Suicide And Social Pathology
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Suicide And Social Pathology

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Suicide And Social Pathology Suicide And Social Pathology Presentation Transcript

  • Social Pathology
    • Presented by
    • G.Ragesh
    • Dept. of Psychiatric Social Work
    • NIMHANS, Bangalore
    • India
  • Social Pathology
    • Suicide
  • Social Pathology
    • A condition or phenomenon in society, such as a widespread and deep civil unrest, generally regarded as unhealthy .
    • A social factor, as poverty, old age, or crime, that tends to increase social disorganization and inhibit personal adjustment, the study of such factors and the social problems they produce.
  • Characteristics of Social Pathology
    • Social pathology may treat of a general defect which spreads throughout the entire social structure ; but more frequently the term applies to a particular class of people within a social group or to a defective function of government.
    • Social pathology includes: substance abuse, violence, abuses of women and children, crime, terrorism, corruption, criminality, discrimination, isolation, stigmatization and human rights violations
    • Social pathologies "often lead to a flood of social, economic and psychological problems that undermine well-being."
    • Suicide
  • Out line
    • Introduction
    • Definitions
    • Historical aspects
    • Global Situation
    • Indian Situation
    • Causes of suicide
    • Risk factors for suicide
    • Legal aspects
    • Suicide Assessment
    • Theories
    • prevention
  • Introduction
    • The word Suicide derives from the Latin word Sui (of oneself) cide or cidium (a killing).
    • The basic definitions of Suicide given from different theoretical perspectives
    • Suicide is intentional, self-inflicted death.
    • Suicide is now understood as a multidimensional disorder which results from a complex interaction of biological, genetic, psychological, sociological and environmental factors (Maris;2002).
  • Definitions (APA) Guidelines 2003
    • Suicide Self inflicted death with evidence(either explicit or implicit) that the intended to die 
    • Suicide attempt  Self injurious behaviour with a non fatal outcome accompanied by evidence (either explicit or implicit) that intended to die
    • Aborted suicide Potentially self injurious behaviour with evidence the person intended to die but stopped the attempt before physical damage occurred
    • Suicidal ideation Thoughts of serving as the agent of ones own death
    • Suicidal intent Subjective expectation and a desire for a self-destructive act to end in death
    • Lethality of suicidal behaviour Objective danger to life associated with a suicide method or action
    • Deliberate self-harm Willful self-inflicting painful, destructive, or injurious acts without intent to die
    • Para suicide
    • Individual who deliberately initiates as an act of non-fatal self injury or who injects a substance in excess of any prescribed dose (Kerithman 1977).
    • Assisted Suicide
    • It is the process by which an individual, who may otherwise be incapable, is provided with the means (drugs or equipment) to commits suicide.
  • Importance of suicide
    • Suicide 1% of all deaths. OPCS 1991
    • 1 million suicides in 2000
    • Rate - 10 per lac in 1950, 18 per lac in 1995
    • Last 45 yrs - 60% increase in rate.
    • Among 3 leading causes of death in age-15 to 44 yrs. In young males - 2 nd after accidents.
  • Historical aspects
    • Suicide –glorified or condemned through the ages and cultures.
    • Christian church declared it unacceptable
    • Japanese samurais – hara-kiri
    • Upanishads condemned suicide
    • Jainism –Sallekhana, Rajasthan –Sati and Johar
  • Global Situation
    • Mental disorders (mainly depression and substance abuse ) contribute to more than 90% causes of suicide, others are complex sociocultural factors.
    • Suicidal attempt - 20 times common than completed suicide and is more common in females (completed suicide is more common in males).
  • Indian Situation
    • Intra - national analysis is more reliable and amenable to detailed analysis.
    • 13 suicides in 1 hr on an average.
    • Rate –45 th position globally.
    • More then 1 lack suicides in 2006.
    • Males – more of socioeconomic causes
    • Females - more of emotional and personal causes .
