Deliberate Self Research Articles

Mental health research trends in Sri Lanka

To review the number of research publications in the field of mental health in Sri Lanka from 1900 to 2009. A search of all publications in psychiatry and mental health from Sri Lanka was conducted using Pubmed, all medical journals published in Sri Lanka and researchers. The identified papers were reviewed for their content and categorised as research in psychiatry and mental health, based on strict inclusion and exclusion criteria. A total of 207 papers were identified. The first mental health research publication from Sri Lanka is in 1964. The last decade (2000-2009) accounted for 62% of the publications with the majority of the papers being published in indexed journals. The Ceylon Medical Journal carried the most number of papers and the topic on which most of the research was conducted was suicide and deliberate self harm. There is an increasing trend towards research in to psychiatry and mental health in Sri Lanka.

Cut - Throat Injuries from Deliberate Self Harm and Homicide in Sokoto, Nigeria

The act of terminating human life may be suicidal or homicidal, involving violent or non violent methods. Cut throat as a violent method in terminating human life is discussed. All cases of cut throat injuries that were from deliberate infliction over a 9year period(September 1999- August 2008) and the circumstances surrounding such injuries were reviewed from a tertiary health institution in north western Nigeria. A total number of 15 cases were seen. All were males with age range of 18 to 60 years(Mean age 32.47years± SD 11.351) . Ten (66.7%) cases were from deliberate self harm(DSH)(Age range:20-60years, mean age 36.9years±SD 13.017) but were known psychiatric patients who had defaulted in follow-up psychiatric care. Five (33.3%) were homicidal(Age range 18-35years ,mean age 23.8years±SD 8.258) as a result of conflicts, three of whom were under the influence of cannabis. Surgical repair and psychiatric treatment were offered concurrently. One required a tracheostomy to prevent upper airway obstruction from laryngeal trauma. Repair was carried out under local anaesthesia in all but one case that required general anaesthesia. Psychosocial disturbances may lead to DSH, suicide or homicidal cut throat injuries. Psychiatric patients who are not on regular medications accounted for 66.7% of the cases of DSH in this study while 33.3% of the cases were homicidal. Therefore continued follow up of psychiatric patients must be emphasized to prevent these injuries in addition to addressing psychosocial issues that may lead to DSH, suicide, or homicide in the society.Key words: Cut throat injury, Deliberate self harm, Homicide,

Parenting style and conduct problems in children: Case report of deliberate self poisoning in a Nigerian child

The correlation between psychosocially unhealthy parenting styles and child psychopathology has been established. This case report describes how chronic harsh and overbearing paternal parenting style tipped a young boy into deliberate self poisoning with the aid of organo-phosphorous chemicals (rat poison). This report is purposed to increase the interest of physicians and psychiatrists in parenting style research and in how potentially its modification could be a therapeutic and preventive tool.

S18-02 - Interventions for childhood behaviour problems

Oppositional defiant disorder and conduct disorder are classified as disruptive disorders. However, they show a wide range of associations with other psychopathological features. Disturbances of emotional regulation, impulse control, narcissism, and paranoid cognitive style may shape the behavioural picture. On the basis of the Heidelberg School Study (n = 6085) those 15 yr old students with externalising behaviour disturbances were analysed regarding internalising behaviour problems, deliberate self harm, suicidal behaviour, living situation, and family problems. Developmental trajectories from infant temperament to adolescent behaviour will be outlined and therapeutic measures like parent training, patient focused cognitive behavioural therapy and multisystemic family interventions will be described on the basis of meta-analytic reviews.

