Dr. Shirley Sze (biography and disclosures)
What I did before
In the area of Non-Suicidal Self Injury, I had little knowledge to classify or deal effectively with this type of behaviour in patient encounters. Often times, these patients would be labelled as Borderline Personality Disorders and with this particular diagnoses, there was generally a lack of treatment options for them. Patients that exhibit this type of behaviour would often have repeated presentations of self injury that raised uncomfortable feelings in me as a family physicians due to gaps in understanding and knowledge about the condition. This lack of understanding of this type of behaviour allowed me to treat these patients only by being empathetic and dealing with their wounds.
What changed my practice
We had a presentation by Dr. Lyn MacBeath, one of our local psychiatrists on this topic which improved my knowledge of this condition especially from the patient’s perspective. I now recognize the inherent high risk of successful suicide (10%) in this population and the need to address non-suicidal self injury with the seriousness that it deserves. Dr. MacBeath has provided clinicians with guidelines to deal with patients that present with non-suicidal self-injury as well as hand-outs for patients. These are attached.
What I do now
I am certainly more aware of the increased risk for suicide in these patients and would make a point of asking about suicidality and following through with a Mental Health Assessment, appropriate treatment and referral for resources in mental health +/- addiction services.
I am also more aware that for a lot of these patients that they have problems verbally expressing some very difficult feelings and that often times, they are highly intelligent and artistic and assisting them in finding ways to verbally communicate effectively may eventually help them in their abstinence from self injury. The twelve step program for addictions seem to be an effective method.
Additional materials:
Download Dr. Lyn MacBeath’s guidelines (View)
Download the patient information sheet (View)
References for the 10 % suicidal risk
Stanley, B, Gameroff, MJ, Michalsen, V, Man, JJ. (2001). Are suicide attempters who self-mutilate a unique population? Am J Psychiatry, 158, 427-432. (View)(UBC Link)
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Would be interested in Dr. McBeath’s guidelines but couldn’t find the attachment on the website – just an article from American Journal of Psychiatry.
Thanks for the discussion on this difficult topic!
This was great. Apparently there were handouts attached, but I was unable to see how to access these. Please advise.
Helpful
Difficult problem and even more difficult patient
These “cutters ” are bipolar not borderlines. Cutting is aan addiction that has to be stopped and then appropriate treatment can begin.
These can be difficult patients and its difficult to not discuss future self injurym though it may be futile. I certainly have found this approach works and people are more likely to come in sooner after an injury or, on one occasion, even before the patient injured herself!
Please see above under “Additional materials” for guidelines. Thank you.
very difficult patients with obsessive features and great inner pain
I was surprised to see the significant incidence of successful suicide in these patients. I plan to ask about suicidal ideation in patients with cuts on the wrist.
I look after many patients who cut or self mutilate. The model I use involves patient education about the addictive nature of self abuse and how common it is in the population especially in teens. I see self mutilation as a cry for help and a poor coping strategy for uncomfortable emotions. I like to separate the self mutilation from suicidal behaviour and do not assume that they are equivalent or even predictive. For patients who are escalating in self abuse I would fully evaluate them for suicidal risk. I also tell my patients that if they decide to kill themselves then I can’t stop them, but I do care what happens to them. I talk about how beginning to identify the triggers for the abuse can help us work out a safety plan and list of behaviours that nurture and soothe. A neutral supportive approach without taking control from the patient will allow them to feel part of the solution. Many patients who are diagnosed as Borderline Personality Disorder often have other mental health disorders. Often Bipolar patients are misdiagnosed as BPD. It is possible to have both diagnoses. As a family doctor I would not want to feel I had to do suicide assessments every time these patients harm themselves. For me, keeping the lines of communication open is a better strategy and taking care of our own feelings of helplessness.
I think need more articles for this difficult subject about difficult pt. thank you
helpful
Good resources and ino