2. Overview
• Definition
• History
• Epidemiology
• Methods
• Warning signs
• Self harm cycle
• Assessment and treatment
• Facts
• Suicide – an overview
• References
3. Definition
• An act with non-fatal outcome, in which an individual deliberately
initiates a non-habitual behavior that, without intervention from
others, will cause self-harm, or deliberately ingests a substance in
excess of the prescribed or generally recognized therapeutic dosage,
and which is aimed at realising changes which the subject desired via
the actual or expected physical consequences. (Platt et al., 1992;
WHO).
4. • ‘Self-poisoning or injury, irrespective of the apparent purpose of the
act’. (NICE, 2004)
• ‘Self-injury is a compulsion or impulse to inflict physical wounds on
one's own body, motivated by a need to cope with unbearable
psychological distress or regain a sense of emotional balance. The act
is usually carried out without suicidal, sexual, or decorative intent.’
(Sutton 2005)
6. • The term self-mutilation is sometimes used, although this phrase
evokes connotations that some find worrisome, inaccurate, or
offensive.
• Self-inflicted wounds is a specific term associated with soldiers to
describe non-lethal injuries inflicted in order to obtain early dismissal
from combat.
7. History
• The Maya priesthood performed auto-
sacrifice by cutting and piercing their
bodies in order to draw blood.
• A reference to the priests
of Baal "cutting themselves with blades
until blood flowed" can be found in the
Hebrew Bible.
Auto-sacrifice of
Maya priesthood
8. • Self-harm is practiced in Hinduism by the
ascetics known as sadhus.
• In Catholicism it is known as mortification
of the flesh.
• Some branches of Islam mark the Day of
Ashura, the commemoration of the
martyrdom of Imam Hussein, with a ritual
of self-flagellation, using chains and
swords
9. • In former days these behaviors were often regarded as failed suicides.
• However, this view did not appear to be correct, and the great
majority of patients in fact do not try to kill themselves.
• Therefore, the term deliberate self-harm was introduced to describe
the behavior without implying any specific motive.
• Intentions may vary from attention seeking or communication of
despair, appeal for help, to a means for stress reduction
10. Epidemiology
• In the 1960s and 1970s, there was a sharp increase in the number of
people treated in hospitals in Europe, the United States and Australia
because of intentional overdoses or self-injury.
• In the 1980s several studies showed a stabilization.
• In the early 1990s these numbers increased further in some regions
• Between 1985 and 1995 the rates of DSH increased by 62 per cent in
males and 42 per cent in females
11. Sex and age :
• WHO Multicenter Study on Suicidal Behavior - the female
DSH rates were 1.5 times higher than the male rates.
• DSH rates were consistently higher among those in the
young age groups, with the highest person-based male DSH
rates in the age group 25–34 years,
• whereas for females in most centers the highest rates were
found in the age group 15–24 years
12. Sexuality and DSH
• Growing evidence supports an association between sexual orientation
and self-harm in men and women (O'Connor et al., 2009b; Skegg et
al., 2003).
• In a recent systematic review and meta-analysis (including data from
214,344 heterosexual and 11,971 non-heterosexual people),
homosexuals and bisexual people were at a heightened risk of self-
harm compared with heterosexual people (King et al., 2008).
• The evidence for this association thus far is strongest for young
people.
13. Sociodemographic characteristics :
• Single and divorced people were over-represented among people
who engaged in DSH in the WHO/EURO study.
• Nearly half of the males and 38 per cent of the females were never
married.
• DSH rates over the period 1995–1999, 26 per cent of the males and
14 per cent of the females were unemployed.
• DSH patients disproportionately have had low education and poverty.
14. Methods :
• In the WHO Multicenter Study, 65 per cent of males and 82 per cent
of females took an overdose.
• Cutting, mostly wrist cutting, was employed in 16 per cent of male
cases and 9 per cent of female cases
• There was an increase in the use of paracetamol from 31 per cent of
poisoning cases in 1985 to 50 per cent in 1995.
