Suicide

(1-20-10)

Basic inquiry: always ask about suicide; use direct, concrete language; asks about attempts as well as ideation; specify number of attempts, methods, outcomes; supports; reasons for living

Sample Inquiry

A continuum of suicidal behavior

• Thoughts about suicide
  • passive, intermittent, infrequent, easily dismissed
  • active, constant, frequent, intrusive
  • Intent
• Preparation for suicide: precursor behavior
  • saying goodbye, writing notes, giving away possession
  • procuring materials for attempt
• Attempts at suicide
  • lethality
  • “suicidal gestures”
• Death from suicide
  • Lineham has suggested that the population who die from suicide are different in many ways from the population who show suicidal ideation, preparation, or (nonlethal) attempts. She suggested (consistent with usage in Great Britain) reserving the term “suicide” to refer to self inflicted deaths, and using the term “parasuicide” to refer to all nonlethal behavior (thoughts, preparations, attempts which are survived).
  • Suicidal behavior needs to be distinguished from “self-injurious behavior” (SIB)/deliberate self-harm (DSM)–deliberately hurting oneself (without the intention to die).

Lethality

• The lethality of a suicide attempt can be considered in terms of three characteristics.
  • the dangerousness of the method–how likely it is to end your life (some authors refer to this as “lethality” also, sorry for confusion).
  • the latency of the method–how quickly the method works (or how much opportunity to change your mind you have.
  • the willingness of a person to trigger the method–the cultural/personal acceptability of this method of death.

Risk Factors (Predictors)

• Demographic
  • attempt
    • female
    • raised in belief system without pejorative view of suicide
  • death
    • male
    • older age
    • majority/dominant subculture
    • occupation (knowledge & access to means)
• Trait
  • child/young adolescent
    • maladjustment
    • substance abuse
    • impulsivity (risk factor for attempt)
  • older adolescent/adult
    • substance abuse
    • psychosis
    • emotional disorder (depression, mania, panic disorder, anxiety)
    • chronic medical condition
• State
  • hopelessness
  • social isolation
  • pain (adult)
  • psychological crisis (child & adult)
  • fatigue/illness
  • unemployment (adult)
• Proximal
  • intoxication
  • breakdown of social relationships
  • breakdown of communication
  • opportunity (availability of means, isolation)

Special Populations

• Schizophrenia
  • Risk Factors for “Suicidal Events” [defined as hospitalization to prevent a suicide attempt or behavior seen as representing a significant suicide risk] (Meltzer, H.Y., Alphs, L., Green, A.I., et al. (2003). Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry 60, 82-91.)
    • Previous suicide attempts
    • Previous hospitalizations to prevent suicide
    • Current or past substance abuse
    • Depression
    • Parkinsonism
• Prison Populations
  • Suicide in prison is the leading cause of death in correctional facilities–causing 400 to 600 deaths a year. For years suicide rates in prisons were reported to be 3 to 9 times higher than the rates in general population. Aggressive efforts during the past decade has reduced the occurrence of suicide in prison; and the wisdom of comparing against a general population standard has been called into question (90+% of prison inmates are male). Suicide rates for males are approximately 18 per 100,000. Suicide rates for males in prison declined from approximately 24 per 100,000 in the 1980’s to approximately 18 per 100,000 in 1993 (White, 2004). Highest risk groups are not depressed inmates, but inmates with severe mental disorders (psychosis) involving delusional and paranoid thinking, followed by “inmates in high security institutions serving long sentences who found it impossible to enter or remain in general population (White, 2004, p. 10).
• Adolescents
  • “Parental sexual abuse, offspring sexual abuse, impulsive aggresion, and anxiety disorder are all intercorrelated and all relate to an increased likelihood of offspring mood disorder. Therefore, the factors involved in the transmission of mood disorder and of suicidal behavior are similar. Early identification and treatment of pediatric mood disorder may attenuate the risk of early-onset suicidal behavior. Youths whose parents have a mood disorder and a history of sexual abuse are at particularly high risk of both mood disorder and suicide attmpet, especially when these offspring also experience sexual abuse and have high levels of impulsive aggression. . . . The period of approximately 3 years between the onset of mood disorder and first suicide attempt helps define a window of opportunity in which to identify and treat depressive disorders and in turn prevent the onset of suicidal behavior.” (Brent et al., 2004, 1265).
• Children
  • Children of both sexes tend to use high lethality methods (firearms and hanging).

