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Alan Apter M.D

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Title: Alan Apter M.D


1
suicide
  • Alan Apter M.D
  • Feinberg Child Study Center
  • Schneider Childrens Medical Center

2
Suicidal Behaviour a Major Public Health Problem
in Europe In many European countries suicide
is the leading cause of death among young people
more common than death from road accidents
3
SUICIDE
  • DEFINITIONS
  • EPIDEMIOLOGY
  • AETIOLOGY/RISK FACTORS
  • CLINICAL CONSIDERATIONS

4
SUICIDE
  • PRIMARY PREVENTION
  • SECONDARY PREVENTION
  • TERTIARY PREVENTION

5
DEFINITIONS
6
Suicide Spectrum
  • Suicidal ideation "Thoughts of serving as the
    agent of ones own death. Suicidal ideation may
    vary in seriousness depending on the specificity
    of suicide plans and the degree of suicidal
    intent"
  • Suicidal threats
  • Suicidal gestures "Suicidal behaviors judged to
    be non-serious in intent or medical lethality"

7
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8
Suicide Spectrum
  • Deliberate self harm Willful self-inflicting of
    painful, destructive, or injurious acts without
    intent to die
  • Suicide attempts Self-injurious behavior with a
    nonfatal outcome accompanied by evidence (either
    explicit or implicit) that the person intended at
    some level to kill him/her

9
Suicide Spectrum
  • Interrupted attempt The person is interrupted
    (by an outside circumstance) from starting the
    self-injurious act

10
Continuum Theory Of Suicide
  • Suicidal Thoughts
  • leads to
  • Suicidal Threats
  • Leads to

11
Suicidal Gestures Leads toSuicide
Attempts leads to Failed Suicide leads
toCompleted Suicide
12
Discontinuity TheorySuicidal
IdeationSuicidal ThreatsSuicidal
GesturesSuicide AttemptsSerious Suicide
Attempts
13
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14
Suicide attempts
Completed suicide
15
Consequences of Suicidal Behavior
  • School dropout
  • Leaving home
  • Motor accidents
  • Police arrest
  • Whole spectrum of high risk behavior

16
EPIDEMIOLOGY
17
EPIDEMIOLOGY
  • SEX
  • AGE
  • GEOGRAPHY
  • SOCIECONOMIC STATUS
  • ETHNICITY
  • RELIGION
  • COHORT STATUS

18
EPIDIMIOLOGY OF SUICIDE
  • 300 rise in fatal suicide
  • gt700 rise in non fatal suicidal behavior
  • 10- 30 of adolescents think seriously about
    suicide

19
Attempted Suicide
  • Between 100 and 300 per 100,000
  • Preponderance of females in all countries
  • 50 percent of attempters under 30
  • Excess of divorced persons

20
Attempted Suicide Rates
  • Lower social classes overrepresented
  • Depression in 35 to 79 percent of cases
  • Females aged 15 to 19 - highest rates
  • 1 in 100 in this group attempt suicide each year
  • Highest rate for males is in aged 25 to 29
  • 1 in 200 attempts suicide each year

21
Suicide
  • Suicide rates increase with age
  • Male suicides peak after age 45
  • Females peak after age 55
  • Rates of 40 per 100,000 men gt 65

22
Suicide
  • Males at all ages commit suicide more often than
    females
  • Male female suicide ratios range from 21 to 71
  • Males use more violent methods, like hanging,
    shooting, and jumping

23
Suicide
  • Females more often overdose or drown
  • Ethnic and minority groups tend to be more
    cohesive and have lower suicide rates
  • Rate of suicide among whites is nearly twice that
    among nonwhites (in the US)

24
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25
Attempted suicide by age and sex Holon-Bat Yam
26
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27
Suicide by age
28

29
SUICIDE IN INDIA
30
Homicide and suicide rates by year
31
Total suicide rates per 100,000 for 15 year olds
and over in European countries
Source World Health Statistics Annuals (WHO).
Latest available year. Wasserman, D., Jiang, GX.
32
Change in percentage of suicide rates for males
aged 15 years and over in European countries
between 1989-90 and 1995-96.
Source World Health Statistics Annuals (WHO).
Latest available year. Wasserman, D., Jiang, GX.
33
EPIDEMIOLOGY
  • ELDERLY COMMIT/YOUNG ATTEMPT
  • PROTESTANTSgtCATHOLICSgt
  • JEWSgtMUSLIMS
  • POOR ATTEMPT/RICH COMMIT
  • BLACKSltWHITES
  • HISPANICS AND S.EUROPEANS ATEMPT

34
AETIOLOGY/RISK FACTORS
35
AETIOLOGY/RISK FACTORS
  • PSYCHIATRIC ILLNESS
  • ALCAHOLISM SUBSTANCE ABUSE
  • PHYSICAL AND SEXUAL ABUSE
  • FAMILY AND GENETICS

36
Risk Factors (ii)
  • CONTAGION
  • AVAILABILITY OF MEANS
  • PERSONALITY FACTORS
  • BIOLOGY

37
PSYCHIATRIC ILLNESS
  • DEPRESSION
  • SCHIZOPHRENIA
  • ANXIETY DISORDERS
  • DISSOCIATIVE DISORDERS

38
PSYCHIATRIC ILLNESS
  • CONDUCT DISORDER
  • ANOREXIA NERVOSA
  • BULIMIA NERVOSA
  • PERSONALITY DISORDERS

39
Risk factors for youth suicide
  • Psychiatric disorder/Affective disorder
  • Personality disorder- especially BPD
  • Psychiatric illnesses dangerous when more than
    one illness is present

40
Four co-morbid constellations
  • The combination of schizophrenia, depression and
    substance abuse
  • Substance abuse, conduct disorder and depression
  • Affective disorder, eating disorder and anxiety
    disorders
  • Affective disorder, personality disorder and
    dissociate disorder

41
ALCAHOLISM SUBSTANCE ABUSE
  • SELF MEDICATION
  • INCREASES IMPULSIVITY
  • AFFFECTS JUDGEMENT
  • EXACERBATES DEPRESSION
  • PROVIDES COURAGE

42
Personality Factors
  • Adolescents committing suicide while doing their
    military service in the IDF
  • Clinical work on an adolescent psychiatric
    inpatient unit
  • Work in the ER

43
Three sets of personality constellations
  • Narcissism , perfectionism and the inability to
    tolerate failure
  • Impulsive and aggressive characteristics combined
    with over sensitivity
  • Hopelessness often related to underlying
    depression

44
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45
The narcissistic perfectionist constellation
(case 1)
  • David told us that since age 8 he had been
    concerned by thoughts of death.
  • At 11 he told his friends that he would kill
    himself on the day of his Bar-Mitzvah. A week
    before the event he wrote an elaborate suicide
    note addressed to his parents in which he stated
    that he did not believe in the hereafter and that
    he would just cease to exist.

