Class 7 + 8 Flashcards
Epidemiology suicide
10th cause of death, 3rd leading cause 15-24. 11 suicides per day. 90% of those who commit suicide have a mental health problem. 80% of people who die of suicide are men.
Etiology suicide
Sociologic factors: egoistic: not strongly integrated in a group. Altruistic: excessive integration in a group. Anomic: integration in society is disturbed (divorce, loss of job).
Freud: aggression turned inward against an introjected love object.
Lost love object, narcissistic injury, rage and guilt, identify with a suicide victim, need for punishment, hopelessness, avoid humiliation, developmental stressors, loss of sense of control.
Decrease in serotonin
Hereditary (especially same gender)
Risk factors suicide
history of suicide attempts, psychiatric disorder, hopelessness, divorce, homosexual, occupation (physicians, law enforcement, dentist, artist, mechanic, lawyers, insurance agents), unemployed, military service, chronic pain, neurological disorder, traumatic brain injuries, childhood adversity, rural residence, family history of suicide, homelessness, live alone, have lost a loved one, or have experienced a failed relationship within one year; and possibly in patients with a history of violent behavior in the previous year, the anniversary of a significant relationship loss is also a time of increased risk, low IQ, violence and political coercion are associated with increased rates of suicide, as are economic downturns, advanced paternal age, after discharge, first week of hospitalization.
Protective factors suicide
Social support and family connectedness is protective against suicide, while family discord increases the risk of suicide. Pregnancy decreases the risk of suicide, as does parenthood, particularly for mothers. Religiosity and participating in religious activities is associated with a lower risk of suicide. Being in a relationship, being engaged in work/ school.
suicide attempt
a self injurious act committed with at least some intent to die as a result of the act. don’t have to actually hurt themselves
interrupted attempt
when person starts to take steps to end their life but someone/ something stops them
aborted attempt
when person starts to take steps to end their life but they actually stop themselves
colombia suicide severity rain scale components
suicidal ideation, intensity of ideation, suicidal behaviour,
Dx Greater violence risk:
epilepsy of temporal and frontal lobe, tumor in the limbic system or frontal lobe, trauma to the brain, encephalitis, schizo, MDD, SUD (speed, methamphetamine, cocaine) , BAD, neurocognitive disorder, antisocial, bpd, intermittent explosive
etiology of violence
Modeling, operant conditioning, neurophysiological disorders, biochem, socioeconomic: poverty, environmental: physical crowding, moderately uncomfortable temperature, use of subs.
Rx for violence
Clozapine decreases impulsivity, Trazodone 12,5-25 mg, SSRIS for violent elderly patients with dementia Clonidine, propanolol, pindolol, mood stabilizer (epival especially) LAI
4 key interview techniques to maximize validity of interview contente
Behavioral incident: describe a specific event; what did you do when you got home? Get them comfortable telling their narrative
Gentle assumption: how often do you think about suicide
Sx amplification: amplify number
Denial of the specific
Worst demographic for violence
young men in low socioeconomic status
Goal of risk assessment and management:
• Identify which circle an individual is in
• Identify individuals at risk for moving into a
smaller circle and prevent this from happening
Parasuicide
any nonlethal, deliberate self-harm behavior.
Elements of patient history most predictive of a serious suicide attempt
- Severe anxiety (92%) and/or panic attacks (80%)
- Depressed mood (80%)
- Recent loss of close personal relationship (78%)
- Alcohol or substance abuse (68%)
- Feelings of hopelessness (64%), helplessness (62%), and worthlessness (29%)
- Insomnia, anhedonia, chronic deteriorating medical illness
- Inability to maintain job or student status (36%)
- Recent onset of impulsive behavior (29%)
- Recent diagnosis of a life-threatening illness (e.g., cancer, AIDS) (9%)
Proximal
Risk for suicide individual
- Intensely stressful life event
- Argument w/ parents, girlfriend /boyfriend
- Personal failure / humiliation
- Incarceration
- Perceived loss of independence
- Other life event, losses
- Hopelessness
- Intoxication
- Panic attack?
- Stroke?
Proximal
Risk for suicide environment
- Contagion, e.g. death of acquaintance
* Firearm in home
Distal Risk individual
Mental disorder Substance use / abuse disorder Comorbidity Neurochemical vulnerability Family history of mental disorder/ suicidality History of physical/sexual abuse Previous suicide attempt
Distal Risk environment
Disruptive / dysfunctional, family environment Easy availability of firearms Stigma against mental illness Environment with few protective factors Community violence? Cultural depression / cultural grief?
Protection suicide individual
Enhancement of coping skills
Early identification of mental/ substance use disorder?
Appropriate treatment for mental/substance use disorder?
Appropriate medication management?
Protection suicide environment
Family cohesion Social support? Access to mental health and substance abuse services? Responsible firearm storage? Appropriately trained front-line providers?
Predatory violence
- The killer or perpetrator has often thought out the violence beforehand, frequently derives pleasure from the violent act itself, and feels little if any remorse.
- Seen in many rapists, sadistic perpetrators of children, and individuals with sociopathic personality structures.
Affective violence
- Impulsive violence caused by intense anger and emotion
- Often in response to interpersonal stress
- Frequently under the influence of alcohol and drugs
- Frequently seen in marital violence, child and elder abuse, and violence undertaken at the job or in the streets
Biologically
induced violence
• Pathophysiology
• Includes individuals who are suffering from biochemical
abnormalities such as schizophrenia, or mania.
• Structural damage
• includes people suffering from diseases such as brain tumors, partial complex seizures, intracranial infections, brain trauma, multiple sclerosis, and Alzheimer’s disease.
Proximal
Risk homicide individual
- Argument w/ parents, girl friend / boyfriend`?
- Personal failure / humiliation?
- Intoxication
Distal Risk homicide individual
- Mental disorder — esp: Schizophrenia (55%), Substance use / abuse disorder (41%)
- Comorbidity
- Neurochemical vulnerability
- Family history of antisocial parent
- Previous violence
Distal Risk homicide environment
- Adverse childhood environment (marital problems, alcoholism, depression, drug abuse, and anxiety conditions, such as panic disorder and phobias in the parents)
- Low economic status
- Environment with few protective factors
- Community violence?
homicide individual protection
Enhancement of coping skills
Early identification of mental substance use disorder?
Appropriate treatment for mental and susubstance use disorder?
Appropriate medication management?
homicide environment protection
Family cohesion
Social support?
Access to mental health and substance abuse services?
Appropriately trained front-line providers?
Hierarchy of safety
You- Patient- Community
Essential Points to ensuring your patient’s safety
Good interview style
Never completely trust the information provided by a suicidal or homicidal patient - Your assessment is incomplete without an accurate mental status examination and until you obtain colla al information
Never romise a patient confidentiality
How to interview about suicide
Presenting suicide events: past 48h
Recent suicide events: last 2 months
Past suicide events: all the life
Immediate suicide events: now
questions for Violence Assessmen
• What is the worst act of violence?
• Approximately how many acts of violence have
occurred?
• When was the most recent act of violence?
• Has violence been done to anyone in the past
against whom there is current violent ideation or
fantasy?
• Has a weapon been used in the past and, if so, is
it being considered for use presently?
• Is there an arrest and jail history related to
violence?
The Management of Suicidality
- Psychotherapy: cognitive therapy, DBT for bpd, problem solving, interpersonal, CBT
- Li: bipolar
- Clozapine: schizo
- ECT
Psychotherapy for violence
CBT individual/ group
Prh armacotherapy for Violence
Antipsychotics
Mood stabilizers, especially epival
Clozapine
LAI
