Elective Reflection: Self-Harm - a common emergency presentation in the United Kingdom?
Jacqueline Sim reflects on her time spent as an elective student in the Psychiatry Department of Addenbrookes Hospital in Cambridge, and on the problem of self-harm amongst young people.
1) Elective Reflection
It feels good to be back in the summer heat of Melbourne. I immerse myself in the lush botanical gardens as I write up this reflective entry about my medical elective in Cambridge. It is hard to sum up the surreal experience I had in words. I had set off from Singapore on Christmas Day 2011 and returned just in time to squeeze in a few days with family to round up the 15 days of the Chinese New Year. By then, it was time to return to Melbourne for my final year in medical school! Everything happened in a flash and looking back I am amazed how much I saw and did over the short summer holidays.
I spent a month in the Emergency Department in Addenbrooke's Hospital after a week travelling around Europe. It was overall a really good learning and enjoyable experience. I had not had any previous experience in emergency medicine and felt apprehensive about working in a very different medical system. Yet the fact that the doctors, nurses and patients were so accommodating and friendly made me feel welcomed and provided an environment conducive to learning. Throughout the department, the teaching culture and the strive for academic excellence was clear to me. This was despite the rule in the United Kingdom mandating that a patient be admitted, transferred, or discharged within 4 hours of arrival at an emergency department, which meant a high workload on the staff. I was given ample opportunities and managed to pick up many clinical skills - both procedural as well as effective history taking. I learnt how to exclude red flags and about standard management for common emergency presentations. These are indeed fundamental skills and knowledge that is now serving me well as I go through my emergency rotation in Melbourne. I am grateful for the head-start and varied exposure during this elective.
I was initially apprehensive about arranging my elective alone, without the company of friends, many of whom had chosen the more exciting London. However, looking back, it was a personal challenge that I am extremely glad I went ahead with! I met many like-minded and inspiring people along the way, both in medicine and outside. Coincidentally, there were other elective students where I stayed and most were studying in Australia! Meeting them, as well as the local medical students allowed some of my best memories. I would not have had the same opportunities if I had kept within my own circle of friends elsewhere. I gained confidence in meeting new people, learning about new cultures and how medicine is practiced in different hospitals and countries. Health professionals should strive to achieve the best outcome for patients and it is through exchange and mutual awareness that we can decide what works best for our patients.
Fig 1: Bridge of Sighs, Cambridge
2) Mental Health Issue - the problem of self harm in young people:
A key health issue that caught my attention was the high incidence of emergency admission due to self-harm. This can range from drug overdose to attempted suicide.
During my time in the emergency department, I had the opportunity to spend some time with the psychiatry team and it was saddening to witness patients present repeatedly, usually with paracetamol and alcohol overdose. They were often discharged soon after but would get admitted again within the next few weeks or months. Possible reasons include the lack of insight, or an unwillingness to seek help due to helplessness, stigma or shame. These resulted in continued problems, which led to repeated overdoses and addiction while trying to escape from their problems. Mixing with the wrong company of friends who abused drugs often encouraged these behaviours. The death of loved ones or friends could also spark drug-seeking behaviours. Many appeared to be guarded, depressed and had flat affects when interviewed a few days after admission. Several admitted they were not in a clear state of mind when they overdosed, and had not intended to commit suicide. Nevertheless, they were definitely fortunate to survive and able to tell their stories.
There were also patients, especially young ambitious students who had good family supports and pursuing a good education or career, yet felt compelled to harm themselves with drugs or repeated self-injury. I came across patients pursuing university degrees, who attended the emergency department to have their injuries treated, for instance, after cutting their wrists. They were adamant that the doctors stitched up their wounds and I witnessed some expressing how they had wanted the wounds to be deep enough to require stitches. Many had frequent past admissions when their intentions to harm themselves and the dangers posed to themselves and others were not deemed significant enough to warrant psychiatry referrals. Therefore, they had decided to inflict deeper wounds to seek the attention they desired. I was disappointed that such bright young students with good family support at home had such strong desire for self harm. The irony was that they believed the only way to get help and attention was to inflict deeper cuts and injuries to themselves. Many families at home were unaware about their situations, as many often pleaded with doctors not to inform them. They felt ashamed and it was a dark secret they wanted to hide from loved ones.
