Alan Apter M.D Feinberg Child Study Center Schneider Childrens Medical Center suicide.

Alan Apter M.D

Feinberg Child Study Center

Schneider Children’s Medical Center

suicidesuicide

Suicidal Behaviour: a Major Public Health Suicidal Behaviour: a Major Public Health Problem in EuropeProblem in Europe

In many European countries suicide is the leading In many European countries suicide is the leading cause of death among young people – more cause of death among young people – more

common than death from road accidentscommon than death from road accidents

SUICIDESUICIDE

DEFINITIONS EPIDEMIOLOGY AETIOLOGY/RISK FACTORS CLINICAL CONSIDERATIONS

SUICIDESUICIDE

PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION

DEFINITIONSDEFINITIONS

Suicide SpectrumSuicide SpectrumSuicidal ideation "Thoughts of serving as the

agent of one’s own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent"

Suicidal threatsSuicidal gestures "Suicidal behaviors judged

to be “non-serious” in intent or medical lethality"

Suicide SpectrumSuicide SpectrumDeliberate self harm: Willful self-inflicting of

painful, destructive, or injurious acts without intent to die

Suicide attempts: Self-injurious behavior with a

nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended at some level to kill him/her

Suicide SpectrumSuicide Spectrum

Interrupted attempt: The person is interrupted (by an outside circumstance) from starting the self-injurious act

Continuum Theory Of SuicideContinuum Theory Of Suicide

Suicidal Thoughtsleads to

Suicidal ThreatsLeads to

Suicidal GesturesLeads to

Suicide Attemptsleads to

Failed Suicide leads to

Completed Suicide

Discontinuity TheoryDiscontinuity Theory

Suicidal IdeationSuicidal Ideation

Suicidal ThreatsSuicidal Threats

Suicidal GesturesSuicidal Gestures

Suicide AttemptsSuicide Attempts

Serious Suicide AttemptsSerious Suicide Attempts

Suicide attempts

Completedsuicide

Consequences of Suicidal Consequences of Suicidal BehaviorBehavior

School dropoutLeaving homeMotor accidentsPolice arrestWhole spectrum of high risk behavior

EPIDEMIOLOGYEPIDEMIOLOGY

EPIDEMIOLOGYEPIDEMIOLOGY SEX AGE GEOGRAPHY SOCIECONOMIC STATUS ETHNICITY RELIGION COHORT STATUS

EPIDIMIOLOGY OF SUICIDEEPIDIMIOLOGY OF SUICIDE

300% rise in fatal suicide>700% rise in non fatal suicidal behavior10- 30% of adolescents think seriously about suicide

Attempted SuicideAttempted Suicide

Between 100 and 300 per 100,000 Preponderance of females in all countries 50 percent of attempters under 30 Excess of divorced persons

Attempted Suicide RatesAttempted Suicide Rates

Lower social classes overrepresented Depression in 35 to 79 percent of cases Females aged 15 to 19 - highest rates 1 in 100 in this group attempt suicide each

year Highest rate for males is in aged 25 to 29 1 in 200 attempts suicide each year

SuicideSuicide

Suicide rates increase with age Male suicides peak after age 45 Females peak after age 55 Rates of 40 per 100,000 men > 65

SuicideSuicide

Males at all ages commit suicide more often than females

Male: female suicide ratios range from 2:1 to 7:1

Males use more violent methods, like hanging, shooting, and jumping

SuicideSuicide

Females more often overdose or drown Ethnic and minority groups tend to be more

cohesive and have lower suicide rates Rate of suicide among whites is nearly twice

that among nonwhites (in the US)

Figure 1. Suicide (1990-1995) and attempted suicide (1990-1998) rate per 100,000 by gender, Holon Bat-Yam.

0

50

100

150

200

250

1990 1991 1992 1993 1994 1995 1996 1997 1998

Atte

mpt

ed s

uici

deR

ate

per

100

,000

0

5

10

15

20

25

Sui

cide

Rat

e pe

r 10

0,0

00

Attempted Female

Attempted Male

Suicide Male

Suicide Female

0

50

100

150

200

250

300

350

400

450

15-19 20-24 25-29 30-34 35-44 45-54 55-64 65-74 75+

Age groups

Pers

ons

with

a s

uici

de a

ttem

pt

/

100

.000

male

female

Attempted suicide by age and sex – Holon-Bat Yam

Suicide by ageSuicide by age

Data not availablefor 15-19 years

Lower-middle suicide rate4 (United Kingdom) to 7.6 (Bulgaria)

Low suicide rate0.01 (Malta) to 3.8 (Spain)

Suicide rates in the age group 15-19 years in WHO European region

High suicide rate11 (Croatia) to 24 (Kazakstan)

Upper-middle suicide rate8.1(Czech Republic) to 10.8 (Switzerland)

Data not availablefor 15-19 years

Lower-middle suicide rate4 (United Kingdom) to 7.6 (Bulgaria)

Low suicide rate0.01 (Malta) to 3.8 (Spain)

Suicide rates in the age group 15-19 years in WHO European region

High suicide rate11 (Croatia) to 24 (Kazakstan)

Upper-middle suicide rate8.1(Czech Republic) to 10.8 (Switzerland)

Azerbaijan

ArmeniaGeorgia

Turkmenistan

Bulgaria

Greece

YugoslaviaRomania

Albania

HungaryMoldova, Republic Of

Croatia

Austria

Tajikistan

Kyrgyzstan

Uzbekistan

AndorraFrance

Spain

Ukraine

Italy

Israel

Czech Republic

PolandLithuania

Finland

Sweden

Estonia

Russian Federation

Belgium

Netherlands

United Kingdom

GermanyDenmark

Norway

BelarusLatvia

Kazakhstan

Malta

Portugal

Iceland

Ireland

Turkey

SUICIDE IN INDIASUICIDE IN INDIA

Homicide and suicide rates by yearHomicide and suicide rates by year

Source: World Health Statistics Annuals (WHO). Latest available year.Source: World Health Statistics Annuals (WHO). Latest available year.Wasserman, D., Jiang, GX.Wasserman, D., Jiang, GX.

Total suicide rates per 100,000 for 15 year olds and over in European countries Total suicide rates per 100,000 for 15 year olds and over in European countries

0 10 20 30 40 50 60

Lithuania

Russian Federation

Belarus

Latvia

Kazakstan

Estonia

Hungary

Ukraine

Slovenia

Finland

Switzerland

Croatia

Belgium

Republic of Moldavia

France

Luxembourg

Austria

Bulgaria

Denmark

Czech Republic

Poland

Germany

Slovak Republic

Sweden

Kyrgyzstan

Romania

Norway

Ireland

Iceland

Netherlands

Macedonia

Uzbekistan

Spain

Turkmenistan

Italy

United Kingdom

Israel

Portugal

Tajikistan

Malta

Georgia

Greece

Albania

Armenia

Azerbaijan

Rate per 100 000

Change in percentage of suicide rates for males aged 15 years and over in European Change in percentage of suicide rates for males aged 15 years and over in European countries between 1989-90 and 1995-96. countries between 1989-90 and 1995-96.