P03-445 - Suicide risk awareness in Pakistan: Influence of religious, cultural, legal, socio-economic and interpersonal factors

IntroductionPakistan is an Islamic country where religion is considered an important protective factor against suicide. Recent research and media reports identify that suicide and self harm behaviours are increasing in different parts of Pakistan.ObjectivesTo inform public policy debate and suicide awareness education interventions.AimsTo study socio-cultural, political, interpersonal and religious factors that can influence suicide and suicide awareness.MethodsSystematic search of Medline, Embase, PsychInfo, CINAHL, Pakmedinet, TRIP, and electronic searches of Pakistani Medical Journals, using terms Suicide, Self harm, Deliberate Self Harm, Self Poisoning, Non-Accidental Deaths, Undetermined Deaths. Focus Group Discussion, Aga Khan Medical University, Pakistan Consultation with experts in the field.Resultsa.Epidemiological evidence confirms an increase in suicide rates with variable figures reported from different parts of Pakistan. Higher rates of suicide rates are reported for men with an association with unemployment and mental health problems. Marital Discord and domestic violence identified as risk factors in female suicides.b.Religion is continued to be identified as an important protective factor against suicide.However, Pakistan's legal system that criminalizes suicide and self harm is criticized for exercising negative influence through preventing early identification of high risk individuals. A variable pattern of suicide reported from different parts of Pakistan identifies the need for deep cultural understanding and examination of protective and risk factors that operate with in family structures and sub-cultures in Pakistan.ConclusionsAn increase in suicide rates in Pakistan has raised mental health and public policy awareness.

Prevalence of alcohol and other substances of abuse among injured patients in a Norwegian emergency department

Background Studies have found a high prevalence of both alcohol and other impairing psychoactive drugs in injured patient populations. The aim of this study was to assess the prevalence of potentially impairing psychoactive substances in all patients admitted to a hospital emergency department with injuries from accidents, assault or deliberate self harm. Methods A total of 1272 patients over 18 years of age, admitted to the hospital within 12 h of injury, were included. Presence of alcohol was determined by an enzymatic method and other drugs by liquid chromatography–mass spectrometry (LC–MS) or gas chromatography–mass spectrometry (GC–MS), both highly specific analytical methods for determining recent intake. Results There were 510 (40%) women in the sample. Of the patients, 38% of the women and 48% of the men had a positive blood sample for psychoactive substances on admission. The most prevalent psychoactive substance was alcohol (27%) with an average concentration of 1.5 g/kg. A further 21% of patients tested showed use of medicinal drugs, and 9% showed use of illicit substances. Cannabis was the most prevalent illicit drug (6.2%). Diazepam (7.4%) and zopiclone (5.3%) were the most prevalent medicinal drugs. In road traffic accidents, 25% of the car drivers had positive findings, about half of them for alcohol. Conclusion Psychoactive substances were found in nearly half the patients admitted with injuries. The most common substance was alcohol. Alcohol was particularly related to violence, whereas medicinal drugs were most prevalent in accidents at home.

Comparison of the Composite International Diagnostic Interview (CIDI-Auto) with Clinical Diagnosis in a Suicidal Population

The objective was to examine agreement between routine clinician diagnoses of DSM-IV Anxiety, Depressive, Substance-Use disorders with diagnoses generated by CIDI-Auto Version 2.1, administered by trained interviewers. Subjects were 329 deliberate self poisoning patients at a tertiary referral center in Australia. Tests of agreement were: percentage agreement, sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and Cohen's kappa coefficients, for 1 month and 12 month CIDI diagnoses. Agreement was poor (kappa <0.40) for Anxiety, Depressive and Substance-Use disorders. Since diagnosis largely determines subsequent treatment, these findings did not support the use of the less expensive CIDI-Auto procedure to replace clinical diagnosis by experienced clinicians for this group of patients exhibiting suicidal behavior.