    • (Source: National Crime Records Bureau 2006)
  • Methods of suicide
    • Male –more violent methods
    • Females-non-violent
  • Place of occurrence
    • Home and immediate vicinity (81.3%)
    • Water bodies (3.1%)
    • Hotels and lodgings (1.8%)
    • Public parks (1.1%)
    • Shopping areas (1.1%)
    • NIMHANS Bangalore Study 2001.
  • Suicidal thought - attempt - act
    • 100 : 10 : 1
    • Presence of suicidal thought – 5 -10% in the Indian population.
    • Underreporting is a problem.
    • Methods of attempt, women- self-inflicted burn, men – poisoning.
    • WHO NIMHANS Study
  •  
  • Facts
    • Mass/Family suicide –
    • 237 cases in 2006. Max. in Chhattisgarh, then Kerala and Rajasthan.
    • Govt. servant- 1.8% of total. Students 5.2%
    • More than 20% – by housewives.
    • 47% married male, 25.3% married females
    • 72.2% married, 20.7% unmarried
    • One-fifth of senior citizen suicide victims – belong to Kerala.
    • Max. child suicide – Andhra Pradesh 14.8% (364 out of 2464)
  • SUICIDE: A MULTI-FACTORIAL EVENT Neurobiology Severe Medical Illness Impulsiveness Access To Weapons Hopelessness Life Stressors Family History Suicidal Behavior Personality Disorder/Traits Psychiatric Illness Co-morbidity Psychodynamics/ Psychological Vulnerability Substance Use/Abuse Suicide
  • Causes of suicide
  • Legal aspects
    • IPC 309- punishable
    • 21st March SC Judgment
  • Impact of suicide
    • Shame
    • Social Isolation
    • Financial issues
    • Emotional issues
    • Role changes and frustrations
    • Substance abuse
    • Suicidal ideation for family members
  • Recent trends
    • Homicide – suicide
    • Mass suicides
    • Increase in suicide rates in - males and younger population
    • Suicides under influence of cults (doomsday cults, religious cults).
    • Myths Versus Facts
    • About Suicide
  • Myths versus facts…
    • MYTH:
    • People who talk about suicide don’t complete suicide.
    • FACT:
    • Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.
  • Myths versus facts…
    • MYTH:
    • Suicide happens without warning.
    • FACT :
    • Most suicidal people give many clues and warning signs regarding their suicidal intention.
  • Myths versus facts…
    • MYTH:
    • Suicidal people are fully intent on dying.
    • FACT :
    • Most suicidal people are undecided about living or dying – which is called suicidal ambivalence. A part of them wants to live, however, death seems like the only way out of their pain and suffering. They may allow themselves to “gamble with death,” leaving it up to others to save them.
  • Myths versus facts…
    • MYTH:
    • Males are more likely to be suicidal.
    • FACT:
    • Men COMPLETE suicide more often than women. However, women attempt suicide three times more often than men.
  • Myths versus facts…
    • MYTH:
    • Asking a depressed person about suicide will push him/her to complete suicide.
    • FACT:
    • Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life.
  • Myths versus facts…
    • MYTH:
    • Improvement following a suicide attempt or crisis means that the risk is over.
    • FACT :
    • Most suicides occur within days or weeks of “improvement” when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts.
  • Myths versus facts…
    • MYTH:
    • Once a person attempts suicide the pain and shame will keep them from trying again.
    • FACT :
    • The most common psychiatric illness that ends in suicide is Major Depression, a recurring illness. Every time a patient gets depressed, the risk of suicide returns.
  • Myths versus facts. . .
    • MYTH:
    • Sometimes a bad event can push a person to complete suicide.
    • FACT:
    • Suicide results from serious psychiatric disorders not just a single event.
  • Myths versus facts. . .
    • MYTH:
    • Suicide occurs in great numbers around holidays in November and December.
    • FACT:
      • Highest rates of suicide are in April while the lowest rates are in December.
