Deliberate Self-Harm (DSH)

•    Definition:

o    Any act of self-poisoning or self-injury, regardless of intent.

o    May be non-suicidal (emotional regulation, cry for help) or suicidal (intent to die).

•    Assessment essentials:

o    Determine intent: was it an attempt to end life or to relieve distress?

o    Evaluate lethality: method used, planning, precautions against discovery.

o    Access to means: ongoing availability of pills, sharp objects, firearms.

•    Psychiatric comorbidity:

o    High association with mood disorders, personality disorders (especially borderline), substance misuse.

Suicide Risk

•    Key risk factors (SAD PERSONS mnemonic):

o    Sex (male higher completion risk)

o    Age (>45 men, >55 women)

o    Depression or hopelessness

o    Previous attempts

o    Ethanol/substance abuse

o    Rational thinking loss (psychosis)

o    Social supports lacking

o    Organised plan

o    No spouse (single/divorced/widowed)

o    Sickness (chronic illness)

•    High-risk markers:

o    Recent serious attempt or high-lethality method.

o    Ongoing strong suicidal ideation, expressed plan.

o    Active psychosis, severe depression, recent major losses.

Management

•    Immediate priorities:

o    Medical stabilisation (if overdose, physical injury).

o    Remove access to lethal means.

o    Maintain safe environment.

•    Psychiatric management:

o    Risk assessment: structured, document thoroughly.

o    Safety planning: identify warning signs, coping strategies, contacts for crisis.

o    Crisis team or community support for moderate risk.

•    Admission indications:

o    Persistent high risk of suicide.

o    Severe psychiatric illness needing intensive treatment.

o    Lack of social support, unable to ensure safety at home.

Extra Revision Pearls

•    Men are more likely to die by suicide, but women make more attempts.

•    Previous suicide attempt is the strongest single predictor of future completed suicide.

•    SSRIs may increase suicidal ideation in young adults early in treatment — close monitoring is crucial.

•    In borderline personality disorder, self-harm is often non-suicidal but still requires careful assessment.

•    Always evaluate protective factors: children, family ties, religious beliefs, therapeutic alliance.