Source: World Health Statistics Annuals (WHO). Latest available year.Source: World Health Statistics Annuals (WHO). Latest available year.Wasserman, D., Jiang, GX.Wasserman, D., Jiang, GX.

-40% -20% 0% 20% 40% 60% 80%

Lithuania

Belarus

Latvia

Estonia

Russian Federation

Ukraine

Ireland

Romania

Republic of Moldova

Bulgaria

Poland

Italy

Spain

Netherlands

Greece

France

Austria

Croatia

United Kingdom

Albania

Slovenia

Luxembourg

Iceland

Germany

Portugal

Czech Republic

Finland

Israel

Sweden

Hungary

Norway

Denmark

Malta

EPIDEMIOLOGYEPIDEMIOLOGY

ELDERLY COMMIT/YOUNG ATTEMPT PROTESTANTS>CATHOLICS> JEWS>MUSLIMS POOR ATTEMPT/RICH COMMIT BLACKS<WHITES HISPANICS AND S.EUROPEANS ATEMPT

AETIOLOGY/RISK FACTORSAETIOLOGY/RISK FACTORS

AETIOLOGY/RISK FACTORSAETIOLOGY/RISK FACTORS

PSYCHIATRIC ILLNESSALCAHOLISM & SUBSTANCE ABUSEPHYSICAL AND SEXUAL ABUSEFAMILY AND GENETICS

Risk Factors (ii)Risk Factors (ii)

CONTAGION AVAILABILITY OF MEANS PERSONALITY FACTORS BIOLOGY

PSYCHIATRIC ILLNESSPSYCHIATRIC ILLNESS

DEPRESSION SCHIZOPHRENIA ANXIETY DISORDERS DISSOCIATIVE DISORDERS

PSYCHIATRIC ILLNESSPSYCHIATRIC ILLNESS

CONDUCT DISORDER ANOREXIA NERVOSA BULIMIA NERVOSA PERSONALITY DISORDERS

Risk factors for youth suicideRisk factors for youth suicide

Psychiatric disorder/Affective disorder Personality disorder- especially BPD Psychiatric illnesses – dangerous when

more than one illness is present

Four co-morbid constellationsFour co-morbid constellations

The combination of schizophrenia, depression and substance abuse

Substance abuse, conduct disorder and depression

Affective disorder, eating disorder and anxiety disorders

Affective disorder, personality disorder and dissociate disorder

ALCAHOLISM & SUBSTANCE ABUSEALCAHOLISM & SUBSTANCE ABUSE

SELF MEDICATION INCREASES IMPULSIVITY AFFFECTS JUDGEMENT EXACERBATES DEPRESSION PROVIDES COURAGE

Personality FactorsPersonality Factors

Adolescents committing suicide while doing their military service in the IDF

Clinical work on an adolescent psychiatric inpatient unit

Work in the ER

Three sets of personality Three sets of personality constellationsconstellations

Narcissism , perfectionism and the inability to tolerate failure

Impulsive and aggressive characteristics combined with over sensitivity

Hopelessness often related to underlying depression

The narcissistic perfectionist The narcissistic perfectionist constellation (case 1)constellation (case 1)

David told us that since age 8 he had been concerned by thoughts of death.

At 11 he told his friends that he would kill

himself on the day of his Bar-Mitzvah. A week before the event he wrote an elaborate suicide note addressed to his parents in which he stated that he did not believe in the hereafter and that he would just “cease to exist”.

ContdContd

Despite being popular at school it soon became clear that David had no intimate friendships.

After one year of therapy and extensive psychological testing and observation no axis I diagnosis could be made.

Case 2Case 2 Jonathan was a 20 year old officer when he

killed himself. His family was achievement oriented and had high moral standards. Their ideals stressed controlling one’s emotions and living up to high standards.

Jonathan was a natural leader and popular with his teachers and peers. In the army he excelled and was selected as an instructor for new recruits. His superior commended him for his ability to perform under stress.

Case 2Case 2

He became totally involved in his new duties.

His platoon of trainees did rather well, although their overall performance rating was only average.

Following the course ceremony Jonathan went to his room and shot himself.

Features of psychological Features of psychological post mortem soldierspost mortem soldiers

Strong narcissistic and perfectionist patterns

Schizoid traits in personalityThe will to prove their worthHigh self – expectations and hopesTermed by being private/isolated people

THESE FEATURES ARE OFTEN COMPLICATED BY STRONG ISOLATIVE TRAITS

Distribution Of Axis II Diagnoses Within

Complete Suicide Group

2%paranoid9%

deferred5%borderline

23%narcissistic

5%anti-social

7%avoidant

5%dependant

5%histrionic

2%compulsive

37% schizoid

Case featuresCase features

No turning for help or support

“Better death than shame”

Minor setbacks spiral into

disaster

THE IMPULSIVE AGGRESSIVE THE IMPULSIVE AGGRESSIVE CONSTELLATIONCONSTELLATION

Case material – case 1Case material – case 1

Deborah had always been impulsive and oppositional from an early age.

At about the age of 11 she developed anorexia nervosa probably as a result of her being an accomplished dancer in a ballet troop.

With the onset of adolescence she developed very severe bulimia.

Her first admission to a psychiatric unit was occasioned by a suicide note, which she wrote to her teacher at school.

In the unit she was “an impossible patient”. By the time she was 22 she had made over 100 suicide attempts.

She received all kinds of psychosocial and biological therapies but to no avail, although with age (now 25) there is some tempering of her emotional instability.


Amit, an 18 year old soldier killed himself a few months after joining the army.

He had grown up under conditions of economic deprivation.

The home atmosphere consisted of his mother’s angry accusations and father’s passive silences.

Case 2 (contd.)Case 2 (contd.)

Amit did poorly in elementary school, however managed to complete a vocational high school with fairly good grades.

During high school his behavior changed and he became more compliant.

Amit looked forward to his army service, feeling that it would make a man out of him and requested a frontline unit.

He was a highly motivated recruit but tended to become flustered under stress .

Case 2 (cont.)Case 2 (cont.)

Once when returning late from a home pass, he was told that his next leave was cancelled.

He became irritable and angry. When the teaching staff on the base broached the

possibility of him being unsuitable for a front-line unit he became upset and insisted on continuing. While resting after a training exercise the other recruits began taunting him, Amit lost his temper and attacked his tormenter.

When the 2 were separated, he ran to his tent and shot himself with his weapon.

