Psychiatry: Self - Harm and Capacity
Most of the patients who self-harm (e.g. overdose or cut them-selves) do so as a response to a stress in their life. Common precipitants are problems with relationships or finances.
The majority of deliberate self-harm (DSH) patients seen in the Emergency Department do not have ongoing suicidal intent; of those presenting with an overdose, only a very small fraction go on to commit suicide. Therefore the challenge is to identify patients with a high ongoing risk of suicide.
The modified SADPERSONS scoring system can identify patients at high risk of subsequently committing suicide. The SADPERSONS score should not be viewed in isolation; other indicators that a suicide attempt is associated with a high level of intent are:
• A violent method, e.g. hanging, falls, weapons.
• Avoidance of discovery where the person has attempted to avoid being found.
• Premeditation: most suicide attempts are impulsive, and often related to alcohol consumption. Evidence of having ‘put one’s affairs in order’, e.g. making or changing a will, suggests a high degree of planning. ‘Suicide notes’ are common, but a carefully considered letter is a more worrying indicator than a scrawled note.
DSH patients need medical treatment if necessary and, if assessed as low risk, may be discharged with appropriate community-based follow-up. If at moderate or high risk, these patients should have a psychiatric assessment before discharge.
Within the group of DSH patients there are many more patients with personality disorders than with mental illnesses such as depression or schizophrenia. A personality disorder is not a mental illness per se, but a pattern of behaviour that is consistently outside social norms. Patients with personality disorders are orientated, do not have hallucinations, delusions or thought disorders; they have normal senses and memory.
Patients with a personality disorder may present in a very similar way to a patient with mental illness. Both may harm themselves, and students are often surprised to find that doctors and nurses appear unconcerned by these patients. This is because patients with personality disorders may be manipulative and attention-seeking, and indifference to their behaviour is less likely to reinforce it.
There are three distinct subgroups of personality disorders:
• Suspicious/odd behaviour
• Impulsive/antisocial/emotionally manipulative behaviour
• Anxious/dependent behaviour.
The patients seen in the Emergency Department with self-harm tend to be from group B, who are more likely to be emotionally labile and form fragile relationships. The label ‘borderline personality disorder’ stems from the outdated notion that these patients were ‘on the border’ between psychosis and neurosis. Patients with group B personality disorders may also have drug and alcohol problems and chaotic lives.
Patients with personality disorders are not generally helped by treatments used for serious mental illness: psychiatrists try to avoid admitting them to hospital as this can make the situation worse.
Capacity, consent and ethics
Sometimes a patient may refuse treatment for a potentially life-threatening overdose, or may want to leave the Emergency Department before their treatment is complete. The doctor must then assess whether the patient’s autonomy should be overridden to allow treatment.
The ethical principles that guide medical treatment are:
• Beneficence – doing good.
• Non-maleficence – not doing harm.
• Autonomy – respecting a patient’s decisions.
• Justice – fairness.
In some countries, this situation is covered by mental health legislation, in others by legislation covering consent. In England and Wales, the Mental Capacity Act (2005) formalised a frame-work to assess patients whose mental capacity to consent to treatment is in doubt.
Assesment of mental capacity is person, time and decision specific: can this person make this decision at this time?
To establish mental capacity to a patient must be able to:
• Understand the choices being presented to them
• Retain the information about the choices for enough time to be able to
• Weigh the relative merits of the choices, then be able to
• Communicate the decision to others.
If a patient fails the test for mental capacity (most commonly on the ability to weigh information rationally) then this decision and the reasons for it must be recorded in the notes. Treatment that is necessary to preserve the patient’s life may then proceed against the patient’s wishes. This may include sedation necessary to safely permit life-saving interventions.
Mental capacity can be difficult to assess in patients with pre- existent disabilities or communication difficulties, and these points may help guide assessment.
• Everything possible should be done to maximise a patient’s capacity.
• An unwise decision by the patient does not automatically prove lack of capacity.
• Capacity should be presumed until evidence to the contrary.
• Decisions should act in the best interests of the patient.
• If a decision has to be made, it should be the least restrictive option that meets the patient’s needs.
Advance Directives, sometimes (confusingly) known as ‘living wills’, are a legally binding method to specify treatment decisions in the event that a patient does not have capacity to make those judgements. Not all countries have similar legislation, and such documents must be signed and witnessed, preferably by a medical witness who can verify that the patient had capacity to make that decision at that time.
The advance directive should include a statement that the treatment should be withheld even if the patient’s life is put at risk.