46
Contd
  • Despite being popular at school it soon became
    clear that David had no intimate friendships.
  • After one year of therapy and extensive
    psychological testing and observation no axis I
    diagnosis could be made.

47
Case 2
  • Jonathan was a 20 year old officer when he
    killed himself. His family was achievement
    oriented and had high moral standards. Their
    ideals stressed controlling ones emotions and
    living up to high standards.
  • Jonathan was a natural leader and popular with
    his teachers and peers. In the army he excelled
    and was selected as an instructor for new
    recruits. His superior commended him for his
    ability to perform under stress.

48
Case 2
  • He became totally involved in his new duties.
  • His platoon of trainees did rather well,
    although their overall performance rating was
    only average.
  • Following the course ceremony Jonathan went to
    his room and shot himself.

49
Features of psychological post mortem soldiers
  • Strong narcissistic and perfectionist patterns
  • Schizoid traits in personality
  • The will to prove their worth
  • High self expectations and hopes
  • Termed by being private/isolated people

50
  • THESE FEATURES ARE OFTEN COMPLICATED BY STRONG
    ISOLATIVE TRAITS

51
Distribution Of Axis II Diagnoses WithinComplete
Suicide Group
52
Case features
No turning for help or support
  • Minor setbacks spiral into disaster

Better death than shame
53
THE IMPULSIVE AGGRESSIVE CONSTELLATION
54
Case material case 1
  • Deborah had always been impulsive and
    oppositional from an early age.
  • At about the age of 11 she developed anorexia
    nervosa probably as a result of her being an
    accomplished dancer in a ballet troop.
  • With the onset of adolescence she developed
    very severe bulimia.

55
  • Her first admission to a psychiatric unit was
    occasioned by a suicide note, which she wrote to
    her teacher at school.
  • In the unit she was an impossible patient. By
    the time she was 22 she had made over 100 suicide
    attempts.
  • She received all kinds of psychosocial and
    biological therapies but to no avail, although
    with age (now 25) there is some tempering of her
    emotional instability.

56
Case material case 2
  • Amit, an 18 year old soldier killed himself a
    few months after joining the army.
  • He had grown up under conditions of economic
    deprivation.
  • The home atmosphere consisted of his mothers
    angry accusations and fathers passive silences.

57
Case 2 (contd.)
  • Amit did poorly in elementary school, however
    managed to complete a vocational high school with
    fairly good grades.
  • During high school his behavior changed and
    he became more compliant.
  • Amit looked forward to his army service,
    feeling that it would make a man out of him and
    requested a frontline unit.
  • He was a highly motivated recruit but tended
    to become flustered under stress .

58
Case 2 (cont.)
  • Once when returning late from a home pass, he
    was told that his next leave was cancelled.
  • He became irritable and angry.
  • When the teaching staff on the base broached
    the possibility of him being unsuitable for a
    front-line unit he became upset and insisted on
    continuing. While resting after a training
    exercise the other recruits began taunting him,
    Amit lost his temper and attacked his tormenter.
  • When the 2 were separated, he ran to his tent
    and shot himself with his weapon.

59
Personality constellation
  • There are certain individuals who, when faced
    with relatively minor life stressors will react
    with anger and anxiety and then develop a
    secondary depression which is often accompanied
    by suicidal behavior.

60
Van Praag (1997)
  • serotonin-related anxiety/aggression stressor
    precipitated depression

61
Thanatos
  • A tendency towards impulsive aggression may
    predispose suicidal behavior
  • The risk increases when psychiatric disorder and
    impulsive aggressive personality traits co-occur
    (Kety, 1986)
  • The wish to die the wish to kill and the wish to
    be killed (Freuds death instinct)

62
Adults vs. youngsters
  • There is now substantial evidence that suicide in
    younger people is a somewhat different phenomenon
    than among adults
  • Specifically, there is more impulsivity,
    substance abuse and other personality disorders
    in younger completed suicides

63
Genetics of suicidal behavior
  • Impulsivity and aggression are likely to be
    involved in the genetics of suicidal behavior
  • Higher familial loading for suicidal behavior was
    found in those attempters and completers who made
    more dangerous attempts and who were more
    aggressive

64
Serotonin, suicide and aggression
  • Finding the link between altered serotonergic
    neurotransmission, suicidal behavior and
    impulsive violence
  • Orders of magnitude have been noted in the
    correlations between measures of serotonin,
    suicide attempts, aggression and impulsive risk
    taking

65
Borderline personality disorder (BPD)
  • Traditionally associated with non fatal attempts
    and intentional self-damaging acts
  • One of the critical symptoms is affective
    instability
  • Most adolescent patients require psychiatric help
    and often suffer from major depression

66
Borderline personality disorder (BPD)
  • Anger and Violence - related symptoms.
  • Co morbid conditions conduct disorder,
    multi-impulsive bulimia and substance abuse
  • About 9 of patients eventually kill themselves

67
Impulsivity
  • The adolescent period in contemporary Western
    society is characterized by a distinctive pattern
    of morbidity and mortality
  • Suicidal behavior and completed suicide are more
    common in adolescence than in any other
    developmental epoch (save, for males, in old age)

68
Impulsivity
  • Leading causes of adolescent deaths ( in the
    West) accidents, homicide, and suicide--are
    preventable
  • Associated with life-styles characterized by
    impulsivity, recklessness, and substance or
    alcohol use

69
Impulsivity
  • Adolescence in the industrialized world
    characterized by increased health-threatening
    behaviors
  • Tobacco, alcohol, and drug use unprotected sex
    fighting reckless driving and weapon-carrying
    (Centers for Disease Control and Prevention, 2000)

70
Continuum of Self Destructiveness"
  • Covert (e.g. substance use, unprotected and
    precocious sexual activity, reckless driving)
  • Overt (e.g. self-mutilation and suicide attempts)
  • Suicidal behaviors and other risk behaviors share
    an association with psychiatric diagnoses such as
    mood, disruptive, substance use, and anxiety
    disorders

71
MENTAL-ILLNESS DEMORALIZATION HOPLESSNESS
CONSTELLATION
72
Case material case 1
  • David, aged 18, came from a family with a
    distinguished military background. He appeared to
    have had a poor self image during his school
    years, with intermittent periods of depression,
    insomnia, and weight loss.