Structural and functional neuroimaging studies of the suicidal brain

Suicidality is a major challenge for today's health care. Evidence suggests that there are differences in cognitive functioning of suicidal patients but the knowledge about the underlying neurobiology is limited. Brain imaging offers the advantage of a non-invasive in vivo direct estimation of detailed brain structure, regional brain functioning and estimation of molecular processes in the brain. We have reviewed the literature on neuroimaging studies of the suicidal brain. This article contains studies on structural imaging such as Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) and functional imaging, consisting of Positron Emission Tomography (PET), Single Photon Emission Tomography (SPECT) and functional MRI (fMRI). We classified the results of the different imaging modalities in structural and functional imaging. Within our research, we found no significant differences in the suicidal brain demonstrated by Computed Tomography. Magnetic Resonance Imaging studies in subjects with a history of suicide attempt on the other hand deliver differing results, mostly pointing at a higher prevalence of white (especially deep white matter and periventricular) and grey matter hyperintensities in the frontal, temporal and/or parietal lobe and decreased volumes in the frontal and temporal lobe. There seems to be a trend towards findings of reduced grey matter volume in the frontal lobe. Overall, there is no consensus of opinion on structural imaging of the suicidal brain. Research on functional imaging is further divided into studies in resting state, studies in activation conditions and studies on brain neurotransmitters, transporters and receptors. A common finding in functional neuroimaging in resting conditions is a decreased perfusion in the prefrontal cortex of suicidal patients. During cognitive activation, perfusion deficits in the prefrontal cortex have been observed. After fenfluramine challenge, the prefrontal cortex metabolism seems to be inversely correlated to the lethality of previous suicide attempt. The few studies that examined the serotonin transporter in suicide found no significant differences in binding potential. In suicide attempters there seems to be a negative correlation between impulsivity and SERT binding. Our group found a reduced 5-HT(2A) binding in the frontal cortex in patients with a recent suicide attempt. The binding index was significantly lower in the deliberate self injury patients compared to the deliberate self poisoning patients. The few authors that examined DAT binding in suicide found no significant DAT differences between patients and controls. However they demonstrated significant negative correlations between DAT binding potential and mental energy among suicide attempters, but not in healthy control subjects. We did not find studies measuring the binding potential of the noradrenalin or gamma amino butyric acid transporter or receptor in suicidal subjects. Several reports have suggested abnormalities of GABA neurotransmission in depression. During our literature search, we have focused on neuroimaging studies in suicidal populations, but in the absence of evidence in the literature on this group or when further collateral evidence is appropriate, this overview expands to results in impulsive aggressive or in depressed subjects.

Leslie James Clark-Wilson

OBJECTIVE--To determine the risk of suicide in patients attending an accident and emergency (A&amp;E) department with deliberate self harm. METHODS--Information was obtained on suicides and open verdicts from the coroner9s...

Managment of Organophosphate Poisoning Without Pralidoxim- Is It Possible .................IJMTFM (2011) 1(2):75-77

Introduction: Organophosphate compounds are used as insecticides, nerve gases, ophthalmic agents, and antihelmintics.The primary mechanism of action of organophosphate pesticides is inhibition of acetylcholinesterase (AChE). However Pralidoxim has been introduced as organophosphate `s antidote but recent studies establish that pralidoxim has unclear benefit in treatment of organophosphate poisoning.We explain two cases of organophosphate poisoning that they treaeted well without pralidoxim. The first case was a 36-years old man with history of organophosphates poisoning. He was under mechanical ventilation. Atropine was initiated due to muscarinic signs such as salivation, bronchorrhea and auscultation of alveolar rhales. On admission day, the pseudocholine esterase level was 235 unit per liter. Pralidoxime was not available, so we did not use it for management of this patient.The patient was discharged when he was in free symptom completely on the 22 th day. The second case was a 23 years old woman with the history of deliberate self poisoning with organophosphate compounds. Atropine was started and she was under mechanical. However, pralidoxim was not available. The pseudocholine esterase level was 1690 unit per liter on the first day which dropped to 952 unit per liter on the 2 nd day. After 9 days the discharged from the hospital. Discussion: Pralidoxim has been introduced as organophosphate`s antidote, on the other hand, it has benefit in organophosphate poisoning theoretically, but patients can be treated without it. Key words: Organophosphate, Poisoning, Pralidoxim

