back to reality’. During acts of self-harm, people often feel separated from their feelings and pain. An insight into the thoughts and feelings of young people who self-harm is provided by the quotations listed in Box 3.
Box 2. Some of the reasons for self-harm
In the minority of cases in which self-harm is disclosed reasons may include:
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Box 3. Quotations from young people who self-harm (reference Truth Hurts Report)
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There are a group of adolescents who may ‘experiment’ with self-harm as a one-off event. Sometimes this occurs with a group of friends. The reasons behind this—and thus risks for the future—will differ from those who use self-harm to deal with problems. Similarly, in another group of adolescents self-harm may be a one-off impulsive act often triggered by an emotional upset such as relationship break-up. These acts are frequently fuelled by alcohol and tend to be regretted by the individual afterwards. Sadly, some impulsive self-harm (particularly overdose) can result in unintended death, but for those who survive risk for future self-harm will be lower than in many other self-harming adolescents.
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What are the risk factors? |
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No single proven risk factor has been established for self-harm, although there are several associations (see Box 4). One of the strongest risk factors is a history of a previous deliberate self-harm attempt—this has a sensitivity and specificity of about 60%. Perhaps unsurprisingly, adolescents with emotional, conduct and hyperkinetic disorders have a higher prevalence of self-harm and there is often a history of previous problems in childhood or early adolescence. Because of the possibility of an untreated psychiatric condition, all individuals who self-harm need assessment for mental illness.
Box 4. Risk factors for self-harm
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How should I respond when a young person admits to self-harming? |
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The attitude adopted by the health care professional is fundamental. Young people can find it difficult to talk about their self-harm and may be afraid of how others will react, thus the response they receive upon disclosure is likely to influence future engagement with supportive services. Any indication of a negative response is liable to be detrimental (this also applies to disclosure to family or friends). Remember that the individual is likely to have been trying to conceal the problem and they may have surrounded it with a multiplicity of emotions, such as shame, guilt, fear or simply confusion about why they are doing it. An inquiry into adolescent self-harm in the UK found that disclosure made the situation worse in some cases; young people said they found health services to be judgemental and stigmatizing. It is important for GPs to maintain a non-judgemental, sensitive, open-minded and respectful attitude with the focus kept on the person and not their self-harm behaviour. In addition, GPs should try to carefully negotiate any management plans in a manner that allows the young person to maintain control of the situation—in many instances self-harm is intimately linked with control issues and removing control can exacerbate the situation. Linked with this, it is best not to issue any ultimatums (i.e. punishments for self-harming acts) as this can be very unhelpful and may make the patient conceal their behaviour.
It is particularly important to adopt the right attitude and approach if undisclosed self-harm is suspected (e.g. an instance in which scars from cutting the forearms are noted during a routine examination). This is a common situation as most young people will not admit to self-harming and it may be necessary to gently question them on the subject if suspicion exists, for example asking about how they are coping if they appear to have low mood.
Many adolescents who self-harm have not been able to find somebody with whom they can talk about their problems. A GP can often help by simply taking the time to listen. Using methods such as the brief psychotherapeutic BATHE technique (see Box 5) may help the young person identify and begin to deal with their problems.
Box 5. The BATHE technique
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Initial management
The usual first step in managing self-harm is to take a history which incorporates a risk and needs assessment. Sometimes this must be preceded by the provision of immediate medical treatment, depending on the level of harm inflicted—certainly at some stage, the physical consequences of the self-harm must be addressed. Finally, plans must be made for follow-up. Box 6 outlines a useful approach. The National Institute for Clinical Excellence (NICE) has issued guidance for the initial management of self-harm in both primary and secondary care. It focuses on the first 48 h following an episode and provides a useful guide for dealing with self-injury or self-poisoning.
Box 6. Stages in a deliberate self harm assessment
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Assessment
The assessment usually begins with sensitive questioning about the history of events leading up to the self-harm episode, the episode itself and its consequences. Through this information should be gathered to enable a judgement about the current level of distress and further risk. A decision must be made about whether there are sufficient concerns about the patient, or evidence of mental ill health, to need further help. There should also be an evaluation of mental capacity and willingness to engage in the assessment process, as clearly it is not possible to proceed if the individual cannot participate.
