Suicide Suicidal behavior / parasuicide Self injury Risky behavior.

Suicide Suicidal

behavior / parasuicide

Self injury

Risky behavior

הנעשית פעולהאו התנהגותלמוות כוונהמתוך לגרום

עצמי

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)

SIB SpectrumSupefcial injuries Cutting, hair pulling Self burning, severe head banging Autoenoculation,

autocasration, autosurgery

mild severe

Personality disorders

Eating disorders

Interpersonal context

Mental rtardation

Autism

Congenital syndroms

Severe gender identity disorders

Dissociative disorders

Psychotic states

Epidemiology of SIB

• Prevalence:– 1:600 general population, – 400-1400:100,000

• 40.5% of laxative-abusing bulimics

• 14% of mentally retarded

• Gender differences uncertain, appears to be more prevalent in women.

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

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.

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.

גישות לאובדנות

פילוסופית / ערכית: סוגיה אקזיסטנציאלית •

סוציולוגית: בעיה באינטגרציה, ניכור•

פסיכולוגית: תוקפנות והרס עצמי•

רפואית / פסיכיאטרית: הפרעה נפשית•

Integration )-(

Integration )+(

Regulation )+(

Regulation )-(

anomiaegiosm

altriosmfatalism

העובדות המטרידות

כמיליון אנשים מתאבדים מדי שנה ברחבי העולם.•

הבדלים גיאוגרפיים משמעותיים .•

עליה בהיקף ההתאבדויות, חיקוי, "הידבקות".•

משמעויות חמורות בכל קבוצות הגיל.•

הטרוגניות, גורמי סיכון רבים, יכולת ניבוי מועטה.•

ערך מוגבל לגישות המניעה הראשונית.•

מחיר גבוה, השקעה מערכתית דלה•

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

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)

טווח ההתנהגויות האובדניותטווח ההתנהגויות האובדניות

מחשבות התאבדות

התאבדות איומי

מחוות אובדניים

ניסיונות התאבדות

התאבדות

משבר אובדנימשבר אובדני

סיכון גורמיפרטניים

סיכון גורמימצביים

אמצעי זמינותמשאבי קטל

התמודדות

תמך מקורות

מעכבים גורמים

, נפשיות הפרעותאימפולסיביות

דמוגרפיה, תורשה

, : אובדנים חיים ארועי , חוק, בעיות דחיה

, בעיות, הגירה אבטלה , . טירונות, כשלון בריאות

כליאה,.

ותופעת חיקויהאשכולות.

Demographic male; widowed, divorced, single; increases with age; white

Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access

Psychiatric psychiatric diagnosis; comorbidity

Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system

Psychological Dimensions

hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism

Behavioral Dimensions

impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt

Cognitive Dimensions

thought constriction; polarized thinking

Childhood Trauma

sexual/physical abuse; neglect; parental loss

Genetic & Familial

family history of suicide, mental illness, or abuse

Risk 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

Protective factors

התרחיש האובדני התרחיש האובדני

כאב נפשי בלתי נסבל•

הכפשה עצמית•

“היצרות” החשיבה•

בדידות וניכור•

חוסר תקווה•

היעלמות כפתרון יחיד•

המאפיינים השכיחים 10בהתאבדויות

המניע הנפוץ בהתאבדויות הוא מציאת פתרון.המטרה השכיחה בהתאבדויות היא הפסקת המודעות.

הגירוי המשותף להתאבדויות הנו כאב נפשי בלתי נסבל.גורם הדחק המשותף בהתאבדויות הנו צורך פסיכולוגי מתוסכל.

הרגש השכיח בהתאבדויות הנו חוסר תקווה וחוסר אונים.המצב הקוגניטיבי האופייני להתאבדויות הוא אמביבלנטיות.

המצב התפיסתי האופייני להתאבדויות הוא צמצום.הפעולה האופיינית להתאבדויות הנה הסתלקות.

ההתנהגות הבין-אישית השכיחה בהתאבדויות הנה ביטוי הכוונה.העקביות האופיינית להתאבדויות הנה בדפוסי התמודדות

מתמשכים.

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 19932 Lewis, Hawton & Jones, BJPsy 1997

SUICIDE RISKS IN SPECIFIC DISORDERS

Prior suicide attempt 38.4 0.549 27.5

Eating disorders 23.1

Bipolar disorder 21.7 0.310 15.5

Major depression 20.4 0.292 14.6

Mixed drug abuse 19.2 0.275 14.7

Dysthymia 12.1 0.173 8.6

Obsessive-compulsive 11.5 0.143 8.2

Panic disorder 10.0 0.160 7.2

Schizophrenia 8.45 0.121 6.0

Personality disorders 7.08 0.101 5.1

Alcohol abuse 5.86 0.084 4.2

Cancer 1.80 0.026 1.3

General population 1.00 0.014 0.72

ConditionRR%/y%-Lifetime

Adapted from A.P.A. Guidelines, part A, p. 16

Disorders Correlated With Suicidal Behavior

Mood Disorders (15 percent lifetime risk of suicide) A. The absence of psychosis does not imply safety. B. A misleading reduction of anxious or depressed affect can occur

in some patients who have resolved their ambivalence by deciding to commit suicide.