Temporomandibular dislocation due to aripiprazole induced dystonia

We wish to report the case of a patient who developed temporomandibular joint dislocation due to dystonia following a single dose of aripiprazole. Our patient was a 23-year-old woman presenting with persistent low mood, fatiguability, insomnia and suicidal ideation. There was no past history of psychiatric morbidity. There was family history of depressive episode and deliberate self harm in her husband who was her paternal cousin. She was given 10 mg escitalopram and 0.5 mg clonazepam for insomnia on a diagnosis of a moderate depressive episode and improved over the next 3 weeks. However she developed irritability and agitation while on the above medications for which she was given a single dose of aripiprazole 10 mg at night by another psychiatrist not attached to our institution, which was not appropriate for her condition. The patient had taken 10 mg escitalopram in the morning. There was no history of intake of any over the counter drugs or herbal preparations. Twelve hours after the first dose she developed sedation and salivation and her care givers withheld subsequent doses of aripiprazole, escitalopram and clonazepam. Twenty hours after the first dose, she developed painful spasms of the muscles of her neck on the right side. She also had forced opening and deviation of jaw, both to the left and right. This was followed by persistent deviation of the jaw to the left and pain in the left temporomandibular joint. She was unable to close her mouth, swallow or talk for which she was brought to the emergency department of our hospital. A left-sided temporomandibular dislocation was diagnosed and a manual reduction was performed, after which the pain subsided. The next morning she was examined by us and seen to have forced mouth opening, excessive salivation and bilateral hand tremors. There were no other dystonic reactions. The dystonia and temporomandibular joint dislocation could not be part of the somatic symptoms of depression. We gave her 50 mg promethazine intramuscularly on suspicion of an aripiprazole induced dystonia. Two hours later, the dystonic movements subsided and the patient was sent home on oral promethazine. She did not have dystonic movements on follow-up the next morning. A rechallenge with aripiprazole could not be done for ethical reasons. The dystonia was rated as possibly due to aripiprozole according to the Naranjo adverse drug reaction probability scale [1]. She was restarted on escitalopram and clonazepam. A 1 month follow-up did not reveal any dystonic reactions. The adverse drug reaction was reported to the regional pharmacovigilance reporting centre. Aripiprazole is a second generation anti-psychotic which has a low propensity to cause extra-pyramidal side effects [2]. There are reports of acute dystonia induced by aripiprazole in drug-naive [3], and cocaine dependent patients [4] and in a patient on sertraline [5]. It has been proposed that aripiprazole caused dystonia because it lacked a protective anti-cholinergic action unlike other second generation anti-psychotics like clozapine [3]. Temporomandibular joint dislocations have been reported with conventional neuroleptics [6, 7] but no case has been reported with aripiprazole. Aripiprazole has been found to have no meaningful effect on the pharmacokinetics of escitalopram [8].We propose that our patient developed temporomandibular dislocation due to a dystonic reaction to aripiprazole possibly mediated through a pharmacodynamic synergism with escitalopram as selective serotonin re-uptake inhibitors can cause extrapyramidal side effects including dystonias through serotonergically mediated inhibition of the dopaminergic system [9]. From our case report we recommend a lower starting dose of aripiprazole especially in drug naive non psychotic patients and close monitoring of such patients.

1203 Characteristics and Outcome of Children Referred to Specialist Paediatric Intensive Care Rerieval Team with Poisoning From District General Hospital

Background: Childhood poisonings are common, but infrequently necessitate transfer to intensive care unit (ICU) for further management. This project was done to evaluate all the cases of poisoning referred to Children's Acute Transport Service (CATS), in terms of clinical chacteristics and outcome.Method: All the children with acute poisoning for which advice or retrieval request was received at CATS, were included in this study. Various parameters noted were age, sex of child, type of poisoning/overdose agent, clinical manifestations, and management of child including any antidote used, reasons for refused referral, length of stay in PICU, final outcome of the episode and comparison of outcome of retrieved vs. not retrieved children.Results: There were 42 cases of substance poisoning. Deliberate self harm was most common reason. Pharmaceuticals were most common agents involved.Single agent was involved in most cases. Table 1 Table 1 [Characteristics of children.]Full size table Nervous and cardiovascular symptoms were most common. Intensive supportive treatment was given in most of cases. In only 5 cases specific antidote was used. More than half didn't need retrieval because of improvement at referral hospital itself. No mortality was recorded.Conclusions: Significant proportion of children referred for PICU can be managed at the local hospital, either with close observations and monitoring or temporary use of available adult critical care services for brief periods of ventilation. The vast majority of cases survive their acute episode following a relatively short spell of PICU, small minority may need advanced organ support, especially renal and cardiovascular.