To put into perspective, the UK has one of the highest rates of self harm in Europe at 400 per 100 000 population (1). The National Institute for Clinical Excellence  describes self harm as "Intentional self poisoning or injury, irrespective of the apparent purpose of the act". A multicentre study of self-harm in England has shown that the largest numbers of self-harm by age groups were 15-19 year-old females and 20-24 year-old males. Approximately 80% of self-harm episodes involved self-poisoning, with overdoses of paracetamol the most frequent method (2). In the UK, the number of poisoning deaths involving paracetamol alone registered as suicide, undetermined or accidental death annually during 2000 - 2008 varied between 90 and 155. There are also considerable numbers of deaths involving paracetamol compounds and paracetamol taken with other drugs (3-5).
It is a complex problem, to understand the desperate situations and circumstances patients face leading them down the path of self-destruction. There are so many factors that have to be addressed, from social to individual determinants. When sober and interviewed, many of these young patients frequently expressed regrets. They often committed self-harm out of rashness, solitude or peer pressure, especially under the influence of alcohol. According to published research (6), more than '50% of individuals who engage in self-harm do not have suicidal thoughts at the time'. The most common motivation for self-harm is to cope with distressing personal ordeals or overwhelming emotions, as they seek to feel 'in control' (7). Unfortunately, unintentional deaths have been reported as the methods for self-harm are often similar to those of suicide. Moreover, individuals who self-harm may be at higher risk of further, more severe self-harm and eventually suicide (8).
As a medical student in Australia, I am also aware that this worrying picture is not only confined to the United Kingdom. In 2003-2004, there were 24,087 cases of hospitalised self-harm (115.4 cases per 100,000 people) in Australia (9). Three-quarters of all intentional self-harm cases were aged from 15 to 44 years, and between 1996−97 and 2005−06, the hospitalisation rate for intentional self-harm among young people increased by 43%, from 138 per 100,000 young people to 197 (10). Perhaps it is the easy availability of drugs and alcohol, or perhaps it is our more stressful and hectic lifestyles. Perhaps advertisements and the media also have a part to play in the rising incidences of self-harm and suicidal thoughts. In a study of people engaging in self-harm (aged 18 to 35 years), some participants indicated that ‘outside sources’ such as magazine articles, books and message boards had introduced them to the idea of self-harm (11). 'New' exposures and knowledge can be obtained without proper guidance and under the wrong pressures that normalise or glamorise such detrimental behaviours.
While the media might have perpetuated self-harm to a certain extent, it can also be a powerful tool to shed light on mental health issues and self-harming behaviour. This may in turn prevent an act or encourage people to seek help. For example, the Mind-frame Media and Mental Health (MMMH) project is one of a suite of projects on suicide, mental illness and the media developed as part of the national media strategy. The aim is to build a collaborative relationship with the Australian media and mental health systems to inculcate a more accurate and sensitive portrayal of suicide and mental health issues across all news media in Australia. This is certainly a step in the right direction here.
The issue of self-harm is definitely multifaceted. Individual motives for self-harming behaviour are diverse as the many forms of self-harming behaviours. I have briefly discussed incidences of drug overdose, alcohol abuse and self-injury but there is obviously countless other self-harming behaviour. I have also highlighted the influence of the media, family and social circumstances. Nevertheless, it is not my place to critique policies or to express strong opinions given my limited exposure.