73
case 1
  • David really looked forward to his army service,
    hoping that success there would redeem his low
    self esteem. He applied to join an elite commando
    unit but was turned down by the unit
    psychologist.

74
case 1
  • However, after advanced training David was posted
    to a combat unit. He seemed to do well but
    complained to his parents of being unable to
    cope. His parents alerted the unit mental health
    officer, who interviewed David.
  • During the examination David denied experiencing
    any depression or suicidal thoughts, but David
    was reassigned. The reassignment made David feel
    like a failure soon thereafter he fatally shot
    himself.

75
Case material case 2 (The case of Ellen West)
  • Ellen West was the daughter of wealthy Jewish
    parents who had great control over her.
  • Her father interfered twice when she became
    engaged, and when she finally married it was to a
    cousin.

76
Ellen West
  • From age 19 she developed the fear of becoming
    fat and by 21 had developed Anorexia Nervosa.
  • She was hospitalized but this only increased
    her suicidal thoughts.
  • She was discharged from the sanatorium at the
    request of her family.

77
The case of Ellen West
  • On the third day after returning home she
    appeared to be a changed person she ate and
    enjoyed a walk with her husband. That evening she
    took a lethal dose of poison.

78
Eating disorders
  • Adolescents with Bulimia Nervosa highly prone
    to suicidal behaviors
  • Impulsive and unstable life style.
  • Often make serious suicide attempts, which
    sometimes succeed.
  • Multi-impulsive bulimia was coined to
    describe the increasingly more common association
    between bulimia, BPD, substance abuse, depression
    and conduct disorder.
  • Although most patients with this co-morbid
    constellation of disorders are women, they are
    nevertheless at risk of repeated Para-suicide and
    fatal suicide.

79
The Canterbury suicide project
  • A case control study. It was found that there was
    an elevated risk for mood disorder, substance
    disorder and conduct disorder.
  • The study looked at male and female Finnish
    adolescents 10 years after having received
    outpatient psychiatric care. They found that 16
    male subjects but no female subjects had died.

80
Study findings
  • Current suicidal ideation and suicide attempts,
    poor psychosocial functioning and a
    recommendation for psychiatric hospitalization
    during the index treatment were associated with
    male mortality and suicidality.
  • The study found that 10 of male adolescent
    inpatients and about 1 female inpatients
    eventually kill themselves.

81
Study at psychiatric unit
  • One group recently surveyed admissions to our
    adolescent unit for a period of 24 months
  • Most suicidal patients suffered from Affective
    and Conduct disorder, others had eating disorders
    or anxiety disorders
  • The recent upsurge of drug and alcohol abuse in
    our country has led to an even higher incidence
    of suicidal patients in our ward

82
Depression
  • Major depression appears acutely in a previously
    healthy child.
  • Many other difficulties such as attention
    disorder or separation anxiety disorder before
    becoming depressed
  • Mood disorders tend to be chronic
  • In some cases they may be psychotic and have
    hallucinations and delusions of guilt

83
Bipolar disorder
  • Approximately 20 of all patients have their
    first episode during adolescence (bet.15-19)
  • Lack of clinician awareness has led to under
    diagnosis or misdiagnosis in children and
    adolescents

84
Unique clinical characteristics associated with
the early-onset form
  • Manic or depressive episodes
  • Increased risk for completed suicides.
  • Strober et al (1995)
  • Subjects made at least one medically significant
    suicide attempt.
  • Depressive and manic depressive disorders.
  • Patients who are male or in the depressed phase
    are at higher risk.
  • A major clinical problem is that severe
    depression is common in almost all the patients
    and its difficult to determine what is primary
    and what is secondary.

85
Schizophrenia
  • A common psychiatry disorder of adolescence
  • Some clinicians are hesitant to make this
    diagnosis which denies the child and family
    access to appropriate treatment
  • When the diagnosis is made the patient must be
    followed longitudinally to ensure accuracy

86
  • Patients and families should be educated about
    these issues
  • Many patients are depressed and suicidal.
  • About 10-15 of patients eventually commit
    suicide
  • Most victims are unmarried men who have made
    previous suicide attempts (often shortly after
    discharge)
  • Many adolescent patients also abuse drugs and
    alcohol - sometimes an attempt at self medication

87
Study
  • Participants
  • 32 adolescent inpatients with affective disorders
    (16 suicidal and 16 non-suicidal)
  • 33 adolescent inpatients diagnosed with BPD (17
    suicidal and 16 non-suicidal)

88
  • All subjects were diagnosed using the Hebrew
    version of the childrens version of K-SDADS.
  • The subjects were examined on 8 measures relevant
    to suicidal behavior
  • The BDI BHS SPS SIS ICS OAS MAI SRM.
  • Three dimensions were found on factor analysis
  • Anger-impulsivity-aggression
  • Depression and hopelessness
  • Suicidality

89
Anger
  • Anger in subjects was examined via a two way
    analysis of variance (diagnosis/suicidality)
  • Only diagnosis was found to significantly be
    associated with anger (F1,6117.31pgt0.0001)
    being significantly higher in the BPD subjects
    than in the depressive adolescents
  • The pair-wise Scheffe however showed that anger
    was significantly higher in the BPD suicidals
    than in the depressed non-suicidals

90
Impulsivity
  • Impulsivity in subjects was examined by a two way
    analysis of variance (diagnosis/suicidality).
    Only diagnosis was found to significantly be
    associated with impulsivity (F1,6133.66plt0.0001)
    , with anger being significantly higher in the
    BPD subjects than in the depressive adolescents.
    There was also a strong inter-action between
    impulsivity suicidality and diagnosis
    (F1,614.47plt0.039). Thus impulsivity was higher
    in BPD than in depressive and in suicidal BPD
    compared to non-suicidal BPD. There was no
    difference between depressive suicidals and
    depressive non-suicidals. In addition BPD
    non-suicidal subjects were more impulsive than
    depressive suicidal subjects. Thus impulsivity
    does not appear to play an important role in
    suicidal depression in adolescents.

