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ljkean

Self-harm containment

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hello!

i've been seeing a fair few patients with borderline personality disorder recently and wondered if you had any ideas regarding management plans and ways to contain the self-harm risk?! i've suggested methods such as using elastic bands or ice-cubes against the arm for the shock, distractions, contacting Samaritans etc. any other ideas? other question was, if a patient with chronic self-harm risk presents intoxicated, feeling suicidal, should we consider admission as they are mentally disordered with impaired judgement secondary to alcohol?!

this forum's fantastic.... x

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Hmm. Depends on the patient, and your risk assessment of them. Patients with coping mechanisms that include self harming behaviour are likely to repeatedly use this at times of emotional crisis. It is unlikley that you will change these longstanding patterns by interventions put in place on an on-call shift. What would be more useful would be if the patient could engage in a therapeutic relationship and tackle these issues in psychotherapy or therapeutic community. Offering them the advice you have is great, and provides them with options, but they are likely to remain at risk of further self harm, and therefore at risk of accidentally committing suicide. But then Psychiatry isn't a suicide prevention service, and people can always chose whether to self harm or to seek help at times of stress.

With regards intoxicated self harmers, it would depend on level of intoxication and your risk assessment of them. There isn't a huge amount of info out there on when a patient is too intoxicated for you to get an accurate mental state from. Many present very differently the next morning after sobering up and realising what they have done.

If there are no clear signs of major affective disturbance or psychosis, then you could just as easily argue for them to be kept in a medical ward (organic problem) until they are sober enough to be seen by the liaison team in the morning. Not that A+E are always happy with this suggestion!

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if a patient with chronic self-harm risk presents intoxicated, feeling suicidal, should we consider admission as they are mentally disordered with impaired judgement secondary to alcohol?!

They aren't necessarily mentally disordered from this description...

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(i've suggested methods such as using elastic bands or ice-cubes against the arm for the shock, distractions, contacting Samaritans etc.)

My experience is that, its watching themself bleed which relieves the tension for BPD.

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If they're motivated then you could always suggest they make up ice cubes with red food colouring in it, so that they get the pain from the ice, and also see 'blood.'

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Jelly Bean,

Obviously, I have never heard any senior colleagues suggesting 'RED ICE CUBES' & 'Elastic bands' etc......... I am not an expert on this disorder or (any other disorder for that matter ::). So what I am going to suggest is just personal experiences on working in a PD unit & speaking to and watching some very experienced doctors in that field.

The most important thing to realise is that you 'Alone' cannot be the saviour of that person. Quite often from a psychodynamic perspective, due to transference, the therapist feels that they are duty bound to be the patient's 'saviour'..

The second thing is you need to understand that every engagement,interaction,conversation and chat is therepeutic ! You have learn to maintain professional boundaries(which borderlines are continously trying to breach.. believe me, even the experts have to watch for it)

Try to analyse transference the therapist(you) experiences. in lay man's terms how do you feel after you see them? because Borderline patients use projection and therefore project their emotional chaos onto you. Try to get supervision(where possible) to work through the transference.

Another important aspect to remember is that quite often these individuals cannot understand the range of emotions they are experiencing like anger,sadness,frustation,despair,distress,happiness,pensive,melancholic,unhappy etc..... & how to attach a particular frame of mind to an expression. in short they do not have a wide range of expressions to describe their emotional feelings. So one has to try to help them understand their emotions in a collaborative approach.Over a period of time as they become more adept at expressing their emotions they will stop bracketing them in to anger or sadness.

This will help them engage better with the therapist & adopt a more problem solving approach.

Last but not the least is please remember there is a good evidence base for Pharmacotherapy in Bordrline(SSRI for impulsivity & chronic dysthymia associated with BPD etc.). And ofcourse the utmost important role for social interventions for housing,benefits,debt management, motivational interviewing for substance misuse etc..... are all helpful.

Hope in all my woffle, you have something to think about.

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I forgot to add.......

Most Personality Disordered patients, more so the borderline patients dont take personal responsibility for their actions. That does not mean you dump everything on the patients.Responsibility is given in small increments(so that he or she succeeds and this leads to improved self esteem of the patient). slowly they will be able to take more responsibility for their actions, hopefully.

Finally, the emphasis must be on risk management and aiding them(patients) with problem solving( at a junior doctor level) & allow psychologists & Consultants to deal with other issues that may arise.

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what you should do is find out what the plan for them in this situation is and follow it. if there is not a plan then you should bring that to the attention of their care coordinator and/or consultant.

suggesting ice cubes/elastic bands etc to this patient group is pointless and should not be done (a - where is the evidence for it? b - it makes you look foolish). admitting them because they are intoxicated is also not to be done.

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Well for a start NICE guidelines on self harm recommend that we should consider the use of harm reduction strategies in repeated self harmers. If we accept that we are not going to change their behaviour with our limited time doing a liaison assessment, then we should at least give the patient advice on how to avoid accidental serious injury from future self cutting.

4.6.2 Advice for people who repeatedly self-injure

Advice regarding self-management of superficial injuries, harm minimisation techniques,

alternative coping strategies and how best to deal with scarring should be considered

for people who repeatedly self-injure.

4.6.2.1 For people presenting for treatment who have a history of self-harm,

clinicians may consider offering advice and instructions for the self management

of superficial injuries, including the provision of tissue adhesive.

Discussion with a mental health worker may assist in the decision about

which service users should be offered this treatment option. (GPP)

4.6.2.2 Where service users are likely to repeat self-injury, clinical staff, service users

and carers may wish to discuss harm minimisation issues/techniques. Suitable

material is available from many voluntary organisations. (GPP)

4.6.2.3 Where service users are likely to repeat self-injury, clinical staff, service users

and carers may wish to discuss appropriate alternative coping strategies.

Suitable material is available from many voluntary organisations. (GPP)

4.6.2.4 Where service users have significant scarring from previous self-injury,

consideration should be given to providing information about dealing with

scar tissue. (GPP)

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I agree about not admitting purely due to intoxication though. This is something that should be managed on a medical ward until the patient is medically well enough to participate in a psychiatric interview.

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