Download Introduction Important Summary Important Summary Literature XY/2

XY/2 Evaluation of suicidal behaviour and nonsuicidal self-injury.
XY/2.1 Evaluation of suicidal behaviour. Suicide risk assessment.
Introduction
Suicide is the primary emergency in psychiatry. For the evaluation of suicide risk,
asking questions about suicidal thoughts, plans and feelings is necessary just as
exploring the past suicidal and medical history, and the risk and protective factors
of suicide.
The issue of suicide not only has particular importance because of the individual's
risk and suffering, but the emotional burden of the relatives losing the beloved
person and the clinicians who cared for the patient, and because of the national
health concerns of the question. The rates of completed suicide range between 240 per 100000 persons a year worldwide, 25-30/100000/year in Hungary, and the
number of suicide attempts is approximately 10-20 times higher.
Important
The following questions can help to assess the risk of suicide. It is important that
the phrasing of the questions would be clear and understandable for the patient.
The questions should be asked in the following order, from the feeling that the life
is not worth living to the plan or attempt of suicide.
- Have you ever felt that life was not worth living?
- Have you ever wanted to fall asleep and never wake up?
- Do you find your situation hopeless?
- Have you thought about death recently or wished if only you would die?
- Have you thought about harming yourself recently?
- Have you thought about killing yourself?
- Have you made a specific plan to commit suicide recently? Have you made
any preparations?
- Have you attempted suicide recently?
- Have you ever attempted suicide previously?
If the patient answers yes for any of the previous questions, additional questions
are necessary to clarify the circumstances:
- Since when have you had thoughts/plan like this? Since when have you felt so?
- How often have you had thoughts/plan like this?
- What (kind of life event/life situation) led you up to these thoughts/plans?
- If you have made any preparations for harming/killing yourself, what hold you
back?
- Do you have a firearm? Do you have a bigger amount of medicine at home?
- Do you have plans for the future?
- What would help you to feel more hopeful about future?
- Have you talked about your thoughts/plan to somebody?
If the patient attempted suicide/self-harm already, exploring the details of the
previous attempt(s)/self-harm are necessary:
- How did you attempt suicide before? Could you describe what happened?
- What kind of thoughts did you have/how did you feel before your suicide
attempt?
- How often did you attempt suicide/self-harm?
- Did you seek help before the suicide attempt? Did you receive treatment/help?
- What did you expect, what would be the consequences of the attempt? (e.g.
dying, injury, falling asleep, somebody finds you etc.)
- Did you expect to be discovered or you were found accidentally?
- What happened after? How did you feel? Did you receive treatment? Have your
thoughts changed since then?
If the patient has psychotic symptoms (e.g. delusions, auditory hallucinations),
detailed exploration of them is necessary:
- Could you describe the voices you hear?
- What do the voices say?
- How do you manage them?
- Has it ever happened that you did what the voice told you to do?
- Has it ever happened that the voice told you to harm or kill yourself?
- Do you feel guilty about or blame yourself for something?
- Do you have thoughts about having a serious illness?
Additionally, the exploration of the risk and protective factors of suicide is also
important (Table 2.). The recognition of the following mental disorders has
particular significance:
- mood disorder (e.g. depression or bipolar affective disorder),
- psychotic disorder/state (e.g. schizophrenia),
- substance or alcohol use.
These mental disorders significantly increase the risk of suicidal behaviour: 10%
of patients with schizophrenia and 20% of patients with bipolar disorder commit
suicide, and 50% of them attempt suicide at least one time in their life.
When assessing the risk of suicide we can differentiate static (anamnestic) and
dynamic (present) risk factors. Static risk factors are previous suicide attempt(s),
self-harm(s), suicide in the family history, major psychiatric disorder, severe
somatic illness or disability, divorce, widowhood, loss of job, retirement. Dynamic
risk factors are present suicidal thoughts, suicidal plan or intention, major anxiety
or agitation, hopelessness, burdening recent life event, present substance or
alcohol use.
Summary
Overall, the suicidal risk is significant and needs immediate intervention if the
patient has specific plan or prepared for kill or harm himself, attempted suicide
recently, feels hopeless, lacks social support, has mental disorder and has suicide
attempt is his past medical history.
XY/2.2 Nonsuicidal self-injury.
