> we are plagued by a frequent attender.....34 times in the last 10 
> weeks.  She is a self-harmer and presents with the whole variety of 
> self-harm activities, plus many other complaints - some spurious, some 
> not spurious.
> 
> Is there anyone out there who can give us any idea how to handle this?
> 
> Is there anyone who has a special interest in this problem?
> 
> Please e-mail me privately if you wish, so the list is not cluttered.


I find these quite interesting and challenging patients. I suspect every department has their 
fair share of them. They are often not of interest to psychiatrists, who tell you that they 
have a personality disorder and cannot be treated. They tend to have manipulative, 
attention-seeking personalities and seem to thrive on the disruption and irritation that they 
cause, although the act is often based on a background of perceived desperation. It is 
important to recognise that the self-harmer feels better mentally (although only briefly) after 
injuring themselves and that they feel pain from subsequent wounds just like anyone else.

We have a nearby but off-site challenging adults unit, and we were plagued by three patients 
who were undergoing treatment there, but who seemed to be competing with each other in the 
amount of havoc they could cause. One would self-harm, or place something like bits of 
broken glass in her vagina, and then go and tell a psychiatric nurse what she had done. The 
nurse would ring the psychiatric SHO who would say that he didn't know what to do, so "take 
the patient to casualty". This meant two nurses would have to escort the patient, leaving the 
unit understaffed. Because of the exasperation of A&E staff at one of these reappearing, they 
all would sit in the waiting room to wait in turn, rather than being moved through a little 
quicker to help the psychiatric nurses. A few hours later one of the others would also 
self-harm in some way and the cycle would repeat.

I called a meeting with the Consultant Psychiatrist responsible for the Unit, and we agreed a 
plan. Rather than the nurse ringing the SHO, the call would be made to A&E and a decision 
made on how quickly the patient needed to be seen and if the incident was not immediately 
life-threatening, the patient would come up at a time convenient to both the A&E staff and the 
psychiatric staff. I thought that this would remove some of the secondary gratification from 
having attention paid immediately to the physical injury caused. I was very aware that this 
was quite a high-risk strategy as they may escalate the injuries to regain the initiative.

To my relief and modest pleasure, the strategy worked superbly, and the incidence of 
attendance at A&E declined swiftly. All three were eventually discharged back into relatively 
sheltered accommodation, and whilst one has reappeared on occasion since, nothing so 
orchestrated has happened.

The point of this would seem to be that one should try and engage these sad people in a sort 
of contract. Minimise medicalisation; do not carefully suture each wound but simply place a 
dressing over it. Sutures will get picked out. Promise that if they can minimise disruption to 
the Unit you will see them quickly and with an understanding attitude; A&E staff often 
become frustrated by these patients, and it is important that they show no sign of this. 
Engage the psychiatrists (behavioural therapy is useful) and the GP.

Best wishes,


Rowley Cottingham

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