Personality constellation Personality constellation

There are certain individuals who, when faced with relatively minor life stressors will react with anger and anxiety and then develop a secondary depression which is often accompanied by suicidal behavior.

Van Praag Van Praag (1997)(1997)

“serotonin-related anxiety/aggression stressor precipitated depression”

ThanatosThanatos A tendency towards impulsive aggression

may predispose suicidal behavior The risk increases when psychiatric

disorder and impulsive aggressive personality traits co-occur (Kety, 1986)

The wish to die; the wish to kill and the wish to be killed (Freud’s “death instinct”)

Adults vs. youngsters Adults vs. youngsters

There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among adults

Specifically, there is more impulsivity, substance abuse and other personality disorders in younger completed suicides

Genetics of suicidal behaviorGenetics of suicidal behavior

Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior

Higher familial loading for suicidal behavior was found in those attempters and completers who made more dangerous attempts and who were more aggressive

Serotonin, suicide and aggressionSerotonin, suicide and aggression

Finding the link between altered serotonergic neurotransmission, suicidal behavior and impulsive violence

Orders of magnitude have been noted in the correlations between measures of serotonin, suicide attempts, aggression and impulsive risk taking

Borderline personality disorder Borderline personality disorder (BPD)(BPD)

Traditionally associated with non fatal attempts and intentional self-damaging acts

One of the critical symptoms is “affective instability”

Most adolescent patients require psychiatric help and often suffer from major depression


Anger and Violence - related symptoms.Co morbid conditions: conduct disorder,

“multi-impulsive” bulimia and substance abuse

About 9% of patients eventually kill themselves

ImpulsivityImpulsivity

The adolescent period in contemporary Western society is characterized by a distinctive pattern of morbidity and mortality

Suicidal behavior and completed suicide are more common in adolescence than in any other developmental epoch (save, for males, in old age)

ImpulsivityImpulsivityLeading causes of adolescent deaths ( in the

West) – accidents, homicide, and suicide--are preventable

Associated with life-styles characterized by impulsivity, recklessness, and substance or alcohol use

ImpulsivityImpulsivity

Adolescence in the industrialized world characterized by increased health-threatening behaviors

Tobacco, alcohol, and drug use; unprotected sex; fighting; reckless driving; and weapon-carrying (Centers for Disease Control and Prevention, 2000)

““Continuum of Self Destructiveness"Continuum of Self Destructiveness"

Covert (e.g. substance use, unprotected and precocious sexual activity, reckless driving)

Overt (e.g. self-mutilation and suicide attempts)

Suicidal behaviors and other risk behaviors share an association with psychiatric diagnoses such as mood, disruptive, substance use, and anxiety disorders

MENTAL-ILLNESSMENTAL-ILLNESS DEMORALIZATION – DEMORALIZATION –

HOPLESSNESS CONSTELLATIONHOPLESSNESS CONSTELLATION


David, aged 18, came from a family with a distinguished military background. He appeared to have had a poor self image during his school years, with intermittent periods of depression, insomnia, and weight loss.

case 1case 1

David really looked forward to his army service, hoping that success there would redeem his low self esteem. He applied to join an elite commando unit but was turned down by the unit psychologist.

case 1case 1

However, after advanced training David was posted to a combat unit. He seemed to do well but complained to his parents of being unable to cope. His parents alerted the unit mental health officer, who interviewed David.

During the examination David denied experiencing any depression or suicidal thoughts, but David was reassigned. The reassignment made David feel like a “failure” soon thereafter he fatally shot himself.

Case material – case 2 (“The Case material – case 2 (“The case of Ellen West”)case of Ellen West”)

Ellen West was the daughter of wealthy Jewish parents who had great control over her.

Her father interfered twice when she became engaged, and when she finally married it was to a cousin.

Ellen WestEllen West

From age 19 she developed the fear of becoming fat and by 21 had developed Anorexia Nervosa.

She was hospitalized but this only increased her suicidal thoughts.

She was discharged from the sanatorium at the request of her family.

““The case of Ellen West”The case of Ellen West”

On the third day after returning home she appeared to be a changed person; she ate and enjoyed a walk with her husband. That evening she took a lethal dose of poison.

Eating disordersEating disorders Adolescents with Bulimia Nervosa highly prone to suicidal

behaviors Impulsive and unstable life style. Often make serious suicide attempts, which sometimes

succeed. Multi-impulsive bulimia was coined to describe the

increasingly more common association between bulimia, BPD, substance abuse, depression and conduct disorder.

Although most patients with this co-morbid constellation of disorders are women, they are nevertheless at risk of repeated Para-suicide and fatal suicide.

The Canterbury suicide project The Canterbury suicide project

A case control study. It was found that there was an elevated risk for mood disorder, substance disorder and conduct disorder.

The study looked at male and female Finnish adolescents 10 years after having received outpatient psychiatric care. They found that 16 male subjects but no female subjects had died.

Study findingsStudy findings Current suicidal ideation and suicide

attempts, poor psychosocial functioning and a recommendation for psychiatric hospitalization during the index treatment were associated with male mortality and suicidality.

The study found that 10% of male adolescent inpatients and about 1% female inpatients eventually kill themselves.

Study at psychiatric unitStudy at psychiatric unit

One group recently surveyed admissions to our adolescent unit for a period of 24 months

Most suicidal patients suffered from Affective and Conduct disorder, others had eating disorders or anxiety disorders

The recent upsurge of drug and alcohol abuse in our country has led to an even higher incidence of suicidal patients in our ward

Depression Depression

Major depression appears acutely in a previously healthy child.

Many other difficulties such as attention disorder or separation anxiety disorder before becoming depressed

Mood disorders tend to be chronic In some cases they may be psychotic and

have hallucinations and delusions of guilt

Bipolar disorderBipolar disorder

Approximately 20% of all patients have their first episode during adolescence (bet.15-19)

Lack of clinician awareness has led to under diagnosis or misdiagnosis in children and adolescents

Unique clinical characteristics Unique clinical characteristics associated with the early-onset associated with the early-onset

form : form : Manic or depressive episodes Increased risk for completed suicides.Strober et al (1995) Subjects made at least one medically significant

suicide attempt. Depressive and manic depressive disorders. Patients who are male or in the depressed phase are

at higher risk.A major clinical problem is that severe depression is

common in almost all the patients and it’s difficult to determine what is primary and what is secondary.