Nonsuicidal self-injury is any intentional, self-directed behaviour that causes
immediate destruction of body tissues. This behaviour is manifested in a variety of
forms, such as cutting, burning, severe abrading and punching, more rarely bone
breaking or auto-amputation.
As the first evaluation of many cases with nonsuicidal self-injury is done by
nonpsychiatrists, all clinicians have to be able to recognize the self-injurious
behaviour, to assess its severity, risks and in case of need to send the patients
towards psychiatric care.
The prevalence of nonsuicidal self-injury is 1-4% for the adult population, 15%
for adolescents, while it reaches 17-35% among undergraduates and college
students. The gender distribution according to studies is close to equal, but it
differs according to the method of the self-injury: men injure themselves mostly
with burning or hitting, women with burning or cutting. Mental disorders increase
the incidence of self-injurious thoughts and behaviour. Two to twenty percents of
psychiatric patients and 40-80 % of adolescents receiving psychiatric care report
previous self-injury. Psychiatric disorders increasing the risk of nonsuicidal selfinjury:
- borderline personality disorder (70-75%), one of the diagnostic criterion is selfinjury,
- dissociative disorder (69%),
- eating disorders (26-55%),
- major depression,
- alcohol dependence.
Important
The first step in the examination of patients with self-injury is the assessment of
suicide risk and defining the necessary emergency tasks as written above.
Clarifying the underlying intention, the method and the psychological effect helps
to differentiate the nonsuicidal self-injury from suicidal behaviour. In case of
nonsuicidal self-injury:
- the intention is to reduce the negative mood, negative emotion, not to cause
death,
- the most common method is cutting (70%), but more than two thirds of the
cases use 2 or more methods (burning, abrading, striking, biting, punching),
- self-injury entails the decrease of the negative emotions, the shifting of the
mood into a positive direction, while in case of suicide attempts the mood is
further deteriorating and feelings of disappointment and failure often occur.
When assessing the risk of nonsuicidal self-injury the physician has to look for the
following details:
- suicidal ideations during or before self-injury,
- types of self-injury in which the patient engages,
- age of onset of self-injurious behaviour,
- place (location) on the body that is injured,
- severity and extent of damage caused by self-injury,
- functions of the self-injury for the patient,
- intensity or frequency of intention(s) for self-injury,
- repetition and episodic frequency of self-injury.
The following symptoms and features indicate high risk:
- intense suicidal thoughts during, before or after the self-injury,
- the patient uses multiple types (more than 3) methods,
- the onset is in early childhood and has extended duration or history more than 6
months,
- the location of the injury are the genitals, breasts or face,
- the self-injury needed hospitalisation,
- the self-injury has any relationship to suicide (reduces suicidal thoughts or
intentions),
- repeated more than 50 times since the start and multiple times per week.
The application of psychotherapeutic techniques like empathic communication or
the motivational interview can also help in the examination.
With empathic communication we can make the patient feel that we pay attention
and understand his/her complaints, the causes behind the self-injury. For example:
“It seems you have gone through a lot with your girlfriend recently, and
sometimes you don’t know how to handle the entailing frustration.”
The motivational interview helps to assess the severity of state and the options for
change beside the understanding of the patient’s reasons. For that the questions
below (with specific examples of self-injury) should be useful:
- What are the effects of cutting in your life?
- It seems that self-injury has some functions for you. Does it have any
disadvantages if you continue this behaviour?
- Is there something that should motivate you to stop hitting yourself?
- It seems difficult to handle stressful situations without burning yourself. What
do you think, what your life would be like if you would not use this method?
- There are many options to get help for this problem. What do you think, do you
need help to stop cutting yourself?
Summary
Overall, the recognition and treatment of suicidal behaviour and nonsuicidal selfinjury - because of their frequency and importance – have particular importance in
all fields of medicine.
Literature
References:
Sadock BJ és Sadock VA. Kaplan&Sadock's Synopsis of Psychiatry (10. kiadás).
Lippincott Williams Wilkins, Philadelphia, 2007: 897-907.
Kerr P, Mueblenkamp J és Turner J. (2010) Nonsuicidal self-injury: A review of
current research for family medicine and primary care physicians. J Am Board
Fam Med, 23: 240-259.