91
Overt Aggression
  • Aggression in subjects was examined by two way
    analysis of variance (diagnosis/suicidality).
    Diagnosis was found to significantly be
    associated with impulsivity (F1,6119.14plt0.0001)
    as was suicidality (F1,6118.75plt0.0001), with
    anger being significantly higher in the BPD
    subjects than in the depressive adolescents.
    Aggression was significantly higher in the BPD
    suicidals than the BPD non-suicidals but did not
    differentiate between the depressed suicidals and
    the depressed non-suicidals. Thus impulsivity
    does not appear to play an important role in
    suicidal depression in adolescents.

92
Depressive symptoms and Hopelessness
  • Depressive symptoms (BDI) in subjects was
    examined by two way analysis of variance
    (diagnosis/suicidality).
  • Only suicidality was found to significantly be
    associated with depressive symptoms
    (F1,6131.99plt0.0001), with depressive symptoms
    being significantly higher in the suicidal
    subjects than in the non-suicidal adolescents in
    both diagnostic categories. Exactly the same
    findings were shown for hopelessness
    (F1,6126.31plt0.0001).

93
Suicide Intent
  • SIS was significantly higher in the depressed
    subjects than in the BPD subjects
    (t(31)2.69plt0.011).
  • SIS correlated negatively and significantly with
    impulsivity and aggression.

94
Suicide Risk
  • Was higher for suicidal than non-suicidal
    subjects but did not differentiate between BPD
    and depressive suicidals.

95
Conclusions
  • Suicidal behavior in depressed adolescents
    differs from that of BPD adolescents and the
    recognized connection between impulsivity,
    aggression and suicidality may well relate to BPD
    and conduct disorder only. This has important
    implications for adolescent suicide research in
    general since additional findings regarding the
    association with trauma, sex abuse, broken
    families, dissociation and drug abuse may also be
    related to only one specific type of suicide.
  • Suicidal behavior can no longer be regarded as on
    homogenous group of behaviors and although the
    non-nosological approach developed by Van Praag
    et al (1997) has been a very fruitful one,
    diagnostic and personality differences may well
    have a part to play in the understanding of
    suicide.

96
Canterbury Suicide Project
97
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98
Clinical Settings
  • Primary Care settings (family or pediatric
    practices)
  • Mental health outpatient departments (OPD)
  • Emergency rooms (ER)
  • Intensive care units (ICU)
  • Residential treatment programs

99
Primary Care
  • Early Detection of Internalizing Disorders
  • Early Treatment of Internalizing Disorders
  • Early Referral of Internalizing Disorders
  • Referral of Externalizing Disorders

100
Early Detection
  • Education regarding Childhood Depression and
    Anxiety
  • Routinely Examining for Childhood Depression and
    Anxiety
  • Routine Screening for suicidal ideation (Gould et
    al., 2005)

101
Early Treatment
  • Psycho education (Harrington, 2003)
  • Psychopharmacology (TADS, 2005)
  • Attenuation of Psychosocial Risk Factors (e.g.
    reporting abuse)

102
Early Referral
  • Psychotherapies are best before complications set
    in
  • Obviates long waiting lists for urgent cases
  • Facilitates secondary prevention

103
Internalizing Disorders- Summary
  • Gatekeeper education in terms of pediatricians is
    much under-researched
  • In adult primary care Depression and other
    psychiatric disorders are under-recognized and
    under-treated in the primary care setting
  • There is an opportunity for prevention because up
    to 83 of those who die by suicide have had
    contact with a primary care physician (PCP)
    within a year of their death, and up to 66
    within a month.

104
Internalizing Disorders- - Summary
  • PCPs lack of knowledge about and/or failure to
    screen patients for depression may contribute to
    non-treatment seen in most suicides
  • Therefore, improving physicians' recognition of
    depression and suicide risk is a component of
    most national suicide prevention plans
  • However the special role of the pediatrician is
    still neglected

105
Externalizing Disorders
  • PCP often called upon to deal with those
    externalizing disorders that highly predispose to
    suicidal behavior.
  • Include conduct disorders, attention deficit
    disorders and psychosexual disorders.
  • Diagnosis is often all too evident and the
    primary role of PCP is to alert and mobilize the
    appropriate social, educational and legal
    authorities.

106
Externalizing Disorders
  • Pediatricians and specialists in adolescent
    medicine need to be trained
  • in the diagnosis of sexual and physical abuse,
    the early stages of drug and alcohol abuse
  • and to learn to look for the physical signs of
    self cutting and disordered eating practices

107
Emergency Room Management
  • Establish relationship with suicidal individual
    and family
  • Stress importance of treatment
  • Admit suicide attempters with persistent wish to
    die or clearly abnormal mental state.
  • Obtain information from third-party.

108
Emergency Room Management
  • Availability and presence in the home of firearms
    and lethal medication must be determined
  • parents must be explicitly told to remove
    firearms and lethal medication .
  • warn about the dangerous disinhibiting effects of
    alcohol and other drugs.

109
Emergency Room
  • Value of "no-suicide contracts" is not known.

  • The child or adolescent might not be in a mental
    state to accept or understand the contract, and
    both family and clinician should know not to
    relax their vigilance just because a contract has
    been signed.
  • An appointment should be scheduled for the child
    or adolescent to be seen for a fuller evaluation
    before discharge from the emergency room.

