Underwriting Implications of Intentional Self-Harm
“Today, there is, across the world, a sharp public awareness of self-harm as a major mental health issue.”
Sander L. Gilman, PhD
Emory University Medical School
Journal of Mental and Nervous Disease
“Self-harm is a common clinical problem but is poorly understood and arouses ambivalent feelings in health professionals.”
Keren Skegg, MD
University of Otaga Medical School, New Zealand
What is deliberate self-harm (DHS)?
As is so often the case in psychiatric terminology, this gets a bit confusing.
There are 3 terms used by psychiatrists in this context: [Andover]
- Deliberate self-harm
- Non-fatal self-injury
- Non-suicidal self-injury
“Non-suicidal self-injury” (NSII) excludes all acts known or strongly suspected to be suicide attempts.
“Non-fatal self-injury” (NFSI) and “deliberate self harm” (DSH) include all purposeful self-injuries, regardless of intent. Indeed, some cases will be referred to as suicidal gestures (para-suicides) or suicide attempts.
Because suicide gestures and attempts are relatively more ominous from an underwriting perspective, we will use yet another term – intentional self-harm (ISH) – to encompass all acts of deliberate self-harm except overt suicide gestures and attempts.
And we will also examine the links between ISH, overt suicidal gestures/attempts and completed suicides.
Is intentional self-harm included in the new DSM-5 (Diagnostic and Statistical Manual, 5th edition) as a formal diagnostic entity?
The draft version did include a self-harm disorder category with criteria to make the diagnosis. [Gilman] However, when DSM-5 was published (May 2013), self-harm per se was not included as a formal diagnosis and only minor mention was made of it under “other conditions that may be a focus of clinical attention” (which translates as: potential diagnostic entities for future consideration).
There are 2 formal diagnoses in DSM-V that involve quite specific forms of intentional self-harm in DSM-V:
- Trichotillomania (compulsive pulling of one’s own hair)
- Excoriation disorder (compulsive skin picking and hopefully one’s own as well!)
What are the more prevalent forms of ISH?
The 2 most common are self-poisoning, almost always with medicinal products and self-cutting. [Bethell, Hawton]
Others include burning, scratching, gouging, carving words or symbols into skin, self-hitting, hair pulling, stopping medication to cause self-harm and deliberate recklessness.[Skegg]
How many episodes of intentional self-harm present for medical care annually?
650,000 cases in the United States…and no doubt the substantial majority of episodes do not lead to care seeking by the self-harming subject. [Cooper]
Self-harm is far more common than most of us realize.
The prevalences in UK and Hong Kong adolescents were 16.5% and 23.5%, respectively. [Law, Lereya]
At what ages is self-harm most common?
The most common age for first episode is 16 years old and the overall risk is several-fold higher at ages 18-30 vs. older ages.
However, self-harm occurs at all ages and when it first appears over age 50, the risk of suicide is higher than at younger ages.[O’Connor, Skegg]
What are RED FLAGS for intentional self-harm?
- Prior episode is highly predictive of recurring events
- Risk-taking behaviors including heavy smoking
- History of childhood sexual or physical abuse
- Prior suicidal ideation
- Substance abuse of all types
- Multiple episodes of major depression or bipolar disorder, especially with anhedonia or hopelessness as prominent features
- Post-partum depression is a particularly common depression context for ISH.
- Conduct, oppositional defiant and ADHD diagnoses in children and adolescents
- High level of anger as a response to life events
- Being bullied in childhood
- Longstanding or frequently-recurring benzodiazepine use
- Chronic severe insomnia and frequent nightmares
- Social isolation
[Andover, Challis, Healey, Lereya, Moller, Shih, Singareddy, Wisner, Wu]
Where are we most likely to find undisclosed histories of intentional self-harm?
