Psychiatry:
Self - Harm and Capacity
Deliberate self-harm
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.
Personality disorders
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.
Ethics
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.
Mental capacity
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
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.