SchizophreniaSchizophrenia A common psychiatry disorder of

adolescence Some clinicians are hesitant to make this

diagnosis which denies the child and family access to appropriate treatment

When the diagnosis is made the patient must be followed longitudinally to ensure accuracy

Patients and families should be educated about these issues

Many patients are depressed and suicidal. About 10%-15% of patients eventually commit

suicide Most victims are unmarried men who have made

previous suicide attempts (often shortly after discharge)

Many adolescent patients also abuse drugs and alcohol - sometimes an attempt at self medication

StudyStudy

Participants :32 adolescent inpatients with

affective disorders (16 suicidal and 16 non-suicidal)

33 adolescent inpatients diagnosed with BPD (17 suicidal and 16 non-suicidal)

All subjects were diagnosed using the Hebrew version of the children’s version of K-SDADS.

The subjects were examined on 8 measures relevant to suicidal behavior:

The BDI; BHS; SPS; SIS; ICS; OAS; MAI; SRM.

Three dimensions were found on factor analysis:1. Anger-impulsivity-aggression2. Depression and hopelessness3. Suicidality

Anger Anger Anger in subjects was examined via a two way

analysis of variance (diagnosis/suicidality) Only diagnosis was found to significantly be

associated with anger (F1,61=17.31;p>0.0001) being significantly higher in the BPD subjects than in the depressive adolescents

The pair-wise Scheffe however showed that anger was significantly higher in the BPD suicidals than in the depressed non-suicidals

Impulsivity Impulsivity Impulsivity in subjects was examined by a two way analysis of

variance (diagnosis/suicidality). Only diagnosis was found to significantly be associated with impulsivity (F1,61=33.66;p<0.0001), with anger being significantly higher in the BPD subjects than in the depressive adolescents. There was also a strong inter-action between impulsivity suicidality and diagnosis (F1,61=4.47;p<0.039). Thus impulsivity was higher in BPD than in depressive and in suicidal BPD compared to non-suicidal BPD. There was no difference between depressive suicidals and depressive non-suicidals. In addition BPD non-suicidal subjects were more impulsive than depressive suicidal subjects. Thus impulsivity does not appear to play an important role in suicidal depression in adolescents.

Overt AggressionOvert AggressionAggression in subjects was examined by two way

analysis of variance (diagnosis/suicidality). Diagnosis was found to significantly be associated with impulsivity (F1,61=19.14;p<0.0001) as was suicidality (F1,61=18.75;p<0.0001), with anger being significantly higher in the BPD subjects than in the depressive adolescents. Aggression was significantly higher in the BPD suicidals than the BPD non-suicidals but did not differentiate between the depressed suicidals and the depressed non-suicidals. Thus impulsivity does not appear to play an important role in suicidal depression in adolescents.

Depressive symptoms Depressive symptoms and and

HopelessnessHopelessnessDepressive symptoms (BDI) in subjects was

examined by two way analysis of variance (diagnosis/suicidality).

Only suicidality was found to significantly be associated with depressive symptoms (F1,61=31.99;p<0.0001), with depressive symptoms being significantly higher in the suicidal subjects than in the non-suicidal adolescents in both diagnostic categories. Exactly the same findings were shown for hopelessness (F1,61=26.31;p<0.0001).

Suicide IntentSuicide Intent

SIS was significantly higher in the depressed subjects than in the BPD subjects (t(31)=2.69p<0.011).

SIS correlated negatively and significantly with impulsivity and aggression.

Suicide RiskSuicide Risk

Was higher for suicidal than non-suicidal subjects but did not differentiate between BPD and depressive suicidals.

ConclusionsConclusionsSuicidal behavior in depressed adolescents differs from that of BPD

adolescents and the recognized connection between impulsivity, aggression and suicidality may well relate to BPD and conduct disorder only. This has important implications for adolescent suicide research in general since additional findings regarding the association with trauma, sex abuse, broken families, dissociation and drug abuse may also be related to only one specific type of suicide.

Suicidal behavior can no longer be regarded as on homogenous group of behaviors and although the non-nosological approach developed by Van Praag et al (1997) has been a very fruitful one, diagnostic and personality differences may well have a part to play in the understanding of suicide.

Canterbury Suicide Project

Clinical SettingsClinical Settings

Primary Care settings (family or pediatric practices)

Mental health outpatient departments (OPD)

Emergency rooms (ER)Intensive care units (ICU)Residential treatment programs

Primary CarePrimary Care

Early Detection of Internalizing Disorders

Early Treatment of Internalizing Disorders

Early Referral of Internalizing Disorders

Referral of Externalizing Disorders

Early DetectionEarly Detection

Education regarding Childhood Depression and Anxiety

Routinely Examining for Childhood Depression and Anxiety

Routine Screening for suicidal ideation (Gould et

al., 2005)

Early TreatmentEarly Treatment

Psycho education (Harrington, 2003)

Psychopharmacology (TADS, 2005)

Attenuation of Psychosocial Risk Factors (e.g. reporting abuse)

Early ReferralEarly Referral

Psychotherapies are best before complications set in

Obviates long waiting lists for urgent cases

Facilitates secondary prevention

Internalizing Disorders- SummaryInternalizing Disorders- Summary

Gatekeeper education in terms of pediatricians is much under-researched

In adult primary care Depression and other psychiatric

disorders are under-recognized and under-treated in the primary care setting

There is an opportunity for prevention because up to 83% of those who die by suicide have had contact with a primary care physician (PCP) within a year of their death, and up to 66% within a month.

Internalizing Disorders- - Internalizing Disorders- - SummarySummary

PCPs’ lack of knowledge about and/or failure to screen patients for depression may contribute to non-treatment seen in most suicides

Therefore, improving physicians' recognition of depression and suicide risk is a component of most national suicide prevention plans

However the special role of the pediatrician is still

neglected

Externalizing DisordersExternalizing Disorders

PCP often called upon to deal with those externalizing disorders that highly predispose to suicidal behavior.

Include conduct disorders, attention deficit disorders and psychosexual disorders.

Diagnosis is often all too evident and the primary role of PCP is to alert and mobilize the appropriate social, educational and legal authorities.

Externalizing DisordersExternalizing Disorders

Pediatricians and specialists in adolescent medicine need to be trained

in the diagnosis of sexual and physical abuse, the early stages of drug and alcohol abuse

and to learn to look for the physical signs of self cutting and disordered eating practices

Emergency Room ManagementEmergency Room Management

Establish relationship with suicidal individual and family

Stress importance of treatmentAdmit suicide attempters with persistent

wish to die or clearly abnormal mental state.Obtain information from third-party.

Emergency Room ManagementEmergency Room Management

Availability and presence in the home of firearms and lethal medication must be determined

parents must be explicitly told to remove firearms and lethal medication .

warn about the dangerous disinhibiting effects of alcohol and other drugs.

Emergency RoomEmergency Room

Value of "no-suicide contracts" is not known. The child or adolescent might not be in a mental state

to accept or understand the contract, and both family and clinician should know not to relax their vigilance just because a contract has been signed.

