When thinking about
self-harm, we most associate it with youth. More than half of 11-14 year olds
and eight out of ten 18-21 year olds have self-harmed - or know someone who has
- according to the results of a UK poll undertaken during 2015.1 The
number of children in England and Wales admitted to hospital after self-harming
has risen 14% over the past three years.2 Low self-esteem, poor
body-image and bullying are obvious causes. However, self-harm is also common
among older adults with multiple life problems.
There's no single reason
why one person self-harms and another doesn't - and mental health isn’t always
linked. Only around 30% of people who repeatedly self-harm have borderline
personality or anxiety disorders, depression or post-traumatic stress.3 It
frequently begins with no identifiable psychiatric cause. Difficulties with
alcohol or in personal relationships, domestic violence, bereavement, work pressures,
in addition to isolation and loneliness - all contribute. Many people fail to
seek help; rather they hide the evidence of harm or act in secret, meaning it
goes unnoticed and untreated.
It is often difficult
for others to understand why a person would deliberately harm themselves by
cutting, scratching or poisoning with tablets. A critical distinction is made
between acts where the person’s intention is to end his or her life and those
where they are not. This latter group is called non-suicidal self-injury
(NSSI). Individuals in this group self-harm when they are overwhelmed by
psychological distress. The pain brings relief from the distress, feelings of
anxiety, shame or guilt.
While these groups may
appear clearly differentiated, they are linked in complex ways. A 2015 study
found that self-harm increased the risk of attempting suicide “seven-fold” and
that clinicians should not just dismiss the behaviour as “nothing serious.”4 Individualized
clinical support has a key role in suicide prevention. Cognitive therapy is
used to build resilience. Antidepressants help to ease anxiety and improve
well-being but there are too few trials of other promising interventions to
conclude as to their effectiveness.5
Assessing suicide risk
is a complex task for clinicians. It involves identifying the presence of
intent and mental illness, in addition to exploring the immediate causes of the
problems and the more enduring social, psychological and medical issues that
the individual experiences. Unfortunately, the formal risk assessment
instruments do not perform well, and the risk factors identified in the
literature are so common in mental health practice that they rarely help in a
given individual. Predicting rare events is difficult.
As a result, people who
self-harm present a similar dilemma at underwriting because the majority will
not end their lives by suicide. It is important that we not assume the worst
outcome is inevitable. Underwriters should look for evidence of suicidal
intent, the nature of any attempt (for instance, violent means such as
drowning, hanging or jumping), and a diagnosis of mental illness - in addition
to the proximal causes of the harm - and always bear in mind that the suicide
risk diminishes over time since the last act of harm.
Endnotes
1. http://www.themix.org.uk/news-and-research/news/poll-reveals-affect-of-online-self-harm-images-on-children-and-young-people.
3. Townsend, E. et al.,
Self-harm and life problems: findings from the Multicentre Study of Self-harm
in England, Social Psychiatry and Psychiatric Epidemiology, February 2016, v51,
issue 2, 183-192.
4. Dickstein, D. et al.,
Self-injurious implicit attitudes among adolescent suicide attempters versus
those engaged in non-suicidal self-injury, Journal of Child Psychology and
Psychiatry, 2015.
5. Gunnell, D et al.,
Psychosocial interventions following self-harm in adults: a systematic review
and meta-analysis, The Lancet Psychiatry Vol 3, No 8 740-750, 2016.
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