110
Emergency Room Management
  • available to the patient and family (for example,
    receive and make phone calls outside of
    therapeutic hours)
  • have adequate physician coverage if away
  • have experience managing suicidal crises
  • have support available for him or herself

111
AFTER CARE
  • No after care was recommended to 28.5 of the
    boys and 25.7 of the girls
  • A negative attitude towards care and treatment
    staff is not unusual among young people

112
AFTER CARE
  • It is also common not only for adults, but also
    for young people to deny suicide acts with great
    vehemence (Spirito 1996).
  • Parents lack of involvement, ignorance of the
    suicide attempt, possibly negative attitude of
    their own towards care and desire to trivialize
    the suicide attempt make it easier for a
    teenager to turn down an offer of treatment.

113
Intensive Care Units
  • The Canterbury Suicide Project
  • Almost equal numbers of males and females made
    serious suicide attempts
  • Severe psychiatric disturbance

114
Intensive Care Units (Apter A, et al., Compr.
Psychiatry 42 (1) 70-75, 2001)
  • 80 subjects
  • 20 ICU suicidal,20 non-ICU suicidal, 20
    psychiatric non suicidal and 20 control subjects
  • ICU subjects had significant lower levels of self
    disclosure

115
Mental Health OPD
  • PCP - secondary prevention.
  • Are expected to detect those young people who are
    at risk for suicide
  • OPD -children who have already attempted suicide
  • Tertiary prevention

116
Mental Health OPD
  • No treatment has been proven fully effective in
    an outpatient setting
  • depression is the most common diagnosis
  • behavioral disorders common. (Kerfoot et
    al.,1996).
  • Also PTSD, eating disorders and schizophrenia
    (Herrington Saleem, 2003).





117
Psychosocial treatments
  • domiciliary oriented outreach programs
  • motivational enhancement methods,
  • Both non-effective in preventing suicide (Raj,
    Kumaraiah Bhide, 2001).

118
Psychosocial treatments
  • Dialectical behavior therapy effective in
    reducing suicide rate in a 6 month follow-up,
    non-significant in a 1-year follow-up (Linehan,
    Armstrong, Suarez et al., 1991)
  • Problem-solving skills training effective to a
    certain extent in decreasing psychological
    distress and the number of suicide attempts
    (Salkovskis, Atha Storer, 1990).

119
Consequences of Suicidal Behavior
  • School dropout
  • Leaving home
  • Motor accidents
  • Police arrest
  • Whole spectrum of high risk behavior

120
Treatment
  • Poor compliance
  • Is Emergency room intervention enough?
  • Mandatory hospitalization as a policy

121
Suicidal Behavior
  • Suicide and suicide attempts are frequently
    associated with
  • Axis I disorder
  • Depression
  • Co-morbid conditions

122
Risk factors beyond psychopathology
  • One of the most pressing clinical research
    questions is to determine what factors predispose
    suicide.

123
Risk factors for suicidal behavior
  • Social factors
  • Unemployment
  • Poverty
  • Availability of guns
  • National character
  • Biological factors
  • Personal factors

124
Adults vs. youngsters
  • There is now substantial evidence that suicide in
    younger people is a somewhat different phenomenon
    than among adults.
  • Specifically, there is more impulsivity,
    substance abuse and other personality disorders
    in younger completed suicides.

125
Genetics of suicidal behavior
  • Impulsivity and aggression are likely to be
    involved in the genetics of suicidal behavior.
  • Higher familial loading for suicidal behavior was
    found in those attempters and completers who made
    more dangerous attempts and who were more
    aggressive.

126
Serotonin, suicide and aggression
  • Finding the link between altered serotonergic
    neurotransmission, suicidal behavior and
    impulsive violence.
  • Orders of magnitude have been noted in the
    correlations between measures of serotonin,
    suicide attempts, aggression and impulsive risk
    taking.

127
Borderline personality disorder (BPD)
  • Traditionally associated with non fatal attempts
    and intentional self-damaging acts.
  • One of the critical symptoms is affective
    instability
  • Most adolescent patients require psychiatric help
    and often suffer from major depression.
  • Anger and Violence - related symptoms.
  • Co morbid conditions conduct disorder,
    multi-impulsive bulimia and substance abuse.
  • About 9 of patients eventually kill themselves.

128
MENTAL-ILLNESS DEMORALIZATION HOPLESSNESS
CONSTELLATION
129
Case material case 1
  • David, aged 18, came from a family with a
    distinguished military background. He appeared to
    have had a poor self image during his school
    years, with intermittent periods of depression,
    insomnia, and weight loss.
  • David really looked forward to his army service,
    hoping that success there would redeem his low
    self esteem. He applied to join an elite commando
    unit but was turned down by the unit
    psychologist. However, after advanced training
    David was posted to a combat unit. He seemed to
    do well but complained to his parents of being
    unable to cope. His parents alerted the unit
    mental health officer, who interviewed David.
    During the examination David denied experiencing
    any depression or suicidal thoughts, but David
    was reassigned. The reassignment made David feel
    like a failure soon thereafter he fatally shot
    himself.

130
Case material case 2 (The case of Ellen West)
  • Ellen West was the daughter of wealthy Jewish
    parents who had great control over her. Her
    father interfered twice when she became engaged,
    and when she finally married it was to a cousin.
  • From age 19 she developed the fear of becoming
    fat and by 21 had developed Anorexia Nervosa. She
    was hospitalized but this only increased her
    suicidal thoughts. She was discharged from the
    sanatorium at the request of her family.
  • On the third day after returning home she
    appeared to be a changed person she ate and
    enjoyed a walk with her husband. That evening she
    took a lethal dose of poison.

131
Types of Self-Harm
  • Superficial self-injurious behavior (SIB) such as
    self-cutting, scraping, burning (associated with
    Cluster B personality disorders, eating
    disorders, stress disorders)
  • Repetitive Stereotypical Behavior such as head
    banging and self biting (associated with
    intellectual disability, e.g. MR, autism)
  • Major self mutilation such as self blinding and
    castration (rare occurs in psychotic disorders
    and substance intoxication) Harris, JC, 2005

132
SIB as a stress related disorder
  • Common in laboratory animals, and domestic
    animals under stress, neglect, or isolation
  • Acral lick syndrome in dogs, feather plucking in
    birds, self-biting in rhesus monkeys
  • Prevalence in normal human development
  • 3.6 to 6.5 head banging rate at 8-36 months
    associated with teething, ear infections.
    Generally terminates by 36 mos. Harris, JC
    (2005)
  • 15 head banging rate at 9-18 mos.
  • (Hammock et al, 1995)

133
Prevalence of SIB
  • Among patients with eating disorders, 34.6 had a
    life-time rate of SIB (N376). (Paul et al, 2002)
  • Community samples in the U.S. vary in estimates
    from 4 to 38 of adolescents.
  • Canadian study found 13.9 of urban and suburban
    high school students had self-injured (Ross
    Heath, 2002).
  • A British report noted a 65 increase in SIB
    disclosures to national childrens hotlines from
    1999 to 2004.

