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Table43.3Recommendedphysicalhealthmonitoringforpatientsusingantipsychotic
medications
Weight Weeklyfor6weeks,at12weeks,at1year,andthen
annually
Waistcircumference Annually
Pulse,bloodpressure,fastingglucose,HbA1c,lipid
profile
At12weeks,at1year,andthenannually
Violence,aggression,andself-harm
Patientswithschizophreniaorpsychosismaybecomeviolentoraggressive.Fordetails
on management of violence and aggression see Chapter 45. For concerns regarding
self-harm,seeChapter44.
Furtherreading
1. Barnes T (2011). Evidence-based guidelines for the pharmacological treatment of schizophrenia:
recommendationsfromtheBritishAssociationforPsychopharmacology.JPsychopharmacol.25:567–
620.
2. Joint Formulary Committee. Psychoses and related disorders. In: British National Formulary.
Availableat:https://bnf.nice.org.uk/treatment-summary/psychoses-and-related-disorders.html
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Chapter44
Self-harm
Guidelines:Thischapterwasbasedonthefollowingguidelines:NICECG16
(Self-harm in over 8s: short-term management and prevention of
recurrence):https://www.nice.org.uk/guidance/cg16
NICE CG133 (Self-harm in over 8s: long-term management):
https://www.nice.org.uk/guidance/cg133. Since the chapter was written, the
guidelineshavebeenupdatedwithminorchangesandcombinedinto:NICE
NG225 (Self-harm: assessment, management and preventing recurrence):
https://www.nice.org.uk/guidance/ng225
OUPdisclaimer:OxfordUniversity Press makesno representation, express
or implied, that the drugdosagesarecorrectand thatthe recommendations
are an exclusive or mandatory course of care. All health professionals
readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake
theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Self-harm includes all self-poisoning or injury regardless of intention. Self-harm is
common, with 25.7%of women and 9.7%of men aged 16–24 reportingthatthey have
self-harmed previously.1 Overall, the prevalence is estimated to be 0.5% across all age
groups. The risk of suicideis 49×greater over a 12-month period if an individual has
self-harmed, as compared with the rest of the population.2 It is therefore essential to
carefullyandcompassionatelyassessthecomplexissuesthatliebehindself-harmandto
ensurethataplanisputinplacetotryandavoidmorbidityandmortality.
Diagnosis
Triageintheemergencydepartment:
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Assessrisktophysicalhealth
Assessemotionalandmentalstate
Considerusingthe‘AustralianMentalHealthTriageScale’(see‘Furtherreading’)
Conductapreliminarypsychosocialassessment,toinclude:
Mentalcapacity
Willingnesstoremainforfurtherpsychosocialassessment
Levelofdistress
Evidenceofmentalillness
Askthepatientiftheywouldprefertobeassessedbyamaleorfemaledoctor,ifitispossibleto
complywiththeirrequest
Ifthepatientneedstowaitfortreatment,provideaquietspace,withsupervisiontoensuresafety.
History
The patient may be able to provide a history butif not, ask a collateral witness and/or
paramedic.
Inparticular,askaboutthefollowing:
Natureandtimingofoverdoseorinjuries
Whetheritwasplannedorspontaneous
Substances/medicationsfoundatthescene
Informationaboutthehomeenvironment
Socialandfamilysupportnetwork
Historyleadingtoself-harm
Initialemotionalstateandlevelofdistress
Howthepatientfeelsnow
Previousinteractionswiththementalhealthteam
Theriskoffurtherself-harmorsuicide.
LGBTQ+peopleareatahigherriskofself-harmcomparedtotherestofthepopulation.3Be
awareoftheneedtousetheperson’spreferredpronouns.
Examination
Afullpsychosocialassessmentshouldbecompleted,usuallybyaspecialistmentalhealth
liaison professional (Box 44.1). Ideally this should be held with the patient alone to
facilitateconfidentiality,andincasethereareissueswithcarersthatthepatientwishesto
discuss.
The psychosocial assessment should take place in parallel with medical treatment if
needed(aslongasthepatientisinafitconditiontobeinterviewed).
Ensure that all of the assessment is fully documented and that a copy is sent to the
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patient’sGP.
Box44.1Mentalhealthliaisonteams
Most general hospitals have mental health liaison teams which are often staffed by
experiencedmentalhealthnursesandsocialworkerswithsomepsychiatryinput.They
carryoutpsychosocialassessmentsforpatientspresentingwithself-harm.
Gather information and perform a thorough triage before referring to the mental
healthliaisonteam.
Investigations
In the event of overdose, follow recommendations from TOXBASE and the National
Poisons Information Service (NPIS) regarding what samples to collect (for link see
‘Furtherreading’).
Measureplasmaparacetamol concentrations (Box44.2)inallpatientswithconfirmed
or suspected paracetamol overdose or opioid poisoning, as well as in an unconscious,
collapsedpatientwheredrugoverdoseispossible.
