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Suicide In Youth

(3-24-15)

A continuum of suicidal behavior

  • Thoughts about suicide
    • passive, intermittent, infrequent, easily dismissed
    • active, constant, frequent, intrusive
    • Intent to die is a critical but difficult to evaluate aspect
  • Preparation for suicide: precursor behavior
    • saying goodbye, writing notes, giving away possession
    • procuring materials for attempt arranging for privacy
  • Attempts at suicide
    • 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 aspect alone as “lethality” also, sorry for the 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.
    • “suicidal gestures”
  • Death from suicide

Dr. Marsha Linehan (and some others) have 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). As reasonable as this suggestion might be, it has not affected common usage and the reader/listener is left to determine the exact meaning in any discussion of “suicide.”

Suicidal behavior needs to be distinguished from “self-injurious behavior” (SIB)–deliberately hurting oneself (without the intention to die). SIB, also referred to as Deliberate Self-Harm and/or Self-Mutilating Behavior, occurs in some neurological conditions, is often seen in Borderline Personality Disorder cases, and sometimes occurs during adolescence (possibly in association with depression and/or “rebellious behavior.” Some, such as Dr. Linehan, view self-injurious behavior as a risk factor for suicide. While this may be true in certain populations, e.g. individuals with Borderline Personality Disorder, it may not be in all populations. In any event, SIB and suicide are different and each needs to be considered in its own right.

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.

Prevalence/Age/Sex/Method

Below a certain age (usually 4 or 5 years) we don’t speak of “suicide”, although children may certainly cause their own deaths. Self-inflected deaths below a certain age will usually be viewed as “accidental” deaths–with some justification: our everyday understanding of suicide is of “intentional” self-inflicted death. For this to be the case, two elements seem necessary:

  1. The individual understands the likely consequences of their actions
  2. The individual understands the idea of “death” as an irreversible state

Beyond the age at which we are willing to consider suicide as a possibility, the association with age is positive: rates are very low in childhood, increase significantly during adolescence, and continue increasing across the life span.

Male and female children both attempt and die from suicide at approximately equal numbers; beginning in adolescents a “sex pattern” difference emerges: females attempt more often; males die more often. This is strongly associated with the emergence of differences in choice of method: young males and females both tend to use high lethality methods (firearms and hanging), during early adolescence females tend to switch in greater numbers to lower lethality methods (overdoses, poisons, slashing wounds)–leading to greater survival numbers (and more reattempts). This trend may be weakening, but is still evident in data from the final decades of the 20th century.

Risk factors for suicide

Demographic — in children there are relatively few demographic risk factors other than age (in constast to adults where sex, race, SES, ethnic background, nationality, employment, marital status, and religion or childhood history are significant predictors

  • Personal history
    • history of mood disorder
    • history of substance use disorder
    • problems in school
    • poor health
    • suicide attempt by friend
    • childhood adversity
    • social disadvantage
  • Personal status
    • psychiatric disorder
      • Mood Disorder (depression)/Schizophrenia/Substance Abuse
    • Prior attempts
  • Proximal predictors
    • Blood Alcohol Level/intoxication/substance use
    • Disruption of human relationships
    • Loss of communication opportunities
    • access to methods (especially firearms)

Suicide Prevention

  • “Rational suicides”
  • “Romantic infatuation with suicide”
  • suicide as a political/religious statement and suicide as terrorism
  • typical suicide attempts and completions: conflict, acute crisis, despair–permanent solutions to short term problems
    • Establish communication
    • Delay impulsive decision making
    • Instill realistic hope
    • address underlying problems (depression, substance abuse, environmental stresses, abuse)

Self-Injurious Behavior (SIB)

  • Self injury, Deliberate Self Harm, Nonsuicidal Self-Injurious Behavior, “cutting” all refer to behavior intended not to end life but to inflict pain/disfigurement/mutilation on the individual engaging in the behavior.
  • SIB is associated with some clinical syndromes (Autistic Disorder, Borderline Personality Disorder), some neurological condition (Lesch-Nyhan Disease), some environmental-subject interactions (severe intellectual disability individuals placed in low-stimulation, institutional settings), and some age cohorts (older children and teenagers in current America).
  • In neurologically intact individuals SIB is often understood by professionals as a attempt to regulate aversive emotions
    • Less commonly SIB can be seen as a method of communication (“cry for help”) or method of social influence (manipulation); these perspectives are not mutually exclusive
    • The goal of professionals is usually to eliminate SIB in youth seen for counselling; youth who engage in SIB may have somewhat different goals
  • Teaching alternative (healthier, more adaptive, more mature) methods of emotional regulation is a common treatment approach to SIB
  • Shapiro (2008) is a good workbook for teenagers who self-injure
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