Establishing the risk of suicide or further self-harm is a key aspect of the assessment. Suicide is one of the most common causes of death in young people, indeed it is the most common cause of death in males under the age of 35 years. Tragically, some of these deaths will be the consequence of impulsive acts which may never have intended to result in death, but it is recognized that repeated self-harm is a risk factor for suicide: the median mortality from suicide after deliberate self-harm is approximately 1% per year. However, assessing risk is not always straightforward as some young people will deny suicidal ideation even when it is present. A good history of the events surrounding the episode helps to establish whether true suicidal intent exists; when doing this it is essential to elicit what the individual believed would be the consequences of their actions rather than using the physical severity of self-harm as a guide. Certain clinical, psychological and demographic characteristics associated with risk should be asked about, in particular depression, hopelessness and continuing suicidal intent. Factors which should arouse suspicion are outlined in Box 7. If the level of risk is hard to determine, it is safest to assume the person is at high risk. When there are concerns about suicidal intent, appropriate action must be taken, including referral to specialist services, removing dangerous objects from the home, providing support and pharmacotherapy if indicated and detaining a patient under the mental health act if necessary.
Box 7. Features of self-harm that suggest high suicidal intent
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A useful algorithm for assessing patients who present to the GP with self-harm is provided in Fig. 1. This algorithm also applies to patients who are threatening suicide.
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Alongside the risk assessment, a comprehensive assessment of the needs of all people who have self-harmed should be carried out, including evaluation of the social, psychological and motivational issues behind the act of self-harm plus a full mental health and social needs assessment (see Box 8). In adolescents, this needs to include home life, school life (including bullying) and friendship groups. Family life is particularly important to discuss, including recent family events, family history of psychiatric problems, how the family is currently dealing with the problem and how they have dealt with significant problems in the past. The latter provides an indication of how the family may cope with the current situation.
Box 8. Questions to ask during an assessment
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Medical management in primary care
Any young person who has self-harmed in a potentially serious way needs to be seen by specialists in the hospital setting for a thorough assessment; in most acute presentations, a referral to Accident and Emergency (A&E) referral should be considered. Certainly, a person who has presented with self-poisoning requires referral to A&E, unless it is absolutely sure this is not necessary—this can be hard to ascertain as people are often not sure what drugs they have taken. If doubt exists regarding the decision to refer, or the patient lives in a remote area and cannot attend A&E quickly, NICE advise that the matter be discussed with an A&E consultant. If there is concern about further self-harm, the person is reluctant to attend or they are very distressed, then an appropriate chaperone should be arranged for travel in the ambulance to the emergency department. In cases of self-poisoning where the person cannot quickly attend A&E, some consideration should be made for initiating treatment and collecting samples to test for paracetamol and other drugs—guidance for this can be found using online databases such as TOXBASE (see Box 9 below).
Box 9. Useful organizations
Helpful telephone numbers: Samaritans—08457 90 90 90 ChildLine—0800 1111 Parentline Plus—0808 800 2222 NSPCC—0808 800 5000
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Additional considerations for secondary care
NICE guidance advises that every patient presenting to secondary care with self-harm should have a preliminary psychosocial assessment at triage and ideally should be treated (and wait to be treated) in a separate, safe and quiet environment with regular contact with a named staff member to ensure safety. Persons up to the age of 16 years who have harmed themselves and are taken to an emergency department in a hospital should be seen in a special children's area.
Secondary care is able to provide definitive medical and surgical management of the consequences of self-harm. The management of self-injury will clearly depend upon the wounds inflicted. Superficial uncomplicated wounds can be cleaned and closed with tissue adhesive, while more complicated injuries will need surgical assessment and possibly exploration. Self-poisoning can be treated by reducing absorption, increasing elimination or countering the effects of whatever has been taken. Activated charcoal should be immediately accessible in secondary care and it should be given within 1 h of the act of self-poisoning if the patient is fully conscious, protecting their airway, at risk of significant harm and the substances will be adsorbed by charcoal. It may still be effective if given within 1–2 h of ingestion. This paper does not describe the specific treatments for different drug overdoses—this can be found on TOXBASE, and a guide to managing some of the more common overdoses (e.g. paracetamol) is provided in the British National Formulary.
It may be necessary to temporarily admit a young person following an act of self-harm, especially if there is extreme distress, the person may be returning to an unsafe environment or psychosocial assessment is too difficult owing to intoxication. Reassessment should occur the following day or at the earliest suitable opportunity. Those young people under the age of 16 years should be admitted to a paediatric ward. For young people aged over 14 years, admission to an adolescent ward should be considered if this is available and preferred by the patient.
It may be necessary to make a referral for further treatment, but this should be based upon a comprehensive psychiatric, psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed. All patients who receive treatment for self-harm in secondary care require follow-up, either with mental health services or their own GP.