An appointment should be scheduled for the child or adolescent to be seen for a fuller evaluation before discharge from the emergency room.

Emergency Room Emergency Room ManagementManagement

available to the patient and family (for example, receive

and make phone calls outside of therapeutic hours)

have adequate physician coverage if away

have experience managing suicidal crises

have support available for him or herself

AFTER CAREAFTER CARE

No after care was recommended to 28.5% of the boys and 25.7% of the girls

A negative attitude towards care and treatment staff is not unusual among young people

AFTER CAREAFTER CARE

It is also common not only for adults, but also for young people to deny suicide acts with great vehemence (Spirito 1996).

Parents’ lack of involvement, ignorance of the suicide attempt, possibly negative attitude of their own towards care and desire to trivialize the suicide attempt make it easier for a teenager to turn down an offer of treatment.

Intensive Care UnitsIntensive Care Units

The Canterbury Suicide Project

Almost equal numbers of males and

females made serious suicide attempts

Severe psychiatric disturbance

Intensive Care UnitsIntensive Care Units ((Apter A, et al., Compr. Psychiatry 42 (1) :70-75, 2001)Apter A, et al., Compr. Psychiatry 42 (1) :70-75, 2001)

80 subjects

20 ICU suicidal,20 non-ICU suicidal, 20 psychiatric non –suicidal and 20 control subjects

ICU subjects had significant lower levels of self disclosure

Mental Health OPDMental Health OPD

PCP - secondary prevention. Are expected to detect those young people

who are at risk for suicideOPD -children who have already attempted

suicideTertiary prevention

Mental Health OPDMental Health OPD

No treatment has been proven fully effective in an outpatient setting

depression is the most common diagnosis behavioral disorders common. (Kerfoot et al.,1996). Also PTSD, eating disorders and schizophrenia

(Herrington & Saleem, 2003).

Psychosocial treatmentsPsychosocial treatments

domiciliary oriented “outreach” programs

motivational enhancement methods,

Both non-effective in preventing suicide

(Raj, Kumaraiah & Bhide, 2001).

Psychosocial treatmentsPsychosocial treatments

Dialectical behavior therapy effective in reducing suicide rate in a 6 month follow-up, non-significant in a 1-year follow-up (Linehan, Armstrong, Suarez et al., 1991)

Problem-solving skills training effective to a certain extent in decreasing psychological distress and the number of suicide attempts (Salkovskis, Atha & Storer, 1990).

Consequences of Suicidal Consequences of Suicidal BehaviorBehavior

School dropoutLeaving homeMotor accidentsPolice arrestWhole spectrum of high risk behavior

TreatmentTreatment

Poor compliance

Is Emergency room intervention enough?

Mandatory hospitalization as a policy

Suicidal BehaviorSuicidal Behavior

Suicide and suicide attempts are frequently associated with:

Axis I disorder Depression Co-morbid conditions

Risk factors beyond Risk factors beyond psychopathologypsychopathology

One of the most pressing clinical research questions is to determine what factors predispose suicide.

Risk factors for suicidal Risk factors for suicidal behaviorbehavior

Social factors: Unemployment Poverty Availability of guns “National character”Biological factorsPersonal factors

Adults vs. youngsters Adults vs. youngsters

There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among adults.

Specifically, there is more impulsivity, substance abuse and other personality disorders in younger completed suicides.

Genetics of suicidal behaviorGenetics of suicidal behavior

Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior.

Higher familial loading for suicidal behavior was found in those attempters and completers who made more dangerous attempts and who were more aggressive.

Serotonin, suicide and Serotonin, suicide and aggressionaggression

Finding the link between altered serotonergic neurotransmission, suicidal behavior and impulsive violence.

Orders of magnitude have been noted in the correlations between measures of serotonin, suicide attempts, aggression and impulsive risk taking.


Traditionally associated with non fatal attempts and intentional self-damaging acts.

One of the critical symptoms is “affective instability”

Most adolescent patients require psychiatric help and often suffer from major depression.

Anger and Violence - related symptoms. Co morbid conditions: conduct disorder, “multi-

impulsive” bulimia and substance abuse. About 9% of patients eventually kill themselves.

MENTAL-ILLNESS MENTAL-ILLNESS DEMORALIZATION – DEMORALIZATION –

HOPLESSNESS HOPLESSNESS CONSTELLATIONCONSTELLATION


David, aged 18, came from a family with a distinguished military background. He appeared to have had a poor self image during his school years, with intermittent periods of depression, insomnia, and weight loss.

David really looked forward to his army service, hoping that success there would redeem his low self esteem. He applied to join an elite commando unit but was turned down by the unit psychologist. However, after advanced training David was posted to a combat unit. He seemed to do well but complained to his parents of being unable to cope. His parents alerted the unit mental health officer, who interviewed David. During the examination David denied experiencing any depression or suicidal thoughts, but David was reassigned. The reassignment made David feel like a “failure” soon thereafter he fatally shot himself.

Case material – case 2 (“The Case material – case 2 (“The case of Ellen West”)case of Ellen West”)

Ellen West was the daughter of wealthy Jewish parents who had great control over her. Her father interfered twice when she became engaged, and when she finally married it was to a cousin.

From age 19 she developed the fear of becoming fat and by 21 had developed Anorexia Nervosa. She was hospitalized but this only increased her suicidal thoughts. She was discharged from the sanatorium at the request of her family.

On the third day after returning home she appeared to be a changed person; she ate and enjoyed a walk with her husband. That evening she took a lethal dose of poison.

Types of Self-HarmTypes of Self-Harm

Superficial self-injurious behavior (SIB) such as self-cutting, scraping, burning (associated with Cluster B personality disorders, eating disorders, stress disorders)

Repetitive Stereotypical Behavior such as head banging and self biting (associated with intellectual disability, e.g. MR, autism)

Major self mutilation such as self blinding and castration (rare; occurs in psychotic disorders and substance intoxication) Harris, JC, 2005

SIB as a “stress related SIB as a “stress related disorder”disorder”

– Common in laboratory animals, and domestic animals under stress, neglect, or isolation

Acral lick syndrome in dogs, feather plucking in birds, self-biting in rhesus monkeys

– Prevalence in normal human development: 3.6 to 6.5% head banging rate at 8-36 months;

associated with teething, ear infections. Generally terminates by 36 mos. Harris, JC (2005)

15% head banging rate at 9-18 mos. (Hammock et al, 1995)

Prevalence of SIBPrevalence of SIB

Among patients with eating disorders, 34.6% had a life-time rate of SIB (N=376). (Paul et al, 2002)

Community samples in the U.S. vary in estimates from 4% to 38% of adolescents.

Canadian study found 13.9% of urban and suburban high school students had self-injured (Ross & Heath, 2002).

A British report noted a 65% increase in SIB disclosures to national children’s hotlines from 1999 to 2004.