A lack of recognition of mental health problems as a key health issue may result in subsequent failure to offer further adequate services. As illustrated, despite my short elective in the emergency department, I had witness numerous cases of deliberate self harm. Cambridge is well-known to be a vibrant student town, a place for students and academics with high aspirations, the brightest talents and future. However, self-harming behaviour typically commences in adolescence (12), hence it is unsurprisingly prevalent among its student population.
The number of self-harm admissions to emergency departments worldwide is alarming. I postulate that resources invested because of these admissions can be reduced if patients are able to seek help from mental health services earlier or if public education is more widespread. This is a social problem that has to be addressed by global communities and governments.
Nevertheless, I had the most incredible time in the United Kingdom. I had spent more than 50 hours on planes, 20 hours on trains and travelled between 3 continents! I also witnessed the first snowfall in London this year and most importantly, I met many great people who have now become close friends. These memories are definitely unforgettable and only possible because of the opportunity to undertake my elective in Cambridge. As I have pen down these thoughts, I would like to take this opportunity to thank the staff and friends who have made my time as an elective student at Addenbrooke's Hospital as memorable as it was.
Fig 2: Addenbrooke's Hospital
1) Horrocks, J, House, A. Self Poisoning and Self Injury in Adults, Clinical Medicine, 2 (6), 509-512 (2002) http://www.ingentaconnect.com/content/rcop/cm/2002/00000002/00000006/art...
2) Hawton, K., Bergen, H., Casey, D., Simkin, S., Palmer, B., Cooper, J., Kapur, N., Horrocks, J., House, A., Lilley, R., Noble, R. & Owens, D. (2007). Self-harm in England: a tale of three cities. Multicentre study of self-harm. Social Psychiatry and Psychiatric Epidemiology 42, 513-521.doi:10.1007/s00127-007-0199-7
3) Office for National Statistics: Deaths related to drug poisoning: England and Wales, 1993-2005. Health Stat Q 2007, 33:82-88. http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--33--sp...
4) Office for National Statistics: Deaths related to drug poisoning in England and Wales, 2003-07. Health Stat Q 2008, 39:82-88. http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--39--au...
5) Wells C: Deaths related to drug poisoning in England and Wales, 2008. Health Stat Q 2009, 43:48-55. http://www.ons.gov.uk/ons/rel/hsq/health-statistics-quarterly/no--43--au...
6) Hawton, K., Bergen, H., Simkin, S., Arensman, E., Corcoran, P., Cooper, J., et al. (2011). Impact of different pack sizes of paracetamol in the United Kingdom and Ireland on intentional overdoses: a comparative study. BMC Public Health, 11, 460. doi:10.1186/1471-2458-11-460
7) Stanley, B., Gameroff, M., Michalsen, V & Mann, J. (2001). Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, Vol. 158, Iss. 3, pp. 427-432. doi:10.1176/appi.ajp.158.3.427
8) Farrand, J. & Solomon, Y. (1996). ‘Why don’t you do it properly? Young women who self-injure. Journal of Adolescence, Vol. 19, No. 2, pp. 111-119.doi:/10.1006/jado.1996.0011
9) Conner, K., Langley, J., Tomaszewski, K. & Conwell, Y. (2003). Injury hospitalisation and risks for subsequent self-injury and suicide: A national study from New Zealand. American Journal of Public Health, Vol. 93, pp. 1128-1131. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447921/?tool=pubmed
10) Auseinet. (2007). Australian Self-harm Statistics: Key Findings. Adelaide: Australian Network for Promotion, Prevention and Early Intervention for Mental Health. http://www.frsa.org.au/UserFiles/file/Virtual%20Library%20Collection/sel...
11) Eldridge, D. (2008). Injury among young Australians. AIWH bulletin series no. 60. Cat. no. AUS 102. Canberra: AIWH. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442452801
12) Hodgson, S. (2004). Cutting through the silence: A sociological construction of self-injury. Sociological Inquiry, Vol. 74, No. 2, pp. 162-179. doi:10.1111/j.1475-682X.2004.00085.x