Suicide Risk Assessment OSCE - Self-Harm without Suicidal Intent

Diagnosis: Self-Harm without Suicidal Intent

Case Overview

  • Age/Sex: 16-year-old female
  • Occupation: High school student (Year 11)
  • Setting: Emergency department / School nurse referral
  • Chief complaint: "Thoughts of self-harm"

Patient Script

Who I Am

I'm 16, I go to high school, and I'm kind of embarrassed to be here — I don’t usually tell people this stuff.

What Brings Me In

I’ve been having thoughts about hurting myself and I cut myself a few times — I thought I should get checked.

My Story

It started about 6 months ago when I had a lot of stress at school and some fights at home. I first scratched my forearm with a razor blade and it made me feel a bit calmer. Since then I’ve been doing it more often — maybe once or twice a week lately, and it got worse after a break-up last month. The most recent time was 3 days ago; it was a small cut on my left forearm and I cleaned it myself. I don’t want to die — I just want the feeling to stop when I’m overwhelmed. I usually cut with a razor blade or occasionally use a sharp piece of metal I found. I hide the scars with long sleeves. I’ve told no one except once I hinted to a friend, but they kind of brushed it off.

My Medical Background

  • Past medical history: none significant; had an ankle sprain playing netball last year (red herring)
  • Medications: combined oral contraceptive pill (for contraception) — started 9 months ago
  • Allergies: none known
  • Mental health: no previous psychiatric admissions; no prior suicide attempts needing hospital treatment
  • Social: lives with mum and younger sister; dad works away most weeks; recently broke up with boyfriend (red herring)
  • Substance use: drinks alcohol rarely at parties (1–2 drinks), smokes cannabis occasionally (about once a week) — I don’t use it to overdose, just to chill (red herring)
  • Family history: mum has anxiety; no family history of suicide

What I Think & Worry About

  • I’m worried you’ll tell my mum and she’ll freak out and make me stop sports or ground me.
  • I don’t want to be locked up in hospital; I’d rather get some help and keep living normally.
  • I’m scared I’ll mess up my exams if this keeps happening.

If You Ask Me About Other Symptoms...

  • Mood: I feel down a lot, more tired and less interested in the things I used to like.
  • Sleep: I sleep okay most nights but wake up early sometimes.
  • Appetite: about the same; I haven’t lost much weight.
  • Suicidal thoughts: I sometimes think, "I wish I could just disappear" but I don’t plan or want to kill myself.
  • Hallucinations: no, I don’t hear voices.
  • Impulsivity: I can act on impulse when I’m really upset.
  • Access to means: I keep a razor blade in a tin in my room.
  • School: grades slipping a bit; teachers think I’m distracted (red herring — may be related)

Clinical Summary

Examination

  • General: Alert, cooperative but reluctant; appears slightly guarded
  • Vitals: HR 86 bpm, BP 110/68 mmHg, RR 14/min, Temp 36.6°C, SpO2 99% on room air
  • BMI: 21 kg/m2
  • Skin: multiple linear superficial scars on volar aspects of both forearms (approximately 10–12 scars, 0.5–4 cm), varying stages of healing; one recent superficial 0.5 cm shallow laceration on left forearm with minimal crusting, no active bleeding, no surrounding erythema or discharge
  • HEENT/Neck/Chest/Abdomen: unremarkable
  • Neurological: grossly normal
  • Mental state: mood described as "down"; affect restricted; thought content: denies current suicidal intent or plan, expresses strong urge to self-harm to relieve distress; denies psychotic symptoms; insight limited but acknowledges harm is a way of coping
  • Risk assessment impression: moderate risk for ongoing non-suicidal self-injury due to frequency, access to blades, ongoing stressors; no immediate evidence of imminent suicidal intent or plan

Investigations

  • Urine pregnancy test: negative (no pregnancy)
  • Urine drug screen: THC positive (recent cannabis use)
  • FBC: Hb 13.2 g/dL, WBC 6.5 x10^9/L, Platelets 250 x10^9/L (no anaemia or infection)
  • CRP: 1 mg/L (not elevated)
  • LFTs, Urea & Electrolytes: within reference ranges (no metabolic disturbance)
  • Wound swab: not indicated unless signs of infection (none present)
  • ECG: sinus rhythm 78 bpm, no abnormalities (baseline safe if considering SSRI later)

Diagnosis

  • Primary diagnosis: Non-suicidal self-injury (self-harm without suicidal intent)

    • Evidence: repeated deliberate superficial cutting over 6 months, used to regulate distress, patient explicitly denies intent to die, wounds superficial, no prior serious suicide attempts.

  • Differentials:

    • Major depressive disorder — possible given low mood, reduced interest, sleep disturbance, but current history emphasises self-harm as emotion regulation rather than intent to die; screen for severity and duration.
    • Borderline personality traits/emerging personality disorder — repeated self-harm and impulsivity could represent traits, but patient is an adolescent; must be cautious diagnosing personality disorder at this age.
    • Adjustment disorder with disturbance of conduct/emotion — temporal association with stressors (school, breakup) could fit if symptoms are time-limited.
    • Substance-related mood symptoms — cannabis use may influence mood/impulsivity but is unlikely the sole cause.

Management

  • Immediate:
    • Provide first-aid/wound care for recent superficial laceration; clean and dress; give tetanus status check if required.
    • Conduct a thorough, documented risk assessment focusing on current suicidal intent, plans, means, and protective factors.
    • Remove immediate access to implements (discuss voluntary removal of razor blades; involve family if patient agrees or if safety requires).
  • Communication and safeguarding:
    • Explain confidentiality and limits (if there is significant risk to life, confidentiality may be broken); discuss involving mother while respecting adolescent autonomy where possible.
    • Notify parents/caregivers of concerns unless there is a compelling reason not to; arrange a meeting with patient present to agree a plan.
  • Mental health referral and follow-up:
    • Urgent referral to Child and Adolescent Mental Health Services (CAMHS) / adolescent psychiatry for assessment and engagement within 24–72 hours.
    • Safety plan written with the patient (identifying triggers, coping strategies, emergency contacts, steps to take if urges escalate).
    • Arrange follow-up within 1 week in community mental health or with school counsellor; provide crisis line numbers and emergency instructions.
  • Psychosocial interventions:
    • Recommend evidence-based psychological therapy for self-harm in adolescents (e.g., skills-based approaches such as DBT-informed therapy or CBT tailored for adolescents), family therapy where appropriate.
  • Pharmacotherapy:
    • Not first-line for NSSI alone. If moderate–severe depression is diagnosed, consider SSRI after psychiatric assessment with appropriate monitoring for suicidality.
  • Documentation and liaison:
    • Document findings, capacity discussion, and plan; liaise with school nurse/counsellor and GP for longitudinal care.
  • Safety admission criteria:
    • Consider inpatient admission if there is imminent risk (active suicidal plan, high lethality means, severe psychiatric comorbidity) — not indicated currently but threshold must remain low.

Key Learning Points

  • Ask directly about self-harm and suicidal intent — adolescents may differentiate self-harm as a coping mechanism from an intention to die.
  • Assess risk comprehensively (intent, plan, means, frequency, psychiatric comorbidity, substance use) and balance adolescent confidentiality with safeguarding responsibilities.
  • Management focuses on safety planning, removing means, wound care, rapid liaison with adolescent mental health services, and evidence-based psychological interventions rather than immediate medication for NSSI alone.

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