Alan Apter M.D

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suicide

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

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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
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SUICIDE

• DEFINITIONS
• EPIDEMIOLOGY
• AETIOLOGY/RISK FACTORS
• CLINICAL CONSIDERATIONS

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SUICIDE

• PRIMARY PREVENTION
• SECONDARY PREVENTION
• TERTIARY PREVENTION

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DEFINITIONS
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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"

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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

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Suicide Spectrum

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

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Continuum Theory Of Suicide

• Suicidal Thoughts
• leads to
• Suicidal Threats
• Leads to

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Suicidal Gestures Leads toSuicide
Attempts leads to Failed Suicide leads
toCompleted Suicide
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Discontinuity TheorySuicidal
IdeationSuicidal ThreatsSuicidal
GesturesSuicide AttemptsSerious Suicide
Attempts
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Suicide attempts
Completed suicide
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Consequences of Suicidal Behavior

• School dropout
• Leaving home
• Motor accidents
• Police arrest
• Whole spectrum of high risk behavior

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EPIDEMIOLOGY
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EPIDEMIOLOGY

• SEX
• AGE
• GEOGRAPHY
• SOCIECONOMIC STATUS
• ETHNICITY
• RELIGION
• COHORT STATUS

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EPIDIMIOLOGY OF SUICIDE

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

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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

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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

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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

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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

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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)

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Attempted suicide by age and sex Holon-Bat Yam
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Suicide by age
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SUICIDE IN INDIA
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Homicide and suicide rates by year
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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.
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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.
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EPIDEMIOLOGY

• ELDERLY COMMIT/YOUNG ATTEMPT
• PROTESTANTSgtCATHOLICSgt
• JEWSgtMUSLIMS
• POOR ATTEMPT/RICH COMMIT
• BLACKSltWHITES
• HISPANICS AND S.EUROPEANS ATEMPT

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AETIOLOGY/RISK FACTORS
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AETIOLOGY/RISK FACTORS

• PSYCHIATRIC ILLNESS
• ALCAHOLISM SUBSTANCE ABUSE
• PHYSICAL AND SEXUAL ABUSE
• FAMILY AND GENETICS

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Risk Factors (ii)

• CONTAGION
• AVAILABILITY OF MEANS
• PERSONALITY FACTORS
• BIOLOGY

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PSYCHIATRIC ILLNESS

• DEPRESSION
• SCHIZOPHRENIA
• ANXIETY DISORDERS
• DISSOCIATIVE DISORDERS

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PSYCHIATRIC ILLNESS

• CONDUCT DISORDER
• ANOREXIA NERVOSA
• BULIMIA NERVOSA
• PERSONALITY DISORDERS

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Risk factors for youth suicide

• Psychiatric disorder/Affective disorder
• Personality disorder- especially BPD
• Psychiatric illnesses dangerous when more than
  one illness is present

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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

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ALCAHOLISM SUBSTANCE ABUSE

• SELF MEDICATION
• INCREASES IMPULSIVITY
• AFFFECTS JUDGEMENT
• EXACERBATES DEPRESSION
• PROVIDES COURAGE

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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

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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

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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.

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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.

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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.

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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.

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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

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• THESE FEATURES ARE OFTEN COMPLICATED BY STRONG
  ISOLATIVE TRAITS

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Distribution Of Axis II Diagnoses WithinComplete
Suicide Group
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Case features
No turning for help or support

• Minor setbacks spiral into disaster

Better death than shame
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THE IMPULSIVE AGGRESSIVE CONSTELLATION
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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.

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• 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.

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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.

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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 .

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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.

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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.

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Van Praag (1997)

• serotonin-related anxiety/aggression stressor
  precipitated depression

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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)

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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

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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

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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

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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

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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

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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)
  

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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

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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)

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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

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MENTAL-ILLNESS DEMORALIZATION HOPLESSNESS
CONSTELLATION
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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

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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.

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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

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• 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

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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)

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• 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

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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

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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.

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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.

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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).

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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.

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Suicide Risk

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

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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.

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Canterbury Suicide Project
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Clinical Settings

• Primary Care settings (family or pediatric
  practices)
• Mental health outpatient departments (OPD)
• Emergency rooms (ER)
• Intensive care units (ICU)
• Residential treatment programs

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Primary Care

• Early Detection of Internalizing Disorders
• Early Treatment of Internalizing Disorders
• Early Referral of Internalizing Disorders
• Referral of Externalizing Disorders

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Early Detection

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

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Early Treatment

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

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Early Referral

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

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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.

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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

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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.

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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

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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.

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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.

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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

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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

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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

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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).
  
  
  
  
  

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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.

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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.

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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)

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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.

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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?)

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Suicide Continuum
Passive Death Wish
Suicidal Ideation, no method
Suicidal Ideation with method
Attempt
Completion
Gesture
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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__

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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

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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.

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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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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