Lecture 10 - Non-suicidal self-injury and Suicide Flashcards
Definitions
- Suicide: Death resulting from intentional self-injurious behavior, associated with
any intent to die as a result of the behavior - Suicide Attempt: A nonfatal self-directed potentially injurious behavior with any
intent to die as a result of the behavior - Interrupted Attempt: A person takes steps toward making a suicide attempt but
is stopped by another person prior to any injury or potential injury - Self-interrupted/ Aborted Attempt: A person takes steps to injure self but stops
self prior to any injury or potential for injury - Preparatory acts or behavior: Acts or preparation toward making a suicide
attempt - Suicidal Ideation: Thoughts of suicide
-is very common (spectrum) - Non-suicidal self-injurious behavior (NSSI): Behavior that is self-directed and
deliberately results in injury or the potential for injury to oneself
-Non-suicidal self-injurious behavior (NSSI) does NOT have the intent to die (if cutting yourself in order to practice for dying, would not count as non-suicidal self-injurious behavior)
Suicide statistics
- In 2016, 9th leading cause of death across all
age groups in Canada - Almost 4,000 people
- In Quebec: almost 900 people
- Males: 16.3 deaths per 100,000 people
- Females: 5.7 deaths per 100,000 people
- Suicidal thoughts: 3.4 million
- 1.1 million 18 to 34
- 487, 500 males 18 to 34
- 656,700 females 18 to 34
Suicide is a bigger problem than homicide in Canada in terms of mortality rates (10x more)
Key Elements (World Health Organization)
- Agency = self-initiated (but doesn’t have to be self-inflicted)
-ex: suicide by cop (provoking police so they kill them)
-can also be the absence of action (ex: not taking insulin as diabetic) - Intent = = desire or intent for death
-what differenciates nssi from suicide attempts (even if severe injury)
-does not equal risky behavior. Ex: sky diving, drunk driving… dangerous but no intent to die - Outcome = actual and or perceived potential for death from the behaviour
-injury doesn’t have to occur
-doesn’t have to actually be life-threatening
-as long as person doing it believes in potential for death
Ex: even if can’t die from idk, drinking a bunch of coffee, if the person thinks they can die from it and is trying to, would still count as a suicide attempt
(The vignette with the drunk man who shot himself during Russian roulette would be none of the options on the slide. More like accidental self-injury)
Suicide and NSSI in the DSM
- Prior to DSM-5, suicide and NSSI
were listed as symptoms of
Depression and BPD - DSM-5 now includes under
“conditions for further study,” - Suicidal Behavior Disorder
- Nonsuicidal self-injury disorder
Research Methods in Suicidality
Challenges
* Rare
* Etiologically complex
* Difficult to study longitudinally
* Stigma/ legal constraints
* Replication
Common research methods
* Archival → Data is obtained from pre-existing records, databases. Look at
how variables relate to each other at any given moment
* Psychological Autopsy → Reconstruct what a person was like before the
suicide through interviews with family, friends, co-workers, etc.
* Big Data → passively collect data from individuals (e.g., geolocation, social
media, activity trackers, phone calls, purchasing history, etc.)
* Experimental → Compare individuals’ responses to tasks,
manipulations, etc.