Distinguishing SIB from Distinguishing SIB from Suicidal BehaviorSuicidal Behavior

Suicidal behavior is distinct from SIB in terms of motivation, intent, and lethality.

Suicidal behavior is accompanied by some degree of wish to die and intent to die; i.e. the patient believes that the behavior will possibly, or will definitely, result in death.

Carefully assess motivations (to die, to escape, to influence someone, to communicate feelings, to relieve emotional distress, and intent (what was the expected outcome of the behavior?)

Suicide ContinuumSuicide Continuum

Passive Death Wish

Suicidal Ideation, no method

Suicidal Ideation with method

Gesture

Attempt

Completion

Assessing Current SafetyAssessing Current Safety

Assess the presence or absence of suicidality and the degree of severity (frequency, intensity, duration) over the past 48 hours or since last visit.

Negotiate No-Suicide/No Harm “Safety Plan.” Collaborate and review this plan with family. If family conflict is a common precipitant to

suicidality or self harm, help teen and family negotiate a “truce.”

Formulating the Safety PlanFormulating the Safety Plan

A collaborative process Includes the phone numbers of trusted adults,

therapist, 24-hour emergency coverage Includes a set of coping strategies (written card

containing specific emotion regulation skills, relaxation skills, social supports, coping statements, “hope kit”)

A promise between teen, parents and therapist, that teen will contact a responsible adult or therapist before acting on suicidal impulses

Contract and Commitment PhaseContract and Commitment Phase

Establishing a “commitment” to treatment from both teen and family

___agrees to do whatever it takes to say alive during the period of this contract. This contract lasts from __ to__

Contract and Commitment Contract and Commitment Phase (continuedPhase (continued))

Priorities for intervention are as follows:I. Decreasing life threatening behaviors

cutting, overdosing, any tissue damage or other life threatening behavior

II. Decreasing therapy interfering behaviors (any behavior that makes therapy less likely to occur)

Refusing to bring in or get rid of razors or other dangerous objects

Any other therapy interfering behaviors

Patient AgreementsPatient Agreements

Stay in therapy for the specified time.Attend scheduled therapy sessions.Work toward reducing suicidal

behaviors/self-injurious behaviors as a goal of therapy.

Work on problems that arise that interfere with progress in therapy.

Therapist AgreementsTherapist Agreements

Make every reasonable effort to conduct competent and effective therapy.

Obey standard ethical and professional guidelines. Be available for weekly therapy sessions, phone

consultations, and provide needed therapy back- up when on vacation or away.

Respect the integrity of and rights of the patient. Maintain confidentiality. Obtain consultation when needed.

Negotiating Treatment Negotiating Treatment ContractContract

Initially patients with history of self-cutting may not be able to agree to abstain entirely from SIB.

Explore teen’s concerns about their SIB and negative consequences of the behavior to increase motivation for change. (remain non-judgemental.)

Negotiate with teen to try specific emotion regulation strategies first, and to delay cutting for longer periods after the urge begins.

Negotiate with teen to avoid triggers for self-injury.

Understanding Self-injurious Understanding Self-injurious BehaviorBehavior

SIB is identified by the patient as non-suicidal, and is typically aimed at relieving distress. It is marked by:– An irresistible impulse to self-harm– Mounting agitation – no escape from tension– Cognitive constriction- no alternatives considered– Rapid, temporary relief following the act of self

injury

Functions Self-injury may ServeFunctions Self-injury may Serve

Escape or reduce painful emotionsDistract from painful memories or thoughtsSelf-expression of emotionsPunishment of selfTension reduction/Anger reductionGet attention, social support, or helpTo feel alive

Characteristics of Self-injurersCharacteristics of Self-injurers

The teen may have difficulties:– Labeling their emotions– Effectively regulating emotions– Trusting experiences as valid responses to

events (therefore individual searches environment for cues about how to respond)

– Tolerating distress– Effectively solving problems (Miller, 1999)

Emotional VulnerabilityEmotional Vulnerability

High sensitivity– Immediate reactions– Low threshold for emotional reaction

High reactivity– Extreme reactions – High arousal dysregulates cognitive processing

Slow return to baseline– Long lasting reactions– Creates high sensitivity to next emotional stimulus

Borderline Personality Borderline Personality DisorderDisorder

Many self-injurers display some of these traits:– Emotion dysregulation (affect lability)– Interpersonal dysregulation (chaotic

relationships)– Self-dysregulation (identity disturbance)– Behavioral dysregulation (self-injury)– Cognitive dysregulation (paranoia)

What We See in the TeenWhat We See in the Teen

Critical, hostile statements toward self and feelings of guilt, shame, anger when experiencing strong emotions

These reactions serve to intensify the pain of the original emotion and further support the self-critical backlash

The Invalidating EnvironmentThe Invalidating Environment

Families may:– Indiscriminantly reject– Punish emotional displays and intermittently

reinforce emotional escalation.– Over-simplify the ease of problem-solving and

meeting goals– Indiscriminantly indulge

Creating a Validating Therapeutic Creating a Validating Therapeutic EnvironmentEnvironment

Therapist validates the emotional need behind the behavior.

Therapist must non-judgmentally acknowledge destructiveness of teen’s behavior.

“You’re doing the best you can, and you can do better.”

Therapist refrains from criticizing the individual but instead elicits negative consequences about specific behaviors from teen.

Levels of Validation Levels of Validation (Miller & Comtois, 2002)(Miller & Comtois, 2002)

Unbiased listening and observing.Accurate reflectionArticulating the “unverbalized” Validation in terms of past learning or

biological dysfunctionValidation in terms of present contextRadical genuineness

BreakBreak

Time for a 15 minute break!

Developing the Treatment Developing the Treatment ApproachApproach

Protocol driven treatments (one size fits all, what to do instructions) work with severe and chronic Axis I problems

Principle-driven treatments (based on principles that tell you how to figure out what to do) are needed with multi-diagnostic and/or Axis II patients

Miller, 2002

Chain analysis as a Chain analysis as a GuideGuide to to Case ConceptualizationCase Conceptualization

A form of behavioral analysisTranslation of the behavior problem (SIB)

into “links” in the “chain” of emotions, events, behavior and consequences

Assessing at a micro-level to reconstruct the sequence in time

Chain Analysis as a Guide Chain Analysis as a Guide

Start by asking teen to walk you through the events that led up to the self-injury.

Help teen identify vulnerability factors that may have contributed.

Ask teen to describe in detail the precipitants, thoughts, images, and feelings they may have experienced as well as what was going on “outside”.

Ask about (+) and (-) consequences of the SIB.

