Over 50 per cent are judged to need psychiatric and/or social work follow-up as outpatients, but a high proportion fail to keep follow-up appointments. From

10 to 20 per cent of cases are judged to need psychiatric hospital admission because of psychiatric illness and/or continuing suicidal intentions.

Acute dilemmas may arise in the general hospital when self-harm patients are brought in but refuse medical treatments such as stomach washout or suture of lacerations. The Mental Health Act 1983 does not cover administration of medical treatment (as opposed to psychiatric treatment) against the patient's will; however, in a life-threatening emergency, it is permitted to give this under common law. The chosen course of action should be justified in the case notes, and full explanations to patients and/or relatives given.

Repeated DSH is a frequent feature of borderline personality disorder; every hospital or community mental health team will have a small number of regular attenders with the presentation. Often, the behaviour worsens if the patient is repeatedly admitted to hospital. Sometimes, management by behavioural means is appropriate; for example, patients sign a contract that if they self-harm they will be admitted to the hospital overnight and discharged the next day.

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