134
Distinguishing SIB from Suicidal Behavior
  • Suicidal behavior is distinct from SIB in terms
    of motivation, intent, and lethality.
  • Suicidal behavior is accompanied by some degree
    of wish to die and intent to die i.e. the
    patient believes that the behavior will possibly,
    or will definitely, result in death.
  • Carefully assess motivations (to die, to escape,
    to influence someone, to communicate feelings, to
    relieve emotional distress, and intent (what was
    the expected outcome of the behavior?)

135
Suicide Continuum
Passive Death Wish
Suicidal Ideation, no method
Suicidal Ideation with method
Attempt
Completion
Gesture
136
Assessing Current Safety
  • Assess the presence or absence of suicidality and
    the degree of severity (frequency, intensity,
    duration) over the past 48 hours or since last
    visit.
  • Negotiate No-Suicide/No Harm Safety Plan.
  • Collaborate and review this plan with family.
  • If family conflict is a common precipitant to
    suicidality or self harm, help teen and family
    negotiate a truce.

137
Formulating the Safety Plan
  • A collaborative process
  • Includes the phone numbers of trusted adults,
    therapist, 24-hour emergency coverage
  • Includes a set of coping strategies (written card
    containing specific emotion regulation skills,
    relaxation skills, social supports, coping
    statements, hope kit)
  • A promise between teen, parents and therapist,
    that teen will contact a responsible adult or
    therapist before acting on suicidal impulses

138
Contract and Commitment Phase
  • Establishing a commitment to treatment from
    both teen and family
  • ___agrees to do whatever it takes to say alive
    during the period of this contract. This
    contract lasts from __ to__

139
Contract and Commitment Phase (continued)
  • Priorities for intervention are as follows
  • I. Decreasing life threatening behaviors
  • cutting, overdosing, any tissue damage or other
    life threatening behavior
  • II. Decreasing therapy interfering behaviors
    (any behavior that makes therapy less likely to
    occur)
  • Refusing to bring in or get rid of razors or
    other dangerous objects
  • Any other therapy interfering behaviors

140
Patient Agreements
  • Stay in therapy for the specified time.
  • Attend scheduled therapy sessions.
  • Work toward reducing suicidal behaviors/self-injur
    ious behaviors as a goal of therapy.
  • Work on problems that arise that interfere with
    progress in therapy.

141
Therapist Agreements
  • Make every reasonable effort to conduct competent
    and effective therapy.
  • Obey standard ethical and professional
    guidelines.
  • Be available for weekly therapy sessions, phone
    consultations, and provide needed therapy back-
    up when on vacation or away.
  • Respect the integrity of and rights of the
    patient.
  • Maintain confidentiality.
  • Obtain consultation when needed.

142
Negotiating Treatment Contract
  • Initially patients with history of self-cutting
    may not be able to agree to abstain entirely from
    SIB.
  • Explore teens concerns about their SIB and
    negative consequences of the behavior to increase
    motivation for change. (remain non-judgemental.)
  • Negotiate with teen to try specific emotion
    regulation strategies first, and to delay cutting
    for longer periods after the urge begins.
  • Negotiate with teen to avoid triggers for
    self-injury.

143
Understanding Self-injurious Behavior
  • SIB is identified by the patient as non-suicidal,
    and is typically aimed at relieving distress. It
    is marked by
  • An irresistible impulse to self-harm
  • Mounting agitation no escape from tension
  • Cognitive constriction- no alternatives
    considered
  • Rapid, temporary relief following the act of self
    injury

144
Functions Self-injury may Serve
  • Escape or reduce painful emotions
  • Distract from painful memories or thoughts
  • Self-expression of emotions
  • Punishment of self
  • Tension reduction/Anger reduction
  • Get attention, social support, or help
  • To feel alive

145
Characteristics of Self-injurers
  • The teen may have difficulties
  • Labeling their emotions
  • Effectively regulating emotions
  • Trusting experiences as valid responses to events
    (therefore individual searches environment for
    cues about how to respond)
  • Tolerating distress
  • Effectively solving problems (Miller, 1999)

146
Emotional Vulnerability
  • High sensitivity
  • Immediate reactions
  • Low threshold for emotional reaction
  • High reactivity
  • Extreme reactions
  • High arousal dysregulates cognitive processing
  • Slow return to baseline
  • Long lasting reactions
  • Creates high sensitivity to next emotional
    stimulus

147
Borderline Personality Disorder
  • Many self-injurers display some of these traits
  • Emotion dysregulation (affect lability)
  • Interpersonal dysregulation (chaotic
    relationships)
  • Self-dysregulation (identity disturbance)
  • Behavioral dysregulation (self-injury)
  • Cognitive dysregulation (paranoia)

148
What We See in the Teen
  • Critical, hostile statements toward self and
    feelings of guilt, shame, anger when experiencing
    strong emotions
  • These reactions serve to intensify the pain of
    the original emotion and further support the
    self-critical backlash

149
The Invalidating Environment
  • Families may
  • Indiscriminantly reject
  • Punish emotional displays and intermittently
    reinforce emotional escalation.
  • Over-simplify the ease of problem-solving and
    meeting goals
  • Indiscriminantly indulge

150
Creating a Validating Therapeutic Environment
  • Therapist validates the emotional need behind the
    behavior.
  • Therapist must non-judgmentally acknowledge
    destructiveness of teens behavior.
  • Youre doing the best you can, and you can do
    better.
  • Therapist refrains from criticizing the
    individual but instead elicits negative
    consequences about specific behaviors from teen.