Long-term management
Most significant self-harm is dealt with on an outpatient basis in the longer term. As it is frequently used as a form of coping strategy, the young person needs to recognize the problems which trigger it and learn about other outlets for the build up of tension—successful treatment depends on teaching the individual new ways of coping with their emotions and feelings. Frequently, mental health services, such as the CAMHS, are involved and a variety of techniques are employed (with varying amounts of evidence for each). This range of treatments is necessary as each young person is different and thus the services required will vary accordingly. A brief description of some of the treatments available is outlined below:
- Distraction techniques—there are a number of relatively simple techniques which a young person can be taught to use as alternatives self-harm. These include:
- the ‘5-minute rule’: when the person feels the urge to self-harm, they should wait 5 minutes and in that time do something else instead, such as go for a walk or another constructive activity. Once the 5 minutes is up, they should see if they can manage another 5 minutes and so on.
- using a red water-soluble felt tip pen to mark the skin instead of cut
- hitting a punch bag
- rubbing ice on the skin instead of cutting
- putting elastic bands on wrists and flicking them instead of cutting
- scribbling on a large piece of paper with a red crayon or pen
- making lots of noise, e.g. with a musical instrument or banging on a tub
- writing negative feelings on a piece of paper and then ripping it up
- writing a diary or journal
- talking to a friend (not necessarily about self-harm)
- collage or artwork
- physical exercise
- going online and looking at self-help websites
- the ‘5-minute rule’: when the person feels the urge to self-harm, they should wait 5 minutes and in that time do something else instead, such as go for a walk or another constructive activity. Once the 5 minutes is up, they should see if they can manage another 5 minutes and so on.
- Self-help is very useful in young people. Self-help groups can work well; if a person has self-harmed more than once, they may be offered group therapy with others of their age group who have also harmed themselves. Ideally, this should last six or more sessions and in some cases may be provided through the school setting. This can be very helpful in reducing the sense of isolation that some young people feel—many are relieved to find that they are not the only person with such problems.
- Peer support—young people frequently wish to turn to other young people for support, desiring simply to talk to somebody who will listen to them and respect them, not even necessarily to talk about the self-harm. Schools often have peer-support teams for this reason.
- Cognitive Behavioural Therapy can be used to find alternative ways for an individual to express their feelings, emotions and tensions and tackle issues with low self-esteem. It is particularly useful when there is associated depression.
- Problem-solving therapy—there is evidence to suggest that this type of therapy can help with self-harm, either used on an individual basis or for family therapy. It is particularly suitable for adolescents as it is relatively direct and easy to understand. The process involved is outlined in Fig. 2. There are usually around six 1-h sessions, with some reading and other work between. It can be delivered by any experienced mental health professional, with suitable training and supervision.
- Family therapy is used to resolve conflict and promote communication between members of the family. Sessions are run by family therapists and may help young people whose reasons for self-harm are related to family problems. Usually, there are five or six sessions and these can be home based.
- Psychotherapy—in some cases, it may also be appropriate to use psychotherapy to explore a history of sexual, physical or mental abuse.
- Intensive therapy sessions may be indicated for some people who are likely to repeatedly self-harm. In this case, the individual should be treated for a minimum of 3 months, during which time they have frequent access to a therapist when needed, support by telephone and treatment at home when necessary. They may also be provided with outreach support whereby if they miss an appointment they are contacted to see how they are feeling.
- Dialectic behaviour therapy was introduced to help those with chronic repetitive self-harm, particularly when associated with borderline personality characteristics. It is again intensive, involving a year of individual therapy, group sessions, social skills training and access to crisis contact. There is some evidence to suggest it reduces self-harm in people who have not benefited from other services.
- Crisis cards—there is a small amount of evidence to suggest that patients who present to the health services having taken a first drug overdose may benefit from being given cards which enable them to speak to a psychiatrist at short notice and request psychiatric admission in a crisis. This may help to reduce the repetition of self-harm behaviour.
- Antidepressants—evidence exists to support the use of antidepressants to treat depression after deliberate self-harm, but not to treat people who self-harm who are not depressed. In addition, the prescribing of antidepressants to young people is controversial and due to the many possible negative side effects, they should generally only be initiated by a specialist. When prescribing any medication for a person who is deemed to be at risk of self-poisoning, the prescriber should opt for the drug which is least harmful in overdose and/or consider prescribing limited quantities at a time.
- Websites, Internet forums and telephone helplines—although the quality of Internet-based support may be questionable, it has the advantage of being easily accessed by adolescents (particularly young men) who do not like attending face-to-face services.
- Walk-in counseling services are appropriate for older adolescents who may appreciate the ability to access care when needed.