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Sample Suicide Inquiry

Have you ever thought about killing yourself?

• if “No”: Have you ever tried to kill yourself?
  • if “No”: If you ever did try, how would you do it?
    • Why wouldn’t you kill yourself, what would stop you?
• if “Yes” or no response or evasive response:
  • When was the last time you thought about killing yourself?
    • Tell me about that.
      • What did you think about doing?
      • How would you do that?
      • Do you have [access to means]?
      • What would stop you, why wouldn’t you kill yourself?
      • assess current circumstances, sources of support, knowledge and access to emergency help
    • Have you ever tried to kill yourself?
      • How many times?
      • What did you do the last time? When was that? What happened? What were you thinking, what did you want to happen?
      • What did you do the first time? How old were you? What happened?
      • assess other attempts
    • Has anyone in your family or someone you knew really well ever killed themselves?
    • What would keep you from trying again? What could you do if you began thinking about suicide?

Suicide “contracts”

• 1st choice: a clear, unequivocal statement, declarative :
  • I promise you I will not kill myself.
    • This can be followed up with emergency plans to follow if anything happens which appears to threaten the promise.
• 2nd choice: a conditional statement:
  • I promise you I will not kill myself without first talking to you about it.
  • I promise I will not kill myself during the next week.
  • I promise I will not kill myself between now and our next session.
• If client cannot make a conditional statement, with convication and eye contact, emergency care plans may be necessary

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Deliberate Self-Harm

“Deliberate self-harm is defined as the intentional injuring of one’s own body without apparent suicidal intent.” 

(Klonsky, Oltmanns, & Turkheimer, 2003, p. 1501).

• superficial-moderate self-mutilation
• self-injurious behavior
• parasuicide
• self-wounding

In their review of previous literature, Klonsky et al. note that reports that approximately 4% of the general population & 14% of a college population report a history of deliberate self-harm 

(Klonsky, Oltmanns, & Turkheimer, 2003, p. 1501).

Klonsky evaluated 1,986 Air Force recruits, 62% male. Mean age was 20 years (s.d. 5), mean IQ was 104, 99% were high school graduates. 65% were Caucasian, 17% were African American, 4% were Hispanic, 3% Asian, 1% Native American, 10% listed race as “other.” 25 recruits who reported a history of a suicide attempt were excluded.

The Klonsky et al. study results found that approximately 4% of a nonclinical population had harmed themselves at least once, and that less than 1% had chronically engaged in self-harm. The prevalence rates were similar for males and females.

Individuals with a history of self-harm had more traits of the borderline, schizotypal, dependent, and avoidant personality disorders as measured by both self- and peer reports.

Their data suggested that, “self-harmers are better characterized as anxious than depressed.” (p. 1506).

This DSH is probably different from the self-injurious behavior seen in individuals with autism and other developmental disabilities.

Breau, Camfield, Symons, Bodfish, McKay, Finley, & McGrath (2003) looked at 101 nonverbal children between 3 and 18 years of age. They concluded that data did not support the hypothesis of less sensitivity to pain. Concluded that children with SIB have pain reactions similar to those without SIB. Their data suggested there might be two forms of SIB: 1) one form is less frequent, associated with chronic pain, and involves SIB directed near the site of pain. 2) less related to chronic pain and is directed at the head and hands.

DSH may play a role in affect regulation (especially in clients with “borderline” characteristics and adolescents); this self-injurious behavior is often carried out in secret and the individual attempts to avoid detection; DSH may also be use as an operant to effect the individual’s social environment (“manipulative” self-injurious behavior, also seen in individuals with “borderline” characteristics). Occasionally DSH may be seen in individuals with antisocial characteristics in an attempt to established the legitimacy of a “suicide attempt”; this usually represents deliberate malingering in an effort to avoid or minimize responsibility for prior behavior or actions.