151
Levels of Validation (Miller Comtois, 2002)
  • Unbiased listening and observing.
  • Accurate reflection
  • Articulating the unverbalized
  • Validation in terms of past learning or
    biological dysfunction
  • Validation in terms of present context
  • Radical genuineness

152
Break
  • Time for a 15 minute break!

153
Developing the Treatment Approach
  • Protocol driven treatments (one size fits all,
    what to do instructions) work with severe and
    chronic Axis I problems
  • Principle-driven treatments (based on principles
    that tell you how to figure out what to do) are
    needed with multi-diagnostic and/or Axis II
    patients

  • Miller, 2002

154
Chain analysis as a Guide to Case
Conceptualization
  • A form of behavioral analysis
  • Translation of the behavior problem (SIB) into
    links in the chain of emotions, events,
    behavior and consequences
  • Assessing at a micro-level to reconstruct the
    sequence in time

155
Chain Analysis as a Guide
  • Start by asking teen to walk you through the
    events that led up to the self-injury.
  • Help teen identify vulnerability factors that may
    have contributed.
  • Ask teen to describe in detail the precipitants,
    thoughts, images, and feelings they may have
    experienced as well as what was going on
    outside.
  • Ask about () and (-) consequences of the SIB.

156
Links in the Chain
  • Vulnerability factors
  • Triggering event
  • Emotions
  • Thoughts (self-talk)
  • Physical sensations
  • Urges
  • Behavior
  • Consequences

157
Forming Conceptualization
  • The specific vulnerabilities, self-statements,
    and feelings (internal factors), as well as the
    triggering events and consequences of the SIB
    (external factors), will help you to develop
    the case conceptualization and treatment plan.

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160
Prioritize treatment needs
  • Through chain analyses, the therapist decides
    which skill areas to target first
  • Emotion regulation skills
  • Cognitive restructuring
  • Family Conflict
  • Communication skills
  • Problem-solving
  • Social skills/assertiveness skills

161
LUNCH BREAK !
162
Emotion Education
  • Learning to be nonjudgmental toward self
  • Teach teen how to observe and describe different
    emotions, without labeling them as good or bad,
    but simply to be aware of them.
  • Emotion dysregulation results often because teen
    is overly harsh toward self for having strong
    feelings, and may often judge specific feelings
    as wrong, or invalid, and feel more distressing
    emotions in turn.

163
Emotion Education (continued)
  • Action urges and choices
  • A negative emotion often leads to an irresistible
    urge to act in a self-destructive manner.
  • Important to teach teen that just because they
    have urge to act on a distressing emotion they
    are not obligated to act in this way.
  • Distinguish between urge to act and the
    action itself.

164
Reducing Vulnerability to Negative Emotion
  • Parents and teens should be taught how to
    decrease vulnerability to emotion mind
    (Linehan, 1993).
  • Emphasis on importance of maintaining regular
    sleep schedule.
  • Eating balanced diet, treating physical illness,
    getting regular exercise, avoiding substance
    abuse and planning at least one activity a day
    that elicits a sense of competence and mastery.

165
HEAR ME
  • Health (treat physical illness)
  • Exercise regularly
  • Avoid mood altering drugs
  • Rest (balanced sleep)
  • Mastery (one rewarding activity daily)
  • Eating (balanced diet)

166
Emotions Thermometer
167
Mindfulness of current emotion
  • Steps in the process
  • 1. Observe your emotion
  • 2. Experience Your emotion
  • 3. You are not your emotion
  • 4. Practice Accepting your emotion

168
Mindfulness
  • 1. Observe your emotion
  • Note its presence just observe it
  • Step Back
  • Get Unstuck from the emotion

169
Mindfulness
  • 2. Experience Your Emotion
  • As a wave, coming and going
  • Try not to block or suppress the emotion
  • Dont try to get rid of the emotion
  • Dont push it away
  • Dont try to keep the emotion around
  • Dont hold on to it
  • Dont intensify it

170
Mindfulness
  • 3. Remember You are not your emotion
  • Do not necessarily act on your emotion (that is,
    let destructive action urges pass).
  • Remember times when you have felt different.

171
Mindfulness
  • 4. Practice accepting your emotion
  • Do not judge your emotion as wrong, bad, too
    painful, unfair, embarrassing, etc.
  • Do not criticize yourself for feeling the
    emotion.
  • Accept your emotion as it is in the moment.

172
Chain Analysis as an Intervention The Freeze
Frame Technique (Wexler, 1991)
  • Takes the chain analysis a step further
  • Recalls events as if reviewing a video replay and
    then freezing the frame at critical points.
  • Helps teen to slow time down (especially useful
    for teens who are impulsive and cant remember
    what happened) .

173
Steps of Freeze Frame
  • To review
  • Teen is asked to describe in detail a situation
    in which he/she had a particularly strong
    emotional reaction and/or had adverse
    consequences.
  • These consequences should be both internal and
    external e.g. teen punched his door consequence
    might be he/she has to pay for a new door and
    also feels guilty and ashamed of this behavior.

174
Freeze Frame (continued)
  • In addition to who, what, where, when of the
    problem situation, sensory, interpersonal,
    affective, cognitive details are also recalled
    negative self-talk is especially important to
    articulate.
  • The teen should describe the vulnerability
    factors that made he/she more susceptible to
    negative emotions and problem behavior.

175
Freeze Frame (continued)
  • The teen is instructed to slow time down as the
    scene approaches the moment when the problem
    emotion intensified or the uncontrollable
    behavior started (analogy of the instant replay
    can be used).
  • At the moment just prior to the problem emotion
    or uncontrollable behavior is reached, the teen
    is instructed to FREEZE THE FRAME and describe
    thoughts, feelings, bodily sensations, and action
    urges at that moment.

176
Freeze Frame (continued)
  • The next step is to ask the teen what NEEDS were
    you attempting to meet through the behavior, even
    if the results were negative?
  • Once these needs have been identified , the
    therapist must help teen to develop self-respect
    for these needs (teach teen to validate these
    needs) and formulate alternative ways to take
    care of these needs.

177
Freeze Frame (continued)
  • Needs-Important to teach teen that if they can
    identify their needs and learn different
    behaviors to get their needs met, they can have
    more power.
  • Once you know the needs, you are smarter. Once
    you have new tools for handling the needs, you
    are more powerful (Wexler, 1993).

