Self harm

Deliberate self injury is common but often poorly managed, and so awareness is essential, say Abigail Naomi Kinmond and Kathryn S Kinmond

It's the middle of summer. Your firm has just finished another tedious ward round and is now in the students' mess throwing back the coffee needed to face the long afternoon of lectures ahead. The hot weather means you are all dressed a little more skimpily than usual: everyone is pushing the dress code to the limit for the sake of comfort. A member of your firm sitting across from you shifts. You catch a glimpse of her abdomen, crisscrossed with thin white scars and areas of hyperpigmentation. You quickly look away so as not to be caught staring. You don't want to embarrass her...or yourself.

The recent national inquiry in the United Kingdom from the Camelot Foundation and the Mental Health Foundation has raised the profile of self harm as a major public health issue that affects at least one in 15 people aged 11 to 25.^w1 Also, "there is no such thing as a typical young person who self harms."^w2 The report also warns against assuming that self harm is a female behaviour, especially as young men may hide the damage under the guise of injuries after a fight or unintentional injury.

As medical students, surrounded by young people, we are likely to encounter self harm in our patients, friends, and colleagues. And when we become junior doctors, we require the assessment and management of self harm to be in our "top five" core skills because self harm is one of the top five reasons for hospital admission in the United Kingdom.^w2 But more than that we need to be comfortable with coming into contact with people who harm themselves.

The term self harm includes many behaviours, including cutting, burning, scalding, banging, or scratching your own body; breaking bones; pulling hair; and ingesting toxic substances or objects. The practice is often dismissed as a cry for help, a primitive method of attention seeking. However, as identified in the report, most cases of self harm are hidden, particularly from friends and family.^w1

Chris Holley stated at a Royal College of Nursing conference in April 2006, "It's about people who self injure in order to manage their feelings and live rather than die." These coping strategies give a temporary fix for people who see no other way of managing emotional distress.^w3 For many people self harm is a private activity that they do not want to discuss with anyone.^w4

Other people, however, would talk if they believed listeners were non-judgmental.^w5 Fear that professionals will not meet their needs is a barrier that prevents many young people from seeking medical help.^w1 We must best inform and prepare ourselves to support people who harm themselves.

We are training to be doctors to dedicate our working lives to making people better. Yet, as Babiker and Arnold note, we "operate a very plain language of healing and reparation of the body."^w5 By their own acts, people who self harm seem to renounce these core values. To be non-judgmental and to repair the damage perpetrated by a person on themselves is difficult, particularly if they return consistently for care.

A study of the attitudes of emergency department staff found that sympathy decreased for frequent attendees.^w6 Staff were also more irritated by a person's self harm if they felt the triggering event was controllable (for example, financial difficulties) rather than outside the patient's control (for example, bereavement).

Although it is unhealthy for us not to respond emotionally to our patients, we need to be aware so that we might prevent emotions from undermining our professionalism. Also, although we need to be aware of our negative emotions, we must also retain our positive sense of humanity. Barber said that "there is an apparent decline in humanism as undergraduate training progresses, [which] coupled with the preference students seem to show for the organic rather than the psychological aspects of medicine" may explain why final year medical students and junior doctors have shown more unfavourable attitudes towards patients who self harm than fourth year students and medical social workers.^w7

I was once told that to pass medical school you need "a mind like a sponge," but more than that, I suggest we need a way to compartmentalise all the information we soak up. We devise algorithms to make us more efficient, to help us remember what steps to take in the diagnosis and management of diseases. But self harm does not fit into a nice algorithm. For example, although self harm is a recognised risk factor for suicide, and a recent study showed that relative risk does not differ between people who cut and people who poison themselves,^w8 people who cut are more often discharged without a full psychosocial assessment.^w9 This artificial distinction may be dangerous because studies have shown that thorough psychosocial assessment can reduce the risk of subsequent episodes or suicide.^w10

Self harm is not the illness itself but rather an expression of an illness. So it can be treated, but not cured, which can make the treatment of people at risk fraught with uncertainties. As we become more reliant on algorithms and protocols, we must retain the ability to reason for ourselves, even in the face of uncertainty and remember to treat the person not the disease, however unsettling this may be.

Almost 30 years ago, Blake and Bramble said that undergraduate medical education had progressed such that junior doctors were better equipped to deal with the psychosocial aspects of illness.^w11 Those junior doctors are today's consultants, yet still there are calls for training in the effective treatment of self harm.^w1 I have completed my undergraduate psychiatry teaching, in which I learnt to manage psychiatric conditions following a biopsychosocial approach (as suggested by Williams et al^w12). I do have my management algorithm, but should I be called upon to clerk a patient tomorrow who has harmed him or herself, I'm not sure how I will react emotionally. Perhaps by reflecting with friends and colleagues on my emotions as well as the technicalities I will develop a sense of humanity in my working practice.

A useful starting point might be to consider the words of a participant in the national inquiry who said, "People need to not feel threatened by people [who]are ultimately trying to help them."^w1 Similarly, we need not to feel threatened by the people we are trying to help.

1. Brophy, M. (2006) Truth Hurts: Report of the National Inquiry into Self-harm among Young People http://www.selfharmuk.org/docs/self%20harm%20report%20lowres.pdf accessed 23/04/06
2. NHS centre for reviews and dissemination, University of York (1998) Deliberate selfharm Effective Healthcare 4(6):1-12
3. Hawton, K.; Fagg, J. (1992) ‘Deliberate self-poisoning and self injury in adolescents: a study of characteristics and trends in Oxford, 1976-89.’ British Journal of Psychiatry161: 816-823
4. Spandler, H. (1995) Who’s hurting who? Manchester, 42nd Street
5. Babiker, G.; Arnold, L.; (1997) The language of Injury: Comprehending Self-Mutilation Leicester, BPS Books p15
6. Mackay, N.; Barrowclough, C.; (2005) ‘Accident and emergency staff’s perceptions of deliberate self-harm: attributions, emotions and willingness to help.’ British Journal of Clinical Psychology 44: 255-267
7. Barber, J.; Hodgkin, G.; Patel, A.; Wilson, G. (1975) ‘Effect of teaching on students’ attitude to self-poisoning.’ British Medical Journal 2: 431-434
8. Gairin, I.; House, A.; Owens, D. (2003) ‘Attendance at the Accident and Emergency Department in the year before suicide: retrospective study’ British Journal of Psychiatry 183:28 33.
9. Bennewith, O.; Peters, T.J.; Hawton, K.; House, A.; Gunnell, D. (2005) ‘Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: Results of a national study’ Journal of Affective Disorders 89(1-3): 91-97
10. National Institute for Clinical Excellence (2004) ‘National Institute for Clinical Excellence, Self-Harm: The Short Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care’, National Institute for Clinical Excellence, London.
11. Blake, D.; Bramble, M. (1979) ‘Self-Poisoning: Psychiatric Assessment by Junior Staff.’ British Medical Journal 1: 1763
12. Williams, C.; Milton, S.; Strickland, P. (1997) ‘Impact of Medical School teaching on pre-registration House Officers’ confidence in assessing and managing common’ psychiatric morbidity: Three centre study. British Medical Journal 315: 917-918