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A wide variety of agencies are involved in the care of adolescents who self-harm. As well as the staff in primary and secondary care, school nurses, teachers, educational psychologists, health visitors, counselors and many other professionals become involved. In some cases, it is appropriate to manage cases using a shared care approach between the GP and health visitor. There are also a number of organizations with an interest in managing adolescent mental health, some of which focus on self-harm, who can provide additional support. Some of these are listed in Box 9.
Harm reduction
As with other addictive/obsessive behaviours, it may be more realistic to expect young people to attenuate rather than stop self-harming. In this situation, harm reduction strategies are needed and patients should be provided with tips for how to keep safe. Individuals who are cutting should be advised to use sterile cutting instruments to reduce infections, and they should be encouraged to seek medical treatment to manage deeper wounds. They need to be told not to share cutting implements with other people as this can transmit blood-borne diseases such as HIV. NICE also recommends that those people who repeatedly self-injure should be provided with advice regarding the self-management of superficial injuries (including the provision of tissue adhesive) and how best to deal with scarring (Fig. 3). However, harm minimization strategies are not appropriate for people who have self-harmed by poisoning as there are no safe limits in self-poisoning.
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Ethical issues
Managing cases of self-harm always raises ethical dilemmas and in adolescents there are more still. The main issues involved are capacity and confidentiality. In keeping with the Mental Capacity Act 2005, it should be assumed that all people who have self-harmed have mental capacity unless there is evidence to the contrary. If they are deemed to lack capacity, they can be treated under the Common Law duty of care. However, if after thorough assessment they are deemed to have capacity and they refuse treatment, then they cannot be treated—it is advisable to make meticulous documentation in such cases and make sure they are discussed with senior colleagues and medical defence bodies. Rarely, a young person who has self-harmed may be deemed to have a severe mental illness requiring admission to hospital; if they refuse to cooperate with this admission, they can be detained under the Mental Health Act 1983 for assessment or treatment of their mental ill health without their consent. Generally, further consent is required to treat physical symptoms. Some interpretations of the Mental Health Act allow for treatment of the consequences of mental illness, but there is limited experience of such cases and a person cannot be detained under the Act purely for treatment of self-harm. It is important to remember that even if a patient refuses assessment and treatment for mental health problems, there is a still a duty of care to provide treatment for any physical consequences of their self-harm, as long as they give consent for this.
The above arguments are more complex in adolescents when the capacity to consent (and more importantly dissent) to treatment needs to be carefully considered. ‘Gillick competence’ and the 1989 Children Act are both relevant to the question of whether a young person under the age of 18 years of age can consent to treatment. The former refers to the capacity of persons under the age of 16 years to consent to treatment without the need for parental permission or knowledge. In most cases, individuals need to be over the age of 18 years to be able to refuse treatment and sometimes parents or guardians need to be involved to give their consent to treatment, although this may then cause problems with patient confidentiality. Each case needs to be judged on its own merit, but generally most young people will be able to give informed consent and can expect confidentiality in their dealings with services and staff.
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Do not forget the family and friends |
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The knowledge that a loved family member or friend is self-harming can be very distressing. Carers need support, either through a health care professional or a support group. Many of the organizations listed in Box 9 provide assistance to carers, family and friends. It helps if the carer learns how to listen to the person who is self-harming, keeping an open mind and not necessarily expecting them to stop the behaviour but deal with it in a manner that minimizes harm and risk. Carers can help reduce risk by removing medications and tools of self-harm or changing any regular medications which they use to a safer alternative if there are concerns that they may be taken in overdose.
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What is the prognosis? |
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The prognosis depends in part on the definition of recovery. For some people recovery means that their self-harm is controlled, lessened and they are dealing with the underlying problems instead. For other people recovery can only mean no more self-harming. Either way it is usually a slow process that is intimately related to changes in the circumstances which caused the young person to self-harm in the first place. In some cases, individuals find that over time their needs or circumstances have changed to the extent that they cease to feel a need to self-harm. Others learn new coping strategies, often by adopting successful distraction techniques which allow them to cope with the urge to self-harm. This may still involve a degree of self-harm, at least initially.
Ultimately, promotion of good mental health and emotional well-being is needed to prevent self-harm. This requires effort from many agencies such as schools, health and social care. There is no doubt that anti-bullying strategies and peer support groups help to reduce the types of problems which result in self-harm. A healthy diet, regular exercise and good physical health also help. GPs should endeavor to assist adolescents in dealing with difficulties which may otherwise result in what has become such a prevalent maladaptive behaviour among young people in our society.
Key points
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References |
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Hawton K, James A. Suicide and deliberate self harm in young people. British Medical Journal (2005) 330:891–4.
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