Self-Harm in a Vulnerable Patient

Author: Mars Christian Aragon Sta Ines / Editor: Sarah Edwards / Codes: MHP2, MHP4, PC4, SLO1 / Published: 07/07/2025

A 23-year-old male is brought in by the ambulance after being found by the police in a park, anxious, agitated, and dishevelled. The police witnessed the patient self-inflicting lacerations to both forearms.

The patient’s medical history includes autism ADHD and previous episodes of self-harm. He is not currently engaged with the community mental health services and admits to poor medication adherence. On arrival, he is compliant with the healthcare staff. He further informs the Emergency Medicine (ED) doctor (myself) that there are two creatures instructing him to kill himself and they will leave him alone if he listens.

Past Medical History:

• ADHD
• Autistic spectrum disorder
• Learning difficulties
• Paracetamol intentional overdose
• Suicidal hallucinations (not formal diagnosis from the mental health team)
• Migraine with aura
• Depressed mood
• NAFLD

Family History

• Generalized anxiety disorder, mother

Social History

• Non-smoker
• Social alcohol consumption
• Older brother and mother – primary caregiver

Allergies

• None

Medications (Non-compliant)

• Lisdexamfetamine 50 mg/tab OD
• Melatonin 6mg OD at night
• Sumatriptan 50mg tablets PRN OD
• Naproxen 500mg tablets BD PRN

Examination

• A- patient is talking
• B- RR 19 O2 sats 99% on room air
  symmetric chest expansion, normal breath sounds
• C- BP 120/80 HR 103 normal heart sounds
  abdomen soft and non-tender; full and equal pulses
  capillary refill time <2 seconds
• D- GCS 15, normal neurological examination, PEARL 2–3 mm BMs 7
• E- Temperature 36.5°C, no skin changes or rashes, noted two superficial 2×1 cm laceration wounds on both of his anterior forearm, not actively bleeding and dressed

Two hours after the history and physical examination, the patient starts shouting, pacing and threatening to harm staff when approached. Despite de-escalation attempts, he refuses to engage in a conversation as the creature is telling him that the doctor (myself) will get him detained in a mental hospital. His agitation further escalates, and he throws a chair across the room.

The clinical team determines that immediate intervention is required to ensure the safety of the patient and others.