Box44.2Paracetamollevels
Paracetamollevelstaken4–15hoursafteringestioncanbeusedtoassessriskandguide
treatment,usingatreatmentgraphwhichisavailablefromTOXBASEortheBNF.
Management
Acutemanagement
AssessthepatientusinganABCDEapproach.
For the treatment of poisoning, follow the guidance outlined in TOXBASE. General
principlesofthetreatmentofcommonpoisonsareoutlinedinTable44.1.
Alwaysconsiderthepossibilityofamixedoverdose.
Consider oral activated charcoal treatment for those who present within 2 hours of
overdose,areconscious,haveaprotectedairway,andareatriskofsignificantharmfrom
poisoning(butcheckifalreadygivenbyparamedics/pre-hospital).
SeeTable44.1andBox44.3regardingtheuseofflumazenilornaloxone.
Thefollowingshould notbe offered unlessspecificallyrecommendedbyTOXBASE
ortheNPIS:
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Multipledosesofactivatedcharcoal
Emetics
Cathartics
Gastriclavage
Wholebowelirrigation.
Table44.1Basicmanagementofspecificpoisons(forfurtherdetails,pleasereferto
TOXBASE)
Agent Managementandconsiderations
Paracetamol IVacetylcysteine:
Cancauseanaphylactoidreactions
Benzodiazepines Flumazenil(Box44.3):
Avoid if there is an ↑ risk of seizures, e.g. ingested proconvulsant such as tricyclic
antidepressantorhistoryofepilepsyordependenceonbenzodiazepines
Give ifthe patient can protect their airway but there is respiratory depressionwhich, if left
untreated,willlikelyrequireinvasiveventilation
May be given only by clinicians who have been trained in its use and if resuscitation
equipmentisavailable
Opioids Naloxone(Box44.3):
Useifimpairedconsciousnessorrespiratorydepression,e.g.respiratoryrate≤8
Useminimumeffectivedosetoreverserespiratorydepression
AnIVinfusionmayberequired
Box44.3Usingflumazenilornaloxone
When using flumazenil or naloxone, be prepared to deal with prompt withdrawal
includingagitation,aggression,andviolence.Patientswillalsorequireclosemonitoring
for re-sedation as the effect of the antidotes wears off. In particular, monitor the
respiratoryrateandoxygensaturation.
Treatmentafterstabilization
Physicalhealth
Ensurethatthepatientisstablefromaphysicalhealthperspective.Admitformonitoring
andconsidertheneedforfurthertreatmentofthephysicalconsequencesofself-harm.
MentalHealthAct
Assess if the patient continues to be a danger to themselves or others. If there are
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concerns, they should be assessed for sectioning under the Mental Health Act (see
‘Furtherreading’).
Copingstrategies
Harm minimization strategies are not an option for peoplewho repeatedlyself-harm as
there are no safe limits. If the patient is usually prescribed long-term medications,
consider prescribing the least dangerous option and consider prescribing a reduced
quantityoftablets,e.g.weeklyorevendailydispensing.Thisstrategymayalsoneedtobe
extended to relatives who live in the same home and are prescribed long-term
medications.
Considerdiscussingalternativecopingstrategiesforpeoplewhorepeatedlyself-injure,
e.g. methadone in heroin addiction, information about how to clean wounds. Consider
providinginformationondealingwithscarring,ifappropriate.Thepatientmayrequirea
short admission, particularly if a full assessment has not been possible due to patient
distressorintoxication,orifthehomeenvironmentisunsafe.
Referralforfurtherassessmentortreatment
ItisessentialtofindoutifthepatienthasaResponsibleClinicianasoftenthesepatients’
circumstancesarecomplex.Theycanbechallengingtomanageduetotherisktheypose
to themselves but there may already be a care plan in place which will help guide
decision-making.Ifindoubt,discusswithaseniormemberofstaff.
The need for referralwillbe based on the psychosocialassessment, with the aim of
addressing the underlying problems or mental disorder rather than just addressing the
self-harmingbehaviour.
Longer-term care plans are made by adult mental health services, liaison psychiatry,
CAMHS,orintellectualdisabilityservices.Theyaimto:
Reduceself-harm
Reducerisksarisingfromself-harm
Reduceorstopotherriskbehaviours
Improvesocialoroccupationalfunctioning
Improvequalityoflife
Treattheassociatedmentaldisorder.
Careplans should be multidisciplinary, collaborative, and reviewed at regular intervals.
Theyshouldincludeacrisisplansothatthepatientisabletoobtainhelpintheeventthat
otherstrategieshavefailed.
Consideroffering3–12sessions of structured psychologicaltherapywiththespecific
aimofreducingself-harm.Thisshouldbetailoredtoindividualneedsandcouldinclude
CBT,psychodynamic,orproblem-solvingelements.