C. The likelihood of suicide within 1 year is increased when the patient exhibits: Panic attacks, Psychic anxiety, Anhedonia, Alcohol abuse .

D. The likelihood of suicide during the ensuing 1-5 years is increased when the patient exhibits: Increased hopelessness, Suicidal ideation, History of suicide attempts.

Developed by the Suicide Risk Advisory Committee of the Risk Management Foundation of the Harvard Medical Institutions in 1996.

Disorders Correlated With Suicidal Behavior

Panic Disorder (7-15 percent lifetime risk of suicide) A. Suicide rate may be similar to that of mood

disorders B. Greater likelihood is correlated with more severe

illness or comorbidity C. Suicide does not necessarily occur during a panic

attack D. Demoralization or significant loss increase the

likelihood of suicide E. Agitation may increase the likelihood of

translating impulses into action

Disorders Correlated With Suicidal Behavior

Schizophrenia (10 percent lifetime risk of suicide)

A. Suicide is relatively uncommon during psychotic episodes B. The relationship between command hallucinations and actual

suicide is not clearly causal C. Suicidal ideation occurs in 60-80 percent of patients D. Suicide attempts occur in 30-55 percent of patients E. Suicide potential is increased by:

a. Good premorbid functioning b. Early phase of illness c. Hopelessness or depression d. Recognition of deterioration, e.g., during a post-psychotic depressed

phase

Disorders Correlated With Suicidal Behavior

Alcoholism (3 percent lifetime risk of suicide) A. Abusers of alcohol/drugs comprise 15-25 percent of suicides

B. Alcohol is associated with nearly 50 percent of all suicides

C. Increased suicide potential in an alcoholic patient correlates with:

a. Active substance abuse

b. Adolescence

c. Second or third decades of illness

d. Comorbid psychiatric illness

e. Recent or anticipated interpersonal loss

D. Substance abuse can represent self treatment to blunt the anxiety or mood disturbance associated with a masked, comorbid psychiatric disorder

Disorders Correlated With Suicidal Behavior

Borderline Personality Disorder (7 % lifetime risk of suicide)

A. Much higher risk associated with comorbidity, especially with mood disorder and substance abuse

B. Psychopathology associated with increased risk: a. Impulsivity, hopelessness/despair b. Antisocial features (with dishonesty) c. Interpersonal aloofness ("malignant narcissism") d. Self-mutilating tendencies e. Psychosis with bizarre suicide attempts

C. Psychopathology associated with diminished risk: a. Infantile personality (with hysterical features) b. Masochistic personality

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

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 1996:1145-1152

התאבדויות במניעת כשל גורמי

קושי בזיהוי אנשים בסיכון.

רתיעה מקבלת עזרה נפשית.

חוסר נגישות לסוכנויות התערבות.

אפקטיביות נמוכה של שיטות התערבות.

טיפול מפוצל או בלתי מתואם.

מיקוד מקצועי צר.

בעיות סביב קביעת אחריות ואשמה.

Areas to Evaluate in Suicide Assessment

Psychiatric

Illnesses

Comorbidity, Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.

History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness

Individual strengths /

vulnerabilities

Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain

Psychosocial situation

Acute and chronic stressors; changes in status; quality of support; religious beliefs

Suicidality and Symptoms

Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation

Adapted from APA guidelines, part A, p. 4

The assessment of suicidality is an active process during which clinicians evaluate:

a. Suicidal intent and lethality b. Dynamic meanings and motivation for suicide c. Presence of a suicidal plan d. Presence of overt suicidal/self-destructive behavior e. The patient's physiological, cognitive, and affective

states f. The patient's coping potential g. The patient's epidemiological risk factors

The Detection of Suicidality

The Detection of SuicidalitySuicide-specific questions

1. Are suicidal thoughts/feelings present?

2. What form does the patient's wish for suicide take?

3. What does suicide mean to the patient?

4. Has the patient lost or anticipates losing an essential sustaining

relationship?

5. Has the patient lost or anticipates losing his/her main reason for

living?

6. How far has the suicide planning process proceeded?

7. Have suicidal behaviors occurred in the past?

8. Has the patient engaged in self-mutilating behaviors?

9. Does the patient's mental state increase the potential for

suicide?

10. Are depression and/or despair present?

11. Does the patient's physiologic state increase the potential for suicide?

12. Is the patient vulnerable to painful affects such as aloneness, self-contempt, murderous rage, shame, or panic?

13. Are there recent stresses in the patient's life?

14. What are the patient's capacities for self-regulation?

15. Is the patient able/competent to participate in treatment?

16. Loss of coping mechanism? 

17. Are epidemiological risk factors present? 

The Detection of Suicidality (cont.)

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.

• 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.

Treatment Planning (cont.)

• Contracts Will Not Guarantee the Patient's Safetycontracts 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

Treatment Planning (cont.)