Links in the ChainLinks in the Chain

Vulnerability factors Triggering event Emotions Thoughts (“self-talk”) Physical sensations Urges Behavior Consequences

Forming ConceptualizationForming Conceptualization

The specific vulnerabilities, self-statements, and feelings (“internal factors”), as well as the triggering events and consequences of the SIB (“external factors”), will help you to develop the case conceptualization and treatment plan.

Management of “Internal Factors” in Treatment of AttemptersManagement of “Internal Factors” in Treatment of Attempters

AttemptAttempt

Negative Affect

Emotional Lability

Problem-solving

Positive Health Habits

Cognitive Restructuring

Distress, Tolerance, Treatment Disorder

Emotion Regulation

Impulsivity

Hopelessness and other Disorders

Management of “External Factors” in Treatment of AttemptersManagement of “External Factors” in Treatment of Attempters

AttemptAttempt

Family

Discord

School Problems

Interpersonal Difficulties

Restrict Access to Means

Family Therapy , Education

Treatment of Parents

Case Management

Adjust Expectation

Social Skills

Training

Availability of Lethal Agents

Prioritize treatment needsPrioritize treatment needs

Through chain analyses, the therapist decides which skill areas to target first:– Emotion regulation skills– Cognitive restructuring– Family Conflict– Communication skills– Problem-solving– Social skills/assertiveness skills

LUNCH BREAK !LUNCH BREAK !

Emotion EducationEmotion Education

Learning to be nonjudgmental toward self– Teach teen how to observe and describe

different emotions, without labeling them as good or bad, but simply to be aware of them.

– Emotion dysregulation results often because teen is overly harsh toward self for having strong feelings, and may often judge specific feelings as wrong, or invalid, and feel more distressing emotions in turn.

Emotion Education Emotion Education (continued)(continued)

Action urges and choices– A negative emotion often leads to an irresistible

urge to act in a self-destructive manner.– Important to teach teen that just because they

have urge to act on a distressing emotion they are not “obligated” to act in this way.

– Distinguish between “urge” to act and the “action” itself.

Reducing Vulnerability to Reducing Vulnerability to Negative EmotionNegative Emotion

Parents and teens should be taught how to decrease vulnerability to “emotion mind” (Linehan, 1993).

Emphasis on importance of maintaining regular sleep schedule.

Eating balanced diet, treating physical illness, getting regular exercise, avoiding substance abuse and planning at least one activity a day that elicits a sense of competence and mastery.

HEAR MEHEAR ME

Health (treat physical illness)Exercise regularlyAvoid mood altering drugsRest (balanced sleep)

Mastery (one rewarding activity daily)Eating (balanced diet)

Emotions ThermometerEmotions Thermometer

Mindfulness of current Mindfulness of current emotionemotion

Steps in the process:1. Observe your emotion

2. Experience Your emotion

3. You are not your emotion

4. Practice Accepting your emotion

MindfulnessMindfulness

1. Observe your emotion– Note its presence… just observe it– Step Back– Get Unstuck from the emotion


2. Experience Your Emotion– As a wave, coming and going…– Try not to block or suppress the emotion– Don’t try to get rid of the emotion– Don’t push it away– Don’t try to keep the emotion around– Don’t hold on to it– Don’t intensify it


3. Remember: You are not your emotion

– Do not necessarily act on your emotion (that is, let destructive action urges pass).

– Remember times when you have felt different.


4. Practice accepting your emotion– Do not judge your emotion as wrong, bad, too

painful, unfair, embarrassing, etc.– Do not criticize yourself for feeling the

emotion.– Accept your emotion as it is in the moment.

Chain Analysis as an Chain Analysis as an InterventionIntervention: The : The Freeze Frame Technique (Wexler, 1991)Freeze Frame Technique (Wexler, 1991)

Takes the chain analysis a step further– Recalls events as if reviewing a video replay

and then “freezing the frame” at critical points.– Helps teen to slow time down (especially useful

for teens who are impulsive and “can’t remember what happened”) .

Steps of Freeze FrameSteps of Freeze Frame

To review:– Teen is asked to describe in detail a situation in

which he/she had a particularly strong emotional reaction and/or had adverse consequences.

– These consequences should be both internal and external e.g. teen punched his door –consequence might be he/she has to pay for a new door and also feels guilty and ashamed of this behavior.

Freeze Frame (continued)Freeze Frame (continued)

In addition to “who, what, where, when” of the problem situation, sensory, interpersonal, affective, cognitive details are also recalled; negative self-talk is especially important to articulate.

The teen should describe the “vulnerability factors” that made he/she more susceptible to negative emotions and problem behavior.


The teen is instructed to “slow time down” as the scene approaches the moment when the problem emotion intensified or the “uncontrollable behavior” started (analogy of the instant replay can be used).

At the moment just prior to the problem emotion or “uncontrollable behavior” is reached, the teen is instructed to FREEZE THE FRAME and describe thoughts, feelings, bodily sensations, and action urges at that moment.


The next step is to ask the teen “what NEEDS were you attempting to meet through the behavior, even if the results were negative?”

Once these needs have been identified , the therapist must help teen to develop self-respect for these needs (teach teen to validate these needs) and formulate alternative ways to take care of these needs.


“Needs”-Important to teach teen that if they can identify their needs and learn different behaviors to get their needs met, they can have more power.

“Once you know the needs, you are smarter. Once you have new tools for handling the needs, you are more powerful” (Wexler, 1993).


The Freeze Frame differs from the chain analysis, and becomes an intervention with the final step:

The teen replays the scene and replaces the problem behavior with the new coping skills, and then imagines a new outcome.

Educating Family about Freeze Educating Family about Freeze FrameFrame

The Freeze Frame approach is the basis for generating options and interventions with regard to emotion dysregulation.

We can use this approach to examine emotion dysregulation that occurs interpersonally between family members.

BreakBreak

Time for a 15 minute break!

Distress Tolerance SkillsDistress Tolerance Skills

A crisis survival strategyVital skill to teach teen as they will not

always be able to decrease painful emotions, or get what they need interpersonally, so they will need to learn how to “tolerate” distressing emotions.


Linehan (1993) “Learning how to bear pain skillfully”

Teaching teens to suspend judgment – an emotion simply “is”

Teaching teens to “accept” painful feelings vs. trying to get rid of them quickly


3 Myths about acceptance (Miller, 1997)– If you refuse to accept something, it will

magically change.– If you accept your painful situation, you will

become soft and just give up (or give in).– If you accept your painful situation, you are

accepting a life of pain.


CBT component of Distress Tolerance– Acceptance self-talk

Learning to talk to yourself nonjudgmentally e.g. “I’m doing the best I can”, “I know if I can just get through this difficult time things will get better”.

Acceptance self-talk counters the negative, critical “shoulds” that often accompany painful emotions.


Main emphasis is teaching teens how to soothe themselves .