Emergency care visits for reasons like cuts, “accidental” poisoning, repeat episodes of injury/accident, etc. [Kuehl, Laukkanen]
In a London study, 48% of patients seen for penetrating neck wounds sustained the injury due to self-harm. [Siau]
Patients seeking emergency care for self-harm who are admitted as inpatients have a high risk of using more lethal attempts as well as a prior diagnosis of a major psychiatric disorder. [Olfson]
Applicants with RED FLAG risk factors who go to the emergency department for these reasons should be underwritten carefully, in many cases with emergency care records.
Are repeat visits due to self-harm common?
In one study, 18% had a second episode of emergency care for this reason within 12 months of the first event. Over 7 years, 53% had two or more self-harm events needing immediate intervention. [Hawton]
In another investigation, 24.6% had a second visit in the near-term future. [Bilen]
Do most patients seeking emergency care for ISH have a subsequent psychiatric assessment?
In a large US study, roughly 50% were referred on for such assessments. [Olfson]
When is self-cutting strongly associated with major psychiatric illness?
When it involves sites other than the arm [Laukkanen]
Are nonsuicidal self-harm episodes predictive of future suicidal ideation, attempts and completed suicides?
Experts believe that self-harm is actually an early manifestation of suicidality that often progresses to these other stages. [Brausch, Cox]
At least 40% of suicide completers have a prior history of self-harm. [Nandi]
Whitlock reported that intentional self-harm increased the likelihood of a subsequent suicide attempt 3-fold.
In an earlier study, Whitlock and Knox showed that the likelihood of suicide plans and gestures increased 6-fold and 7-fold respectively in patients treated initially for nonsuicidal self-harm episodes.
Over 20 years of followup, subjects with just a single episode of intentional self-harm had a 4-fold higher risk of suicide when compared to persons with no self-injury history. [Jenkins]
In another study, 5% of self-harm patients committed suicide within 9 years. [Owens]
The highest risk interval from intentional self-harm to suicide is within 12 months of seeking emergency care. [Cooper]
Is the suicide risk in self-harmers mainly due to comorbid psychiatric disorders?
No – the risk is independent of that conferred by mental illness. [Guan, Madsen]
A new study showed that intentional self-harm doubled the risk of suicide in patients with affective (mood) disorders. [Nordentoft]
Therefore, in someone with a psychiatric condition at substantially heightened risk of suicide, episodes of intentional self-harm significantly increase the probability of suicide.
What are the RED FLAGS for suicide in persons with a history of intentional self-harm?
- Past or current major psychiatric illness
- Medically severe self-injuries
- Self-harm events using methods similar to those used in suicide attempts
- Self-harm by partial asphyxiation
- Premeditated vs. spontaneous self-injuries
- Traffic-related intentional self-harm
- Denying at the time of emergency care that an obvious self-injury was intentional
- Clues to current/recent substance abuse in the medical history, driving record, on lab tests, etc.
- Poor physical health, mainly at older ages
- Legal problems
- Living alone with social isolation
[Bergen and Hawton, Cooper, Chen, Harriss, Miller, Silverman, Skegg]
Is there any extra mortality risk in intentional self-harm?
Studies have reported that persons with a self-harm history had 2-fold greater all-cause mortality. [Carter, Hawton and Harriss, Neeleman]
Bergen assessed 30,950 individuals who presented at one of 6 hospitals with intentional self-injuries and were followed for a median interval of 6 years thereafter.
- 6% died over this interval
- Mean age at death was 49.6 years old in males and 54.3 in women.
- 1 in 3 deaths were due to accidents and suicides.
- Deaths in this population due to both natural and unnatural causes were greater than expected.
What are the 6 take-home messages for underwriters?
- Intentional self-harm is common
- Most cases are not detected during the underwriting process; nondisclosure and vague histories assumed to be due to accidents are the likely drivers of this low rate of case recognition during the risk appraisal process.
- Intentional self-harm is a marker for a high risk of psychiatric illness.
- Intentional self-harm is a major risk factor for suicidal ideation, suicidal gestures and attempts, and completed suicides.
- Intentional self-harm is associated with significant excess mortality and morbidity.
- Underwriters need to be alert to the RED FLAGS and other clues to intentional self-harm, as well as to the increased suicide risk in persons with a history of self-harm.
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