The association between personality disorder and an act of deliberate self harm in the older person

Suicide rates are higher in the over 65s than in younger adults and there is a strong link between deliberate self harm (DSH) and suicide in older people. The association between personality disorder (PD) and DSH in older adults remains uncertain. Our objective was to describe this association. A case control study was conducted in which participants were: (i) those who had undertaken an act of DSH and (ii) a hospital-based control group drawn from a geographical contiguous population. PD was assessed using the Standardised Assessment of Personality (SAP). Seventy-seven cases of DSH were identified; 61 (79.2%) of these participants were interviewed. There were 171 potential controls identified of whom 140 (81.9%) were included. An SAP was completed in 45/61 (73.8%) of cases and 100/140 (71.4%) of controls. The mean age was 79.8 years (SD = 9, range 65-103). The crude odds ratio for the association between PD and DSH was 5.91 [(95% CI 2.3, 14.9) p<0.0001]. There was a strong interaction with age stratified at 80 years. There was no association between PD and DSH after age 80. The adjusted odds ratio for PD in the group <80 years was 20.5 [(95% CI 3, 141) p = 0.002]. Borderline and impulsive PD traits tended to be associated with an episode of DSH more than other personality types. PD appears to be a strong and independent risk for an act of DSH in people aged between 65 and 80 years and should be looked for as part of any risk assessment in this population. Access to specialist services may be required to optimally manage this problem and reduce the subsequent risk of suicide.

Risk factors leading to deliberate self harm in patients presenting to the emergency departments: a multi-centre case–control study from Karachi, Pakistan

ObjectivesTo determine the risk factors of patients presenting with deliberate self harm (DSH) to the emergency departments (EDs) of four tertiary care hospitals of Karachi, Pakistan.To determine the outcome (admission...

Responding to Young People who Self Harm

Deliberate Self Harm in Children and Young People may promote anxiety in families and professionals. My presentation describes how the confidence and competence of a Team can reduce such anxiety...

025 The incidence and repetition of hospital-treated deliberate self-harm in Ireland

BackgroundDeliberate self-harm (DSH) is one of the strongest risk factors for suicide and a significant public health problem in its own right. Nationally representative data on the incidence, repetition and...

Suicide and deliberate self harm in older Irish adults

Hospital-treated deliberate self harm and suicide among older adults have rarely been examined at a national level. The Irish Central Statistics Office provided suicide and undetermined death data for 1980-2006. The National Registry of Deliberate Self Harm collected data relating to deliberate self harm presentations made in 2006-2008 to all 40 Irish hospital emergency departments. Rates of female suicide among older adults (over 55 years) were relatively stable in Ireland during 1980-2006 whereas male rates increased in the 1980s and decreased in more recent decades. Respectively, the annual male and female suicide and undetermined death rate was 22.1 and 7.6 per 100,000 in 1997-2006. Male and female deliberate self harm was 3.0 and 11.0 times higher at 67.4 and 83.4 per 100,000, respectively. Deliberate self harm and suicide decreased in incidence with increasing age. Deliberate self harm generally involved drug overdose (male: 72%; female 85%) or self-cutting (male: 15%; female 9%). The most common methods of suicide were hanging (41%) and drowning (29%) for men and drowning (39%) and drug overdose (24%) for women. City and urban district populations had the highest rates of hospital-treated self harm. The highest suicide rates were in urban districts. Older Irish adults have high rates of hospital-treated deliberate self harm but below average rates of suicide. Drowning was relatively common as a method of suicide. Restricting availability of specific medications may reduce both forms of suicidal behavior.