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Donotofferdrugtreatmentspecificallytoreduceself-harm.However,drugtreatment
may be appropriate to treat associated mental disorders. Consider the toxicity of
prescribed drugs in overdose (e.g. SSRIs are less toxic than other antidepressants; see
Chapter38).
Specialconsiderations
Childrenandyoungpeople(<16years)
Allunder 16sshouldbeassessedin thepaediatricsectionof theemergencydepartment.
Theyshouldbeadmittedtoapaediatricwardovernightandfullyassessedthefollowing
daybytheCAMHSteam.
It is necessary to obtain consent from the parent or legally responsible adult before
carryingoutanassessment.Anunderstandingisrequiredoftheissuesrelatingtocapacity
andconsentinthisagegroup.
Learningdisability
Consideranyissuesof capacityand consent andincludeaparent orlegallyresponsible
adult in the decision-making process. If admission is necessary, then liaise with and
arrangearapidreviewbythelearningdisabilityteam.
Olderpeople(>65years)
Thereisahigherriskofself-harmandsuicideinthisagegroup,andallactsofself-harm
shouldberegardedasevidenceofsuicidalintentuntilprovenotherwise.
Furtherreading
1. Australian Government Department of Health. Mental health triage tool. Available at:
https://www1.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh
2.NationalPoisonsInformationService.TOXBASE.Availableat:https://www.toxbase.org/
3. Joint Formulary Committee. Poisoning, emergency treatment. In: British National Formulary.
Availableat:http://www.medicinescomplete.com
4.NHS(2019).MentalHealthAct.Available at:https://www.nhs.uk/using-the-nhs/nhs-services/mental-
health-services/mental-health-act/
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1McManusS,BebbingtonP,JenkinsR,etal.MentalhealthandwellbeinginEngland:AdultPsychiatric
Morbidity Survey 2014. Leeds. 2016. Available at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/556596/apms-
2014-full-rpt.pdf
2HawtonK,BergenH,CooperJ,etal.Suicidefollowingself-harm:findingsfromtheMulticentreStudy
ofSelf-HarminEngland,2000–2012.JAffectDisord.2015;175:147–51.
3KingM,SemlyenJ,SeeTaiS.Asystematicreviewofmentaldisorder,suicide,deliberateself-harmin
lesbian,gayandbisexualpeople.BMCPsychiatry.2008;8:70.
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Chapter45
Violenceandaggression
Guideline:NICENG10(Violenceandaggression:short-termmanagementin
mental health, health and community settings):
https://www.nice.org.uk/guidance/ng10
OUPdisclaimer:OxfordUniversity Press makesno representation, express
or implied, that the drugdosagesarecorrectand thatthe recommendations
are an exclusive or mandatory course of care. All health professionals
readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake
theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Violenceandaggressionincludesanyactionorbehaviourwhichleadstoinjuryorharm
toanotherperson.
Diagnosis
History
Taking a multidisciplinary approach, assess the risk of aggression and violence,
consideringthefollowingfactors:
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Historyofviolenceandaggression
Psychiatrichistory
Severityofillnessandcurrentsymptoms
Incidents between patients (e.g. teasing, bullying, unwanted physical or sexual contact,
miscommunication)
Theimpactofbeingsubjecttorestriction(e.g.beingdetained,beingdeniedleave)
Theimpactofthephysicalenvironment(e.g.accesstobelongingsandspace)
Personalfactors(e.g.familydisputesorfinancialdifficulties)
Theapproachofstafftothepatient(shouldbepositiveandencouraging)
Culturalfactors
Accesstopsychologicaltherapiesandactivities.
Involve the patient and carer in the risk assessment wherever possible (try to obtain
consentfromthepatientbeforeinvolvingthecarer).
Examination
Conduct a mental state examination (Table 45.1). Focus on factors that may lead to
violenceandaggression.
Table45.1Mentalstateexaminationfindingsrelevanttotheriskofaggressionand
violence
Appearance
andbehaviour
Highlevelsofarousal,agitation,violentoraggressiveactstootherpersonsorenvironment,
threateningorintimidatingmanner,evidenceofdrugoralcoholuse
Speech Aggressiveorthreateningtoneorcontent,communicationdifficulties
Mood Anxiety,disappointment,jealousy,frustration,anger
Thoughts Persecutorythoughtcontent,passivityphenomena,violentideationorintent
Perceptions Commandhallucinations
Cognition Cognitiveimpairment,poorexecutivefunction
Insight Lackofinsightintomentaldisorder,riskofviolence,andneedfortreatment
Investigations
Risk prediction instruments can be used to aid clinicaljudgement, e.g. Brøset Violence
ChecklistorDynamicAppraisalofSituationalAggression—InpatientVersion.
Management
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