Suicide ,self harm , and violence presentation

1. Suicide ,self harm , and violence presentation Prepared by : Mr. Ayman El Ghouty Supervised by : Dr. Abed Alkareem Radwan

2. Suicide What do we know about it? How can we prevent it?

3. Background Information • Suicide: Intentionally causing one’s own death. • Sometimes difficult to determine intention • High speed, 1 car accidents • Auto-erotic hangings • Reluctance to label as suicide because of stigma • Life Insurance myth: Suicidal deaths are covered if the death occurs 2 years after policy was purchased.

4. Risk Factors • Adults • Depression, alcohol abuse, cocaine use, separation or divorce. • Youth • Depression, alcohol and drug use, aggressive and/or disruptive behavior in school.

5. Suicide Prevention • Warning Signs • Signs are often not verbal. • Giving away beloved objects. • Changes in eating or sleeping habits. • Displaying a sense of calmness after a period of agitation.

6. Characteristic Unbearable pain Frustrated needs Seeking a solution Hopelessness Cognitive tunnel vision Communication of intention Guideline Reduce the pain Fill needs Provide alternatives Provide hope Increase options Listen, involve others Practical Measures for Helping

7. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric IllnessCo-morbidity Neurobiology Personality Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior

8. PROTECTIVE FACTORS • Children in the home, except among those with postpartum psychosis • Pregnancy • Deterrent religious beliefs • Life satisfaction • Reality testing ability • Positive coping skills • Positive social support • Positive therapeutic relationship

9. AFFECTIVE DISORDERS AND SUICIDE High-Risk Profile: • Suicide occurs early in the course of illness • Psychic anxiety or panic symptoms • Moderate alcohol abuse • First episode of suicidality • Hospitalized for affective disorder secondary to suicidality • Risk for men is four times as high as for women except in bipolar disorder where women are equally at risk

10. PERSONALITY DISORDERS AND SUICIDE • Borderline Personality Disorder • Lifetime rate of suicide - 8.5% • With alcohol problems -19% • With alcohol problems and major affective disorder -38% (Stone 1993). • A comorbid condition in over 30% of the suicides. • Nearly 75% of patients with borderline personality disorder have made at least one suicide attempt in their lives. • Antisocial Personality disorder • Suicide associated with narcissistic injury / impulsivity.

11. CHARACTERISTICS OF A SUICIDE PLAN Risk / Rescue Issues: • Method • Time • Place • Available means • Arranging sequence of events Jacobs (1998)

12. PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE • Hopelessness • Impulsivity / Aggression • Anxiety • Command hallucinations

13. DETERMINE TREATMENT SETTING AND PLAN • Attend to issue of patient’s safety. • Assess treatment plan/setting/alliance. • Somatic treatment modalities: • ECT – used to treat acute suicidal behavior • Benzodiazepines – may reduce risk by treating anxiety • Antidepressants • Lithium, Anticonvulsants • Antipsychotics, recent study on Clozapine • Psychotherapeutic intervention – widely viewed as helpful for suicidal patients, evidence is limited • Provide education to patient and family. • Monitor psychiatric status and response to treatment. • Reassess for safety and suicide risk frequently.

14. SOMATIC TREATMENTS

15. Psychotherapy Regardless of theoretical basis, key element is a positive and sustaining therapeutic relationship Recommended (primarily from clinical consensus) • To target issues • Denial of symptoms • Lack of insight • To manage high risk symptoms • Hopelessness • Anxiety Effective treatment in high risk diagnoses • Depression • Personality disorders (use of D.B.T.)

16. So when, therefore is self harm a problem? Intensity functioning culturally innapropriate repetitiveness disruption distress control pervasiveness severity of outcome when a medic says!!

17. Define self harm To do so, differentiate between self injury and suicide and what about para-suicide?

18. Self Injury is the “ Deliberate damaging of Body Tissue without the conscious attempt to commit suicide” DSM IV TR 3 types

19. Self harm Any harmful act to the self, or omission, in which the direct intent is not to dieSmith 2003

20. What then are the intents in self harm if it is not to die? To survive To communicate To cope To feel better To get help Transfer emotional pain to physical To show I am different To heal To see blood To check I’m alive To feel something I deserve it/punish self To punish others To dissociate To control something Its complex!!