Deliberate self harm in children

To study the nature of deliberate self-harm (DSH) in children and to identify the associated factors. Child Guidance Clinic attached to the Department of Pediatrics of a teaching hospital in South India. Children with history of deliberate self harm who were referred to the CGC for psychological evaluation during a 10 year period. Children and parents were interviewed together and separately and details regarding age, sex, family and school environment, stresses and nature of self harm were documented. Psychiatric diagnosis was made based on DSM IV diagnostic criteria. Among the 30 children included in the study, 21 were boys and 9 were girls. Majority of children were between the ages of 11 and 13 years, the youngest being 6 years old. 76%of children had history of acute stressful life events and 62%of them had chronic ongoing stress. 62%of children had stress in the family and 41%had stress at school. Stress in the family included death of a parent, conflicts with parents or siblings, mental illness in the family, parental alcoholism and parental disharmony. Stress at school included conflicts with classmates, punishment or negative comments by teachers and learning problems. Psychiatric disorders were present in 52%of children, the commonest being depressive disorder. The commonest mode of DSH was self poisoning, and rat poison (zinc phosphide) was the commonest substance used. Deliberate self harm occurs in young children and the risk factors are comparable to those in adolescents.

The influence of several changes in atmospheric states over semi-arid areas on the incidence of mental health disorders

The incidence of suicide attempts [Deliberate Self Harm (DSH); ICD-10: X60-X84] and psychotic attacks (PsA; ICD-10, F20-F29) in association with atmospheric states, typical for areas close to big deserts, was analyzed. A retrospective study is based on the 4,325 cases of DSH and PsA registered in the Mental Health Center (MHC) of Ben-Gurion University (Be'er-Sheva, Israel) during 2001-2003. Pearson and Spearman test correlations were used; the statistical significance was tested at p < 0.1. The influence of temperature and humidity on suicide attempts (N(SU)) and psychotic attacks (N(PS)) was weakly pronounced (p > 0.1). Correlation coefficients between N(SU) and N(PS) and speed WS of westerly wind reaches 0.3 (p < 0.05), while their dependence on easterly WS was weaker (p > 0.09). Variations in easterly wind direction WD influence N(SU) and N(PS) values (p < 0.04), but no corresponding correlation with westerly winds was found (p > 0.3). Obviously ,in transition areas located between different regions ,the main role of air streams in meteorological-biological impact can scarcely be exaggerated. An unstable balance in the internal state of a weather-sensitive person is disturbed when the atmospheric state is changed by specific desert winds, which can provoke significant perturbations in meteorological parameters. Results indicate the importance of wind direction, defining mainly the atmospheric situation in semi-arid areas: changes in direction of the easterly wind influence N(SU) and N(PS), while changes in WS are important for mental health under westerly air streams. Obviously, N(SU) and N(PS) are more affected by the disturbance of weather from its normal state, for a given season, to which the local population is accustomed, than by absolute values of meteorological parameters.

Bullying victimisation, self harm and associated factors in Irish adolescent boys

School bullying victimisation is associated with poor mental health and self harm. However, little is known about the lifestyle factors and negative life events associated with victimisation, or the factors associated with self harm among boys who experience bullying. The objectives of the study were to examine the prevalence of bullying in Irish adolescent boys, the association between bullying and a broad range of risk factors among boys, and factors associated with self harm among bullied boys and their non-bullied peers. Analyses were based on the data of the Irish centre of the Child and Adolescent Self Harm in Europe (CASE) study (boys n=1870). Information was obtained on demographic factors, school bullying, deliberate self harm and psychological and lifestyle factors including negative life events. In total 363 boys (19.4%) reported having been a victim of school bullying at some point in their lives. The odds ratio of lifetime self harm was four times higher for boys who had been bullied than those without this experience. The factors that remained in the multivariate logistic regression model for lifetime history of bullying victimisation among boys were serious physical abuse and self esteem. Factors associated with self harm among bullied boys included psychological factors, problems with schoolwork, worries about sexual orientation and physical abuse, while family support was protective against self harm. Our findings highlight the mental health problems associated with victimisation, underlining the importance of anti-bullying policies in schools. Factors associated with self harm among boys who have been bullied should be taken into account in the identification of boys at risk of self harm.