* Treatment Studies→ Randomly assign people to different conditions
(or treatments) and compare outcomes
- Waitlist Control
- Placebo
- Alternative Treatment
* Meta-analysis → pools results from separate but similar studies to get a
more accurate estimate of the effect
Epidemiology
Data almost exclusively from western samples
Hard if suicide defined in different ways (stigma/legal constraints)
Gender
* Women attempt suicide at
significantly higher rates than men in
N. America
* 77% of deaths by suicide are male
(women more attempts, men more suicide)
* 4.4:1 → 3.6:1
* Greater increases among women
Gender Differences: Proposed Explanations
* Base Rates: women have higher rates of a lot of disorders (mdd, bpd…)
* Lethal means: men tend to use more lethal means (hanging and firearms) vs. women (ingesting toxic stuff and drowning)
* Access: men have more access to firearms in North America
* Greater Intent: inconsistent evidence, hard to measure
* Mental Health Care: women use mental health care more, so we know more about their attempts
* Cultural acceptance: failed attempts/seeking help/reporting attempts attributed to more feminine qualities (attention seeking, manipulation…)
* Reactions from others: women might receive more support than men after attempt
Highest rate in white people and indigenous people in North America
Among kids 5-12, black kids much higher rate than white children
Suicide and First Nations Populations
* Canadian First Nations people have
among the highest rates of suicide in
the world
* Not equally distributed across first
nation populations
* Durkheim
- Language and community cohesion
-Anomie (lack of feeling of belonging)
-In First Nations Populations, greater knowledge of the language of the group = way lower risk of suicide
* Higher community rates of a number
of risk factors
Suicide Mortality: means (North America)
* Most common methods use to
attempt (!) suicide (in order):
- Poisoning
- Cutting
- Stabbing
Most common reason for death (!) from
suicide (in order) in US/ Canada
* Firearm suicides/ Hanging
* Suffocation/Suffocation
* Poisoning/ Poisoning
* Fall/ Firearm
Lower suicide rates in Catholic countries than Protestant
Risk & Protective Factors
Risk factors for POPULATIONS, not individuals
*Risk factors are NOT warning signs
*Some are modifiable (e.g. depression, access to lethal means), and
some are not (e.g. race, genetic predisposition, family history of
suicide)
*Reducing risk factors and increasing protective factors can help
prevent suicide (we think…)
*See list of risk factors
Proximal risk factors (proximal to attempt)
* Intoxication– something like 25-50% of adults who die by suicide are
intoxicated at the time of death. Usually alcohol, but sometimes other substances
as well.
* Rates are higher in younger people
* Access to means– people who have greater access to lethal means are more likely
to die by suicide (treatment = means restriction)
Protective factors
* Treatment– either psychosocial or pharmaceutical
* Lithium and clozapine (for bipolar and psychosis, respectively)
* Preventative interventions like working to reduce aggressive behaviors in early
elementary school seems to delay or prevent the onset of suicidal behaviors in
young adulthood
* Culturally-influenced coping strategies, like values reflecting strong moral
objections to suicide , and high family support = lower incidence of ideation and
attempts among Latinos
Suicide Contagion in the Media
* Exposure to the suicide or suicidal behavior of one or more
persons influences others to engage in these behaviours.
* Exposure can occur via multiple channels (e.g.,
newspaper/tabloids, internet, television, fiction).
* Rates of suicide/suicidal behaviors appear to be influenced by:
o Frequency of media reporting – dose dependent.
-More frequent reporting = more contagion
o Content of media reporting – e.g., dramatic headlines,
front page, explicit about suicide methods.
-More dramatic headlines, explicit about suicide methods= more contagion
o Positive/negative reporting biases – e.g., attitudes toward
suicide, portrayal of suicide completers, consequences.
-Positive reporting of the suicide, not mentioning the effect on other people= more contagion
* Unclear how suicide contagion occurs.
Etiology
Biological Factors
* Evidence from twin studies that
suicidal behaviors are geneticallyinfluenced
* Adoption studies: rates of suicide in
biological relatives of adoptees who
died by suicide higher than rates in
adopted families
* What is inherited?
- Impulsivity
- Fearlessness
Impulsivity and Fearlessness
* Impulsivity has many dimensions
- Poor premeditation, sensation-seeking,
lack of perseverance, negative urgency
* Negative Urgency higher in both
ideators and attempters (compared to
controls)
* Poor premeditation higher in SA (suicide attempters)
* Neither SI (suicide ideators) nor SA higher in sensationseeking or lack of perseverance
* Fearlessness , reduced pain sensitivity
Ideation-to-Action
* Acquired Capability?
* Thomas Joiner: Interpersonal
Psychological Theory
- Exposure to painful and fearsome stimuli
reduces innate fears of pain and death
- Making it easier to approach the task of
attempting suicide
* 3-Step Theory (Klonsky & May)
- Practical
- Dispositional
- Acquired
* Reduced fear of pain and death
Late Positive Potential (LPP)
Sensitive to motivational salience of
images, broadly defined
* Personally-salient images
* Targets
* Ongoing elaboration and sustained
attention
Neutral (clock), pleasant (babies) and unpleasant (snake) images
152 outpatients (all with anxiety, MDD, bipolar) with
no history of suicide attempts
83 outpatients with a history of suicide attempts
Control for current suicidal ideation
Passive picture viewing task (threatening, gory
images; erotic, affiliative images; neutral images)
-Decreased neural response to threat
differentiates patients who have attempted suicide from non-attempters with current ideation
Distinguishing Attempters from Ideators
* Meta-analysis of 27 studies comparing 12 sociodemographic and clinical variables
between suicide attempters and ideators.