21. Self Injury in psychiatryThe three types referred to are:- • Major self Mutilation • Stereotypic self mutilation • Superficial or moderate self mutilation Singular, Episodic, Repetitive

22. So where are we now?

23. Classifying self harm • 1st separate the pathological from the culturally sanctioned

24. Classifying self harm • Culturally sanctioned • Rituals Reflect community tradition, underscored by deep symbolism, link person to community, done to heal, express spiritual enlightenment, marks social order • Practises • Little underlying meaning, may be fad or fashion, ornament, link to cultural group, medical-hygiene reasons

25. What forms of self harm are culturally acceptable? • Neck stretching • Tattooing • Facial scarring • Crucifixion • Lip plates • Piercing • Flagellation • Starvation (fasting)

26. What forms of self harm then are acceptable as fashions? • Tattooing • Piercing • Heroin? • Food • Body modification • Cosmetic surgery • Tongue splitting

27. So how can we assess severity and when to intervene?

28. Assessing risk and safety in self harm (SHARS) Risk and safety should be jointly considered based on the 5 domains of self harm

29. Self Harm Assessment of Risk & Safety (SHARS) About Judgement Considering 5 domains Professional, client and carers opinion Agreeing the dialectical approach

30. 5 domains of self harm • Directness • Intent • Potential lethality • Repetitiveness/frequency • Control/distress

31. Self harm is still not yet a diagnosis in itself it is associated with:- • Post Traumatic Stress Disorder • Dissociative Identity disorder • Eating disorders • Character or personality traits (BPD) • Substance abuse • Clinical depression • Psychosis (coping & bargaining) 1.1.2

32. So what are the common life experiences of those who self harm • Childhood physical or sexual abuse • Violence at home • Stormy parental relationships or broken homes • Loss of a parent through death or divorce • Lack of emotional warmth from parents/neglect 2.1.1

33. So what are the common life experiences of those who self harm • Hypercritical fathers • A history of medical procedures or illnesses resulting in significant hospitalisation in childhood • Parental depression or substance abuse • Confinement in residential establishments • Work in the paramedical fields 2.1.2

34. And what personality factors are associated with self harm by psychiatry • Perfectionist tendencies • Dislike of body shape • Inability to tolerate intense feelings • Inability to express emotional needs or experiences • Prone to rapid mood swings 2,2.1

35. Other life events associated :- • Loss or abandonment • Social isolation, confinement or helplessness • Rejection • Failure • Anger • Guilt 3,1.1

36. How many people self harm 1.4% lifetime incidence 1,400 per 100,000 population Prisoners with PD 24% Institutionalised people 13.6% FE students 12% Bulimia 40.5% Anorexia 35% MPD/DID 43%

37. Dysphoria People who self-injure tend to be dysphoric -- experiencing a depressed mood with a high degree of irritability and sensitivity to rejection and some underlying tension -- even when not actively hurting themselvesHerpertz (1995)

38. “Self harmers in psychiatric services are seen as attention seeking, are disliked by staff and are seen as in control of manipulative behaviour”.

39. Institutional wisdom perceives these “performances” as the maladaptive attention seeking malignancy of untreatable psychopaths. 5,2.1

40. Recent studies have suggested some alarming links between sexual abuse and the development of mental distress in later life, many of these links made by the self harmer themselves. Romme & Escher (1993) Boevink (1995) . In their study Diclemente et al (1991) found that amongst adolescents in a psychiatric service who reported childhood sexual abuse, 83% cut themselves. This mental distress is believed to be a common factor which may manifest itself in many ways. The commonest of these ways is in some form of self harm. 7,4.1

41. Self injury is quite an obvious response to abuse. The need to “get rid of the filth” is often reported by survivors of abuse who cut themselves to get rid of internalised feelings of shame Dianne Harrison (1994) 7,4.2

42. A systematic model for making sense of your experiences and working toward your recovery • Turning points • Identifying • Exploring • Understanding • Resolving and moving on

43. Turning point • A clear turning point which may be a result of an event or an individuals inspiration which results in you resolving to move on and determining to conquer barriers to you living your life. Topor et al (1998)

44. Turning point activities • Give information • Inspire • Offer opportunities • Meet others • Have hope • Self help • Alternative belief systems DES, survival • Focus upon recovery not maintenance

45. Values and perceptions Write down, brainstorm all the different ways you use to cope with life As a group decide which are positive or negative coping strategies

46. Negative Positive Neutral

47. Identifying your experiences • Identifying and forming a clear view in your own language about what your experiences actually have been, how they have changed, when they happened and what were the effects upon you.

48. Activities to identify your experiences • Life history • write the three most important things in your life!! • Interviewing • Guiding • Specific questions • When did it start • What was happening • Why

49. Exploring your experiences • Exploring in depth why and how you have become distressed including any things that trigger your current experiences, relating it beyond yourself to your social system such as the responses of mental health services. What has helped, what hinders, who helps.

50. Activities to explore your experiences • Explore in depth • Look at dissociation • Look at how you feel before and after • How has it changed from 1st experience & why • What has helped you, what hasn’t • What are the real problems, is it self harm or other things or other people? • Most recent experience