Suicide

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Suicide
Suicidal behavior / parasuicide
Self injury
Risky behavior
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Self-Injurious Behavior

• Self-injury (also known as self-harm,
  self-mutilation, self-abuse and self-inflicted
  violence) is a compulsion or impulse to inflict
  physical wounds on one's own body, motivated by
  a need to cope with unbearable psychological
  distress or regain a sense of emotional balance.
  The act is usually carried out without suicidal,
  sexual or decorative intent. 
• (Sutton Others, 2000)
•  

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SIB Spectrum

• Supefcial injuries
• Cutting, hair pulling
• Self burning, severe
  head banging
• 
  Autoenoculation, autocasration,
  autosurgery

mild
severe
Severe gender identity disorders Dissociative
disorders Psychotic states
Mental rtardation Autism Congenital syndroms
Personality disorders Eating disorders Interperson
al context
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Epidemiology of SIB

• Prevalence
• 1600 general population,
• 400-1400100,000
• 40.5 of laxative-abusing bulimics
• 14 of mentally retarded
• Gender differences uncertain, appears to be more
  prevalent in women.

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Neurobiology of SIB

• Animal models
• Dopamin activation L-DOPA induces SIB via
  activation 0f D1 receptor. Selective D1
  antagonists reduce autoagression
• Opioids activation sufentanil induced
  autoagression.
• Serotonin depletion p-chlorophenilalanine
  increases agression and autoagressin

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Neurobiology of SIB

• Human studies
• Lesch-Nyhan Syndrom decreased level of dopamine
  and thyrosine hysroxolase in atopsied brains.
• Cornelia-De-Lange Syndrom Depressed Blood
  serotonin.
• Suicide attempters decreased CSF 5-HIAA, reduced
  prolactin response to fenfluramine.
• Opioid dysregulation increased plasma enkephalin
  in SIB patients, incread CSF endorphins in SIB
  autistics.

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Different Meanings of SIB

• Expression of intense emotions.
• Impulse, self regulation, self control.
• Distraction from psychic pain.
• Self (or others) punishment, atornmement.
• Feeling , excitement.
• Reenactment of trauma.
• A cry for help.
• Psycholgical or secondary gains.

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Regulation ()
altriosm
fatalism
Integration (-)
Integration ()
egiosm
anomia
Regulation (-)
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Facing the facts

• Suicide is considered to be the second leading
  cause of death among college students.
• Suicide is the second leading cause of death for
  people aged 24-34.
• Suicide is the third leading cause of death for
  people aged 10-24.
• Suicide is the fourth leading cause of death for
  adults between the ages of 18 and 65.
• Suicide is highest in white males over 85.
• (48.42/100,000, 2004)

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Risk factors
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Protective factors

• Children in the home, (except postpartum
  psychosis)
• Pregnancy
• Deterrent religious beliefs
• Life satisfaction
• Reality testing ability
• Positive coping skills
• Positive social support
• Positive therapeutic relationship

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High Risk Strategies
While 90 of suicide are considered to be due to
mental disorders, about half have never been in
contact with MH services1 Suicide risk is
extremely high immediately after discharge from a
psychiatric hospital, and for the first year
after deliberate self harm. In these groups, it
takes 385 / 500 cases to treat in order to
prevent one suicide. Major changes in suicide
rates are most likely to result from population
strategies rather then high-risk
strategies Effective interventions for
deliberate self - harm patients are probably the
best high-risk strategies
1 Vassilas Morgan, BMJ 1993 2 Lewis, Hawton
Jones, BJPsy 1997
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Disorders Correlated With Suicidal Behavior
Developed by the Suicide Risk Advisory Committee
of the Risk Management Foundation of the Harvard
Medical Institutions in 1996.

• Mood Disorders (15 percent lifetime risk of
  suicide)
• The absence of psychosis does not imply safety.
• A misleading reduction of anxious or depressed
  affect can occur in some patients who have
  resolved their ambivalence by deciding to commit
  suicide.
• The likelihood of suicide within 1 year is
  increased when the patient exhibits Panic
  attacks, Psychic anxiety, Anhedonia, Alcohol
  abuse .
• The likelihood of suicide during the ensuing 1-5
  years is increased when the patient exhibits
  Increased hopelessness, Suicidal ideation,
  History of suicide attempts.