    • Suicide Assessment
  • SUICIDE PREDICTION vs. SUICIDE ASSESSMENT
    • Suicide Prediction refers to the foretelling of whether suicide will or will not occur at some future time, based on the presence or absence of a specific number of defined factors, within definable limits of statistical probability
    • Suicide (risk) Assessment refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail. Risk assessment carried out in a systematic, disciplined way is more than a guess or intuition – it is a reasoned, inductive process, and a necessary exercise in estimating probability over short periods.
  • COMPONENTS OF SUICIDE ASSESSMENT
    • Appreciate the complexity of suicide / multiple contributing factors
    • Conduct a thorough psychiatric examination, identifying risk factors and protective factors and distinguishing risk factors which can be modified from those which cannot
    • Ask directly about suicide; The Specific Suicide Inquiry
    • Determine level of suicide risk: low, moderate, high
    • Determine treatment setting and plan
    • Document assessments
  • Areas to Evaluate in Suicide Assessment
    • Psychiatric Illnesses: Affective Disorders, Alcohol / Substance Abuse, Schizophrenia, Cluster B Personality disorders.
    • History of Prior suicide attempts, aborted attempts or self harm; Medical diagnoses, Family history of suicide / attempts / mental illness
    • Individual strengths / vulnerabilities:
    • Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain
    • Psychosocial situation: Acute and chronic stressors; changes in status; quality of support; religious beliefs
    • Suicidality and Symptoms Past and present suicidal ideation, plans, behaviors, intent; methods; hopelessness, anhedonia, anxiety symptoms; reasons for living; associated substance use; homicidal ideation
  • RISK FACTORS Demographic male; widowed, divorced, single, increases with age, white Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access Psychiatric psychiatric diagnosis; comorbidity Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system Psychological Dimensions hopelessness; psychic pain/anxiety; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism Behavioral Dimensions impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt Cognitive Dimensions thought constriction; polarized thinking Childhood Trauma sexual/physical abuse; neglect; parental loss Genetic & Familial family history of suicide, mental illness, or abuse
  • Risk factors for suicide
    • Psychiatric illness (globally 90% - depression and substance abuse).
    • Lifetime risk of suicide in- alcoholic 6-15%, schizophrenia 7-15%, personality disorder 20-30%
    • Low frustration tolerance, severe hostility, life expectation and failure, interpersonal conflicts
    • Severe illness
    • Other environmental factors.
  • DETERMINATION OF RISK Psychiatric Examination Risk Factors Protective Factors Specific Suicide Inquiry Modifiable Risk Factors Risk Level: Low, Med., High
  • PROTECTIVE FACTORS
    • Children in the home, except among those with postpartum psychosis
    • Pregnancy
    • Deterrent religious beliefs
    • Life satisfaction
    • Reality testing ability
    • Positive coping skills
    • Positive social support
    • Positive therapeutic relationship
    • SUICIDE RISKS IN SPECIFIC DISORDERS
    • Adapted from A.P.A. Guidelines, part A, p. 16
    • Condition R %/y %-Lifetime
    • Prior suicide attempt 38.4 0.549 27.5
    • Eating disorders 23.1
    • Bipolar disorder 21.7 0.310 15.5
    • Major depression 20.4 0.292 14.6
    • Mixed drug abuse 19.2 0.275 14.7
    • Dysthymia 12.1 0.173 8.6
    • Obsessive-compulsive 11.5 0.143 8.2
    • Panic disorder 10.0 0.160 7.2
    • Schizophrenia 8.45 0.121 6.0
    • Personality disorders 7.08 0.101 5.1
    • Alcohol abuse 5.86 0.084 4.2
    • Cancer 1.80 0.026 1.3
    • General population 1.00 0.014 0.72
  • COMORBIDITY
    • In general, the more diagnoses present, the higher the risk of suicide.