178
Freeze Frame (continued)
  • The Freeze Frame differs from the chain analysis,
    and becomes an intervention with the final step
  • The teen replays the scene and replaces the
    problem behavior with the new coping skills, and
    then imagines a new outcome.

179
Educating Family about Freeze Frame
  • The Freeze Frame approach is the basis for
    generating options and interventions with regard
    to emotion dysregulation.
  • We can use this approach to examine emotion
    dysregulation that occurs interpersonally between
    family members.

180
Break
  • Time for a 15 minute break!

181
Distress Tolerance Skills
  • A crisis survival strategy
  • Vital skill to teach teen as they will not always
    be able to decrease painful emotions, or get what
    they need interpersonally, so they will need to
    learn how to tolerate distressing emotions.

182
Distress Tolerance Skills
  • Linehan (1993) Learning how to bear pain
    skillfully
  • Teaching teens to suspend judgment an emotion
    simply is
  • Teaching teens to accept painful feelings vs.
    trying to get rid of them quickly

183
Distress Tolerance Skills
  • 3 Myths about acceptance (Miller, 1997)
  • If you refuse to accept something, it will
    magically change.
  • If you accept your painful situation, you will
    become soft and just give up (or give in).
  • If you accept your painful situation, you are
    accepting a life of pain.

184
Distress Tolerance Skills
  • CBT component of Distress Tolerance
  • Acceptance self-talk
  • Learning to talk to yourself nonjudgmentally e.g.
    Im doing the best I can, I know if I can just
    get through this difficult time things will get
    better.
  • Acceptance self-talk counters the negative,
    critical shoulds that often accompany painful
    emotions.

185
Distress Tolerance Skills
  • Main emphasis is teaching teens how to soothe
    themselves .
  • Teens may be resistant to this, as their relation
    to the world is predominantly action and other
    oriented.
  • Self-soothing skills involve neither action in
    the external behavior sense nor an explicit
    relation with others.

186
Distress Tolerance Skills
  • Some teens have belief that others should soothe
    them when distressed and have difficulty
    believing that they can depend on themselves.
  • Others may feel that they dont deserve to be
    soothed and may feel guilty, ashamed, angry when
    they try to self-soothe (Linehan, 1993) .

187
Distress Tolerance Skills
  • Some teens have belief that others should soothe
    them when distressed and have difficulty
    believing that they can depend on themselves.
  • Others may feel that they dont deserve to be
    soothed and may feel guilty, ashamed, angry when
    they try to self-soothe (Linehan, 1993) .

188
Self-Soothing Throughthe Five Senses
  • An accessible and easily taught
    self-soothing/distress tolerance skill is the use
    of the 5 senses
  • Vision, hearing, smell, taste, touch
  • Usually at least 2-3 of the five senses are
    engaged or capable of being engaged at any given
    moment as a distraction from distress.

189
Sensory Soothing (continued)
  • Vision
  • Focus on an aspect of nature, or any visual
    detail
  • Hearing
  • Music, nature sounds, relaxation tape, fan noise
  • Smell
  • Lotion, candle, perfume, favorite food cooking
  • Taste
  • Hot chocolate or tea, ice creamtaste slowly
  • Touch
  • Pet your dog, cat, soothing bath, hug, blanket

190
Helping Parents Regulate Their Emotions When in
Conflict with Teen
  • Teach trategies for changing the timing and
    process of confrontations.
  • Important to educate parents that when teen
    attacks and parent becomes dysregulated then
    parent can no longer be effective in enforcing
    rules and consequences.
  • Teens will escalate their behavior in an attempt
    to control outcome of mood and outcome of the
    interaction (Sells, 1998).

191
Creating a Validating Family Environment
  • Help both parents and teen to understand how
    their reactions to each other may be
    invalidating.
  • Kernel of Truth
  • Coaching parents to become more aware of the ways
    in which their communication may be overly
    negative and critical.
  • Validation isnt agreeing with and doesnt have
    to be warm and fuzzy.

192
Strategies to Help Parents Respond Calmly
  • Strategies to help parents respond calmly and
    nonreactively to their teens provocations during
    conflict
  • EXIT AND WAIT
  • STAYING SHORT AND TO THE POINT, USING DEFLECTORS

193
Communication Skills
  • Active Listening (verbal and non verbal skills)
  • Therapist models listening skills
  • Sending clear messages ( use of I statements
    instead of you
  • Practice/role play in session

194
Changing Emotion by Acting Opposite the Current
Emotion
  • Every emotion has an action associated with it.
  • Fear Run
  • Anger.. Attack
  • Sadness..Withdraw
  • Shame.Hide

195
Changing Emotion by Acting Opposite the Current
Emotion
  • Opposite Action
  • Emotion is strongly influenced by our bodily
    posture and facial expressions.
  • By altering posture, behavior and facial
    expressions we can delay, interrupt or
    de-escalate the progression of a problematic
    emotion.

196
Opposite Action for Anger
  • Keep ones palms open when inclined to punch.
  • Whisper when inclined to scream.
  • Breath deeply and slowly rather than angrily
    hyperventilating.
  • Gently avoid the person you are angry with rather
    than attacking.
  • Put yourself in the other persons shoes, and
    imagine sympathy or empathy for the person,
    rather than blame.

197
Opposite Action for Guilt or Shame
  • Repair the mistake.
  • Say youre sorry
  • Make up for what you did to the person you
    offended
  • Try to avoid making the same mistake in the
    future.
  • Accept the consequences for what you did.
  • Then let it go.

198
Opposite action for Sadness or Depression
  • Get active
  • Approach, dont avoid
  • Do things that make you feel effective and
    self-confident
  • Use the half-smile

199
Opposite Action for Envy
  • Someone else has something that you think you
    WANT or NEED. (If you cant have it, they
    SHOULDNT.)
  • Based on a fundamental belief that you are
    DEPRIVED.
  • Radical Acceptance you have to radically accept
    that you dont have it (opposite action).

200
  • Radical Self-Acceptance
  • We must willingly accept all aspects of self.
    Remember that acceptance does not necessarily
    mean approval or agreement, but is simply the
    acknowledgement of what is. Accepting that you
    are human, that you have both failings and
    accomplishments
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