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Disorders Correlated With Suicidal Behavior

• Panic Disorder (7-15 percent lifetime risk of
  suicide)
• Suicide rate may be similar to that of mood
  disorders
• Greater likelihood is correlated with more severe
  illness or comorbidity
• Suicide does not necessarily occur during a panic
  attack
• Demoralization or significant loss increase the
  likelihood of suicide
• Agitation may increase the likelihood of
  translating impulses into action

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Disorders Correlated With Suicidal Behavior

• Schizophrenia (10 percent lifetime risk of
  suicide)
• Suicide is relatively uncommon during psychotic
  episodes
• The relationship between command hallucinations
  and actual suicide is not clearly causal
• Suicidal ideation occurs in 60-80 percent of
  patients
• Suicide attempts occur in 30-55 percent of
  patients
• Suicide potential is increased by
• Good premorbid functioning
• Early phase of illness
• Hopelessness or depression
• Recognition of deterioration, e.g., during a
  post-psychotic depressed phase

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Disorders Correlated With Suicidal Behavior

• Alcoholism (3 percent lifetime risk of suicide)
• Abusers of alcohol/drugs comprise 15-25 percent
  of suicides
• Alcohol is associated with nearly 50 percent of
  all suicides
• Increased suicide potential in an alcoholic
  patient correlates with
• Active substance abuse
• Adolescence
• Second or third decades of illness
• Comorbid psychiatric illness
• Recent or anticipated interpersonal loss
• Substance abuse can represent self treatment to
  blunt the anxiety or mood disturbance associated
  with a masked, comorbid psychiatric disorder

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Disorders Correlated With Suicidal Behavior

• Borderline Personality Disorder (7 lifetime
  risk of suicide)
• Much higher risk associated with comorbidity,
  especially with mood disorder and substance abuse
  
• Psychopathology associated with increased risk
• Impulsivity, hopelessness/despair
• Antisocial features (with dishonesty)
• Interpersonal aloofness ("malignant narcissism")
• Self-mutilating tendencies
• Psychosis with bizarre suicide attempts
• Psychopathology associated with diminished risk
• Infantile personality (with hysterical features)
• Masochistic personality

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The Neurobiology of suicide risk

• Suicidal behavior has neurobiological
  determinants independent of the psychiatric
  illness with which it is associated.
• Vulnerability to act on suicide impulses results
  from the interaction between triggers or
  precipitants and the threshold for suicidal
  behavior
• Studies found decreased serotonin activity in the
  prefrontal cerebral cortex of suicide victims.

J.J. Mann, 1999
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Familial Transmission of Suicidality

• Risk factor for suicide is transmitted in
  families independently of transmission of major
  depression or psychosis, but not independently of
  impulsive aggression.

Brent DA et al, Arch J Psych 19961145-1152
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Areas to Evaluate in Suicide Assessment
Adapted from APA guidelines, part A, p. 4
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The Detection of Suicidality

• The assessment of suicidality is an active
  process during which clinicians evaluate
• Suicidal intent and lethality
• Dynamic meanings and motivation for suicide
• Presence of a suicidal plan
• Presence of overt suicidal/self-destructive
  behavior
• The patient's physiological, cognitive, and
  affective states
• The patient's coping potential
• The patient's epidemiological risk factors

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The Detection of Suicidality

• Suicide-specific questions
• Are suicidal thoughts/feelings present?
• What form does the patient's wish for suicide
  take?
• What does suicide mean to the patient?
• Has the patient lost or anticipates losing an
  essential sustaining relationship?
• Has the patient lost or anticipates losing
  his/her main reason for living?
• How far has the suicide planning process
  proceeded?
• Have suicidal behaviors occurred in the past?
• Has the patient engaged in self-mutilating
  behaviors?
• Does the patient's mental state increase the
  potential for suicide?

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The Detection of Suicidality (cont.)

• Are depression and/or despair present?
• Does the patient's physiologic state increase the
  potential for suicide?
• Is the patient vulnerable to painful affects such
  as aloneness, self-contempt, murderous rage,
  shame, or panic?
• Are there recent stresses in the patient's life?
• What are the patient's capacities for
  self-regulation?
• Is the patient able/competent to participate in
  treatment?
• Loss of coping mechanism? 
• Are epidemiological risk factors present? 

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Treatment Planning

• Treatment planning takes into account
• The patient's potential for suicide,
• Capacity to form a treatment alliance,
• Range of available treatment alternatives from
  outpatient follow-up to hospitalization with
  constant observation.

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Treatment Planning (cont.)

• Collect Data Before Treatment Planning
• Identify a Range of Treatment Alternatives Weigh
  the risks and benefits of each alternative,
  including the alternative "no treatment."
• Involve the Patient and Family in the Treatment
  Planning Process to the Degree Possible
• Consider pharmacotherapy.

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Treatment Planning (cont.)

• Contracts Will Not Guarantee the Patient's Safety
• contracts can give staff a false sense of
  security and interfere with a thorough suicide
  assessment.
• Choose Appropriate Levels of Observation,
  Supervision, and Privileges.
• The treatment team may decide to tolerate short
  term risk to foster long-term growth.
• Documentation should make clear the choices and
  rationale.
• Assess the risk of continued hospitalization