    • Psychological Autopsy of 229 Suicides
    • 44% had 2 or more Axis I diagnoses
    • 31% had Axis I and Axis II diagnoses
    • 50% had Axis I and at least one Axis III diagnosis
    • Only 12 % had an Axis I diagnosis with no comorbidity
    • Henriksson et al, 1993
  • AFFECTIVE DISORDERS AND SUICIDE
    • High-Risk Profile:
        • Suicide occurs early in the course of illness
        • Psychic anxiety or panic symptoms
        • Moderate alcohol abuse
        • First episode of suicidality
        • Hospitalized for affective disorder secondary to suicidality
        • Risk for men is four times as high as for women except in bipolar disorder where women are equally at risk
  • SCHIZOPHRENIA AND SUICIDE
    • High-Risk Profile:
    • Previous suicide attempt(s)
    • Significant depressive symptoms – hopelessness
    • Male gender
    • First decade of illness – (however, rate remains elevated throughout lifetime)
    • Poor premorbid functioning
    • Current substance abuse
    • Poor current work and social functioning
    • Recent hospital discharge
    • Suicide occurs later in the course of the illness with communications of suicidal intent lasting several years
    • In completed suicides, men have higher rates of alcohol abuse, women have higher rates of drug abuse
    ALCOHOL / SUBSTANCE ABUSE AND SUICIDE
  • ALCOHOL / SUBSTANCE ABUSE AND SUICIDE
    • Increased number of substances used, rather than the type of substance appears to be important
    • Most have Comorbid psychiatric disorders, females have Borderline Personality Disorder
    • High Risk Profile:
      • Recent or impending interpersonal loss
      • Comorbid depression
  • PERSONALITY DISORDERS AND SUICIDE
    • Borderline Personality Disorder
      • Lifetime rate of suicide - 8.5%
      • With alcohol problems -19%
      • With alcohol problems and major affective disorder -38% (Stone 1993).
      • A comorbid condition in over 30% of the suicides.
      • Nearly 75% of patients with borderline personality disorder have made at least one suicide attempt in their lives.
    • Antisocial Personality disorder
    • Suicide associated with narcissistic injury / impulsivity.
  • FAMILY HISTORY/GENETICS
    • Relatives of suicidal subjects have a four-fold increased risk compared to relatives of non-suicidal subjects.
    • Twin studies indicate a higher concordance of suicidal behavior between identical rather than fraternal twins.
  • FAMILY HISTORY/GENETICS
    • Adoption studies: a greater risk of suicide among biologic rather than adoptive relatives.
    • Suicide appears to be an independent, inheritable risk factor.
  • FAMILY PSYCHOPATHOLOGY
    • Family history of abuse, violence, or other self-destructive behaviors place individuals at increased risk for suicidal behaviors (Moscicki 1997, van der Kolk 1991).
    • Histories of childhood physical abuse and sexual abuse, as well as parental neglect and separations, may be correlated with a variety of self-destructive behaviors in adulthood (van der Kolk 1991).
  • PSYCHOSOCIAL SITUATION: LIFE STRESSORS
    • Recent severe, stressful life events associated with suicide in vulnerable individuals (Moscicki 1997).
    • Stressors include interpersonal loss or conflict, economic problems, legal problems, and moving (Brent et al 1993b, Lesage et al 1994, Rich et al 1998a, Moscicki 1997).
  • PSYCHOSOCIAL SITUATION: LIFE STRESSORS
    • High risk stressor: humiliating events, e.g., financial ruin associated with scandal, being arrested or being fired (Hirschfeld and Davidson 1988) – can lead to impulsive suicide.
    • Identify stressor in context of personality strength, vulnerabilities, illness, and support system.
  • INDIVIDUAL STRENGTHS/ VULNERABILITIES: PSYCHODYNAMICS
    • Believed that suicide could be understood through the interplay of three internal wishes:
        • Wish to kill
        • Wish to be killed
        • Wish to die
  • PSYCHOLOGICAL VULNERABILITIES: CLINICAL OBSERVATIONS
    • Capacity to manage affect.
    • Ability to tolerate aloneness.
    • Ability to experience and tolerate psychological pain (Shneidman) – Anguish, perturbation.
    • Features of ambivalence.
    • Tunnel vision (dyadic thinking).
    • Nature of object relationships.