Teens may be resistant to this, as their relation to the world is predominantly action and other oriented.

Self-soothing skills involve neither action in the external behavior sense nor an explicit relation with others.


Some teens have belief that others should soothe them when distressed and have difficulty believing that they can depend on themselves.

Others may feel that they don’t deserve to be soothed and may feel guilty, ashamed, angry when they try to self-soothe (Linehan, 1993) .


Some teens have belief that others should soothe them when distressed and have difficulty believing that they can depend on themselves.

Others may feel that they don’t deserve to be soothed and may feel guilty, ashamed, angry when they try to self-soothe (Linehan, 1993) .

Self-Soothing ThroughSelf-Soothing Throughthe Five Sensesthe Five Senses

An accessible and easily taught self-soothing/distress tolerance skill is the use of the 5 senses:– Vision, hearing, smell, taste, touch

Usually at least 2-3 of the five senses are engaged or capable of being engaged at any given moment as a distraction from distress.

Sensory Soothing (continued)Sensory Soothing (continued)

Vision: Focus on an aspect of nature, or any visual detail

Hearing:Music, nature sounds, relaxation tape, fan noise

SmellLotion, candle, perfume, favorite food cooking

TasteHot chocolate or tea, ice cream…taste slowly

TouchPet your dog, cat, soothing bath, hug, blanket

Helping Parents Regulate Their Helping Parents Regulate Their Emotions When in Conflict with TeenEmotions When in Conflict with Teen

Teach trategies for changing the timing and process of confrontations.

Important to educate parents that when teen attacks and parent becomes dysregulated then parent can no longer be effective in enforcing rules and consequences.

Teens will escalate their behavior in an attempt to control outcome of mood and outcome of the interaction (Sells, 1998).

Creating a Validating Family Creating a Validating Family EnvironmentEnvironment

Help both parents and teen to understand how their reactions to each other may be invalidating.

“Kernel of Truth”Coaching parents to become more aware of

the ways in which their communication may be overly negative and critical.

Validation isn’t “agreeing with” and doesn’t have to be “warm and fuzzy.”

Strategies to Help Parents Strategies to Help Parents Respond CalmlyRespond Calmly

Strategies to help parents respond calmly and nonreactively to their teens’ provocations during conflict:– EXIT AND WAIT– STAYING SHORT AND TO THE POINT,

USING DEFLECTORS

Communication SkillsCommunication Skills

Active Listening (verbal and non verbal skills)

Therapist models listening skillsSending clear messages ( use of “I”

statements instead of “you”Practice/role play in session

Changing Emotion by Acting Changing Emotion by Acting Opposite the Current EmotionOpposite the Current Emotion

Every emotion has an action associated with it.– Fear …………Run– Anger………….. Attack– Sadness………..Withdraw– Shame………….Hide

Changing Emotion by Acting Changing Emotion by Acting Opposite the Current EmotionOpposite the Current Emotion

Opposite Action– Emotion is strongly influenced by our bodily

posture and facial expressions. – By altering posture, behavior and facial

expressions we can delay, interrupt or de-escalate the progression of a problematic emotion.

Opposite Action for AngerOpposite Action for Anger

Keep one’s palms open when inclined to punch. Whisper when inclined to scream. Breath deeply and slowly rather than angrily

hyperventilating. Gently avoid the person you are angry with rather

than attacking. Put yourself in the other person’s shoes, and

imagine sympathy or empathy for the person, rather than blame.

Opposite Action for Guilt or Opposite Action for Guilt or ShameShame

Repair the mistake.– Say you’re sorry– Make up for what you did to the person you

offended

Try to avoid making the same mistake in the future.

Accept the consequences for what you did.Then let it go.

Opposite action for Sadness Opposite action for Sadness or Depressionor Depression

Get activeApproach, don’t avoidDo things that make you feel effective and

self-confidentUse the “half-smile”

Opposite Action for EnvyOpposite Action for Envy

Someone else has something that you think you WANT or NEED. (If you can’t have it, they SHOULDN’T.)

Based on a fundamental belief that you are DEPRIVED.

Radical Acceptance: you have to radically accept that you don’t have it (opposite action).

Radical Self-Acceptance

We must willingly accept all aspects of self. Remember that acceptance does not necessarily mean approval or agreement, but is simply the acknowledgement of what is. Accepting that you are human, that you have both failings and accomplishments in your life experiences, and that you are inherently both flawed and gifted is radical self-acceptance. Practice accepting insights, both what you like and don’t like with an open-heart. Accept yourself wholeheartedly, without fear that doing so will make you worse.

Steps to practice using Steps to practice using opposite action opposite action

What emotion am I experiencing?What is the action (what is the emotion

trying to get me to do)?Do I really want to reduce this emotion?What is the opposite action?DO the opposite action.Practice, practice, practice!

Relaxation SkillsRelaxation Skills

Deep Breathing with a Self-Statement, Counting Backward

Deep Breathing with Pleasant ImageryLeaving the scene for a breakGuided Imagery for Relaxation (Spaceship

to the Moon and back; Falling Leaf…)Progressive Muscle Relaxation

SummarySummary

Important to assess most severe episode suicidal thoughts or behavior and evaluate the precipitants and motivations.

Important to gather history of suicidal thoughts and behaviors in all patients.

Gather current information and history of self-injurious behaviors or urges.

Summary (continued)Summary (continued)

Establish no harm/no suicide safety plan with teen and family. If conflict has been a precipitant, work with family to call a “truce”.

Evaluate possible reinforcers for the teen to continue self-injurious behaviors (what does he/she get or gain). Remain non-judgmental.


The essential “Commitment Phase” of treatment

Decreasing vulnerability factorsTeaching Use of “Freeze Frame” Emotion Regulation skills to teen and

parents.Enhance Family Communication skills


Self-soothing skillsHelping parents regulate their emotions

when in conflict. Strategies to help.Changing Emotion by “opposite action”

techniqueDistress Tolerance Skills

Questions and Discussion

We acknowledge with gratitude the Pennsylvania We acknowledge with gratitude the Pennsylvania Legislature for its support of the STAR-Center and our Legislature for its support of the STAR-Center and our

outreach efforts.outreach efforts.

This presentation may not be reproduced without This presentation may not be reproduced without written permission from: STAR-Center Outreach, written permission from: STAR-Center Outreach,

Western Psychiatric Institute and Clinic, 3811 O’Hara Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213. Street, Pittsburgh, PA 15213.

(412) 687-2495 (412) 687-2495All Rights Reserved, 2006All Rights Reserved, 2006

Alan Apter M.D Feinberg Child Study Center Schneider Childrens Medical Center suicide.

Documents

suicide suicide rates

suicide females

suicide males

fatal suicide

epidimiology of suicide

failed suicide

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year slide