1. Depression severity **
2. PTSD **
3. Depressive disorder **
4. Hopelessness
5. Anxiety disorder
6. Drug use disorder
7. Alcohol use disorder
8. Sexual abuse
9. Marital status
10.Race
11.Gender
12.Education
**Suicide ideators versus nonsuicidal individuals
(relisten cuz idgi)
Environmental Influences on Capability
- Capacity can arise through practice, habituation,
experience: - Playing more hours of violent video games
correlated with greater capacity, even when
controlling for previous painful life events - Among veterinary students, greater exposure to
euthanasia is associated with increased
fearlessness - Among physicians, greater exposure to
provocative work experiences (performing
surgeries or treating traumatic injuries), is
associated with increased capacity
Could very well be an active gene-environment correlation
Ex: already don’t fear death and pain… therefore choose a path like vet where you have to deal with pain and death often… and being exposed to it (habituated) also increases your risk
NSSI: Course and Prevalence Rates
- Like suicide attempts, NSSI onset tends to peak during adolescence/ young
adulthood - NSSI has slightly earlier age of onset (around 13) compared to suicide attempts
(around 16) - Rates of NSSI may decrease with middle age
- Lifetime prevalence of NSSI: 13-28% worldwide
- In clinical samples as high as 80%
- Prevalence fairly stable in all regions of the world that have been studied
NSSI: Methods, Lethality, Frequency
- Suicide Attempts: Most often highly lethal methods
- Hanging
- Ingestion of toxic substances
- NSSI: low-lethality behaviors that result in minimal damage
- Cutting
- Skin abrading
- Interfering with wound healing
- Banging/ self-hitting
- Burning
- Number of methods:
- Most people who endorse repeated NSSI use more than one method (average of 4)
- People endorsing Suicide Attempts often use the same method, but increase the lethality
NSSI: Sexual Orientation and Gender
- Male-female inconclusive
-Inconclusive which sex does nssi more - Rates of NSSI higher in LGBTQ
individuals than heterosexual - Risk for NSSI (and suicide attempts)
peaks during the coming-out process
-Almost no longitudinal studies of nssi in lgbt… - Risk somewhat more pronounced for
males than females
NSSI: Functions
Multiple functions
Interpersonal:
* Autonomy
* Interpersonal boundaries
* Interpersonal influence
* Peer Bonding
* Revenge
* Sensation seeking
* Toughness
Intrapersonal:
* Affect Regulation !!!!!
* Anti-dissociation
* Anti-suicide
* Marking distress
* Self-punishment
NSSI= negative reinforcement
NSSI in real-time
* If participants had intense but brief thoughts about
self-harming, they were more likely to do it.
* Thoughts about NSSI were more likely to occur when
participants were feeling overwhelmed or
scared/anxious.
- Feeling rejected, holding anger towards oneself or
others, self-hatred, feeling numb/nothing predicted
NSSI.
* Function of NSSI: Most common reason was to
decrease/distract from negative thoughts/feelings
(64.7% of episodes).
Study:
131 females with bulimia nervosa
* 19 with NSSI and 112 without NSSI
* Collected EMA over 2-week period
* Reported engagement in NSSI (“I cut
myself”, “I scratched myself”, “I burned
myself”, “I hit myself”, and “I banged my
head”) as well as positive and negative
affect.
Positive affect went up and negative affect went down after NSSI onset
Relationship to Suicide
* Up to 85% of people attempting suicide have a history of NSSI
* College students with a history of NSSI 8 x more likely to have suicidal ideation, 25
times more likely to have attempted suicide than students with no NSSI
* BUT many people with a history of NSSI do not go on to attempt suicide (more
than 60%)
* Repetitive and/or severe NSSI seems to be a particularly strong predictor