    • Ability to use external resources
  • DIRECT QUESTIONING ABOUT SUICIDE: THE SPECIFIC SUICIDE INQUIRY
    • Ask About:
    • Suicidal ideation
    • Suicide plans
    • Give Added Consideration to:
    • Suicide attempts (actual and aborted)
    • First episode of suicidality (Kessler 1999)
    • Hopelessness
    • Ambivalence: a chance to intervene
    • Psychological pain history
  • COMPONENTS OF SUICIDAL IDEATION
    • Intent:
      • Subjective expectation and desire for a self-destructive act to end in death.
    • Lethality:
      • Objective danger to life associated with a suicide method or action. Lethality is distinct from and may not always coincide with an individual’s expectation of what is medically dangerous.
    • Degree of ambivalence - wish to live, wish to die
    • Intensity, frequency
    • Rehearsal/availability of method
    • Presence/absence of suicide note
    • Deterrents (e.g. family, religion, positive therapeutic relationship, positive support system - including work)
  • CHARACTERISTICS OF A SUICIDE PLAN
    • Risk / Rescue Issues:
      • Method
      • Time
      • Place
      • Available means
      • Arranging sequence of events
  • PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE
    • Hopelessness
    • Impulsivity / Aggression
    • Anxiety
    • Command hallucinations
  • PSYCHIATRIC SYMPTOMATOLOGY: HOPELESSNESS
    • Research indicates relationship between hopelessness and suicidal intent in both hospitalized and non-hospitalized patients (Beck 1985, Beck 1990)
    • Subjective hopelessness was associated with fewer reasons for living and increased risk for suicide (Malone 2000)
    • Modifiable through various interventions
  • PSYCHIATRIC SYMPTOMATOLOGY: IMPULSIVITY / AGGRESSION
    • May contribute to suicidal behavior
    • It is important to assess level of impulsiveness when assessing for suicidality (Sher 2001, Fawcett et al, in press)
    • Suicide attempters may be more likely to present traits of impulsiveness / aggression regardless of psychiatric diagnosis (Mann et al 1999).
    • Important in assessing risk of murder-suicide
  • PSYCHIATRIC SYMPTOMATOLOGY: ANXIETY
    • Anxiety symptoms (independent of an anxiety disorder) associated with suicide risk:
    • Panic Attacks
    • Severe Psychic Anxiety (subjective anxiety)
    • Anxious Ruminations
    • Agitation
    • In a review of inpatient suicides 79% met criteria for severe or extreme anxiety or agitation
  • DETERMINATION OF THE LEVEL OF RISK
    • Clinical judgment based upon consideration of relevant risk factors, present episode of illness, symptoms, and the specific suicide inquiry.
    • Seek consultation / supervision as needed
    • Suicide risk will need to be reassessed at various points throughout treatment, as a patient’s risk level will wax and wane.
  • DETERMINE TREATMENT SETTING AND PLAN
      • Attend to issue of patient’s safety.
      • Assess treatment plan/setting/alliance.
      • Somatic treatment modalities:
        • ECT – used to treat acute suicidal behavior
        • Benzodiazepines – may reduce risk by treating anxiety
        • Antidepressants
        • Lithium, Anticonvulsants
        • Antipsychotics, recent study on Clozapine
      • Psychotherapeutic intervention – widely viewed as helpful for suicidal patients, evidence is limited
      • Provide education to patient and family.
      • Monitor psychiatric status and response to treatment.
      • Reassess for safety and suicide risk frequently.
  • Psychotherapy
    • Regardless of theoretical basis, key element is a positive and sustaining therapeutic relationship
    • Recommended (primarily from clinical consensus)
    • To target issues
      • Denial of symptoms
      • Lack of insight
    • To manage high risk symptoms
      • Hopelessness
      • Anxiety
    • Effective treatment in high risk diagnoses
      • Depression
      • Personality disorders (use of D.B.T.)
  • SUICIDE CONTRACTS
    • Problems:
      • Commonly used, but no studies demonstrating ability to reduce suicide.
      • Not a legal document, whether signed or not.
      • Used pro-forma, without evaluation by psychiatrist.
    • Possibilities:
      • Useful when there is positive therapeutic relationship (do not use when covering for colleague).
      • If employed, outline terms in patient’s record.
      • Useful when they emphasize availability of clinician.
      • Rejection of contracts have significance.
    • Bottom line – still considered within standard of care but usage should be
  • WHEN TO DOCUMENT SUICIDE RISK ASSESSMENTS
    • At first psychiatric assessment or admission.
    • With occurrence of any suicidal behavior or ideation.
    • Whenever there is any noteworthy clinical change.
    • For inpatients:
        • Before increasing privileges/giving passes
        • Before discharge
        • The issue of firearms:
        • If present - document instructions
        • If absent - document as pertinent negative
  • WHAT TO DOCUMENT IN A SUICIDE ASSESSMENT
    • Document:
      • The risk level
      • The basis for the risk level
      • The treatment plan for reducing the risk
  • Example
    • This 62 year old, recently separated man is experiencing his first episode of major depressive disorder. In spite of his denial of current suicidal ideation, he is at moderate to high risk for suicide, because of his serious suicide attempt and his continued anxiety and hopelessness. The plan is to hospitalize with suicide precautions and medications, consider ECT w/u. Reassess tomorrow.
  • WHEN A SUICIDE OCCURS?
    • Despite best efforts at suicide assessment and treatment, suicides can and do occur in clinical practice
    • Approximately, 12,000-14,000 suicides per year occur while in treatment.
    • To facilitate the aftercare process:
    • Ensure that the patient’s records are complete
    • Be available to assist grieving family members
    • Remember the medical record is still official and confidentiality still exists
    • Seek support from colleagues / supervisors
    • Consult risk managers
    • Theories of suicide
  • Methods of collecting data
    • Psychological autopsy.
    • Data from counseling centers, hospitals newspapers, local police, registrar of births and deaths.
  •  
  • Sociological theories
    • Sociological theories
    • Durkheim proposed four types of suicides
    • Altruistic
    • Egoistic
    • Anomic
    • Fatalistic
    • Altruistic suicide occurs when the integration of individual with the group is very close.
    • This type is found among many primitive people, where social integration is very strong
    • It is also found in more advanced societies such as in India and Japan, where the sense of social responsibility is highly developed
    • Egoistic suicide occurs when the integration of the individual with the group is too loose and ill-defined.
    • Much of the suicide in modern society reflects this lack of integration.
    • When the group is disorganized in this way egoistic suicide become the predominant form of self destruction.
    • Anomic suicide results from a large scale lack of social regulation of individual behaviour.
    • It may rise from a severe break in the social equilibrium such as a business loss, an inflation, or boom.
    • Fatalistic – excessive regulation
    • Economic modeling of suicide Under Income Uncertainty
    • Preventing Suicide
  • Each person contemplating suicide needs a supporting hand, a comforting shoulder and a patient hearing….
  • Preventing Suicide . . .
    • Prevention within our community
    • Education
    • Screening
    • Treatment
    • Means Restriction
    • Media Guidelines
  • Preventing Suicide. . .
    • Education
      • Individual and Public Awareness
      • Professional Awareness
      • Education Tools
  • Preventing Suicide . . .
    • Screening
    • Identify At Risk Individuals
        • Columbia Teen Screen
        • AFSP College screening instrument
        • National Depression Screening Day*
        • (First Thursday of October)
        • Annual Childhood Depression Awareness Day (May 4 th )
  • Preventing Suicide. . .
    • Treatment
        • Antidepressants
        • Psychotherapy
        • Social welfare measures
        • Social policy changes
  • Preventing Suicide. . .
    • Media
    • Guidelines
    • Considerations
  •  
  •  
  • Organizations
    • WHO
    • APA
    • Befrienders association
  • References
    • Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. American Journal of Psychiatry (Suppl.) Vol. 160, No. 11, November 2003
    • WHO
    • APA
    • THANK YOU