15. • Cutting 80%
• Bruising 24%
• Burning 20%
• Head banging 15%
• Biting 7%
Self Injury Poll (2004) What is your primary method of self-injury
http:vote.pollit.com/webpoll2?ID=25897
16. • Hawton et al. found that 22 to 26 per cent of DSH patients had
consumed alcohol at the time of the act (males more frequent than
females),
• And 44 to 50 per cent had consumed alcohol during the 6 hours
before the DSH acts
• This is more common in males than in females
17. Incidence and onset
• 4% in the general population
• Equal numbers of males and females (though more females present
for treatment)
• Typical onset: puberty
• Can be seen also in young children and adults
• Often lasts 5-10 years
• But can last longer without treatment.
18. Prevalence
• The aggregate lifetime and 12-month prevalence of suicide attempts was
6% and 4.5% respectively.
• The aggregate lifetime and 12-month prevalence of non-suicidal self-injury
was 22.1% and 19.5% respectively.
• The aggregate lifetime and 12-month prevalence of deliberate self-harm
was 13.7% and 14.2% respectively.
(Global Lifetime and 12-Month Prevalence of Suicidal Behavior, Deliberate Self-
Harm and Non-Suicidal Self-Injury between 1989 and 2018: A Meta-Analysis)
19. • Adolescents : 13-16% (Ross & Heath,
2002)
• College students : 17-36% (Whitlock et
al.,2006)
• Adults :4% (Klonsky et al., 2003)
20. Prevalence and Characteristics of Self-Harm in Adolescents: Meta-
Analyses of Community-Based Studies 1990-2015.
• One hundred seventy-two datasets reporting self-harm in 597,548
participants from 41 countries were included
• Overall lifetime prevalence was 16.9% with rates increasing to 2015.
• Girls were more likely to self-harm The mean age of starting self-harm
was 13 years,
• Cutting being the most common type (45%).
25. • The mild type of DSH encompasses mostly relatively nonviolent
methods followed by non-serious physical injury.
• Characteristics associated with mild forms of attempted
suicide/deliberate self-harm are:
1. Young age,
2. living together
3. low level of suicidal preoccupation,
4. low suicidal intent
• In mixed type, persons show mixed characteristics.
26. • The severe category consists mostly of relatively hard methods
followed by serious physical consequences.
• Characteristics associated with severe forms of attempted
suicide/deliberate self-harm are :
1. Older age (over 40),
2. Many precautions to prevent discovery,
3. High level of suicidal preoccupation, high suicidal intent,
4. Previous attempted suicides,
5. Drug dependence,
6. Poor physical health,
7. Previous psychiatric treatment
28. Schizophrenia and self harm
• Schizophrenia may also be a contributing factor for self-harm. Those
diagnosed with schizophrenia have a high risk of suicide, which is
particularly greater in younger patients .
• Patients of schizophrenia are known to attempt self-harm due to
command hallucination, catatonic excitement, religious
preoccupations or because of associated depression.
• Major self-mutilation includes amputation of limbs or genitals and
eye enucleation.
• Minor self-mutilation includes self-cutting and self-hitting.
29. Psychological
• Abuse during childhood
• Bereavement
• Troubled parental or partner relationships.
• Factors such as war, poverty, and unemployment
• Feelings of entrapment, defeat, lack of belonging, and perceiving
oneself as a burden
30. Drugs and alcohol
• Benzodiazepine dependence
• benzodiazepine withdrawal
• Alcohol
• Smoking
• Cannabis use - A more recent meta-
analysis on literature concerning the
association between cannabis use and
self-injurious behaviors to be 95%
(Journal of Affective Disorders, 2020. 278: 85–
98)
31. • Substance abuse is also considered a risk factor are some personal
characteristics such as poor problem-solving skills and impulsivity.
• There are parallels between self-harm and Münchausen syndrome, a
psychiatric disorder in which individuals feign illness or trauma
32. Pathophysiology
• Self-harm is not typically suicidal behavior, although there is the
possibility that a self-inflicted injury may result in life-threatening
damage.
• The motivations for self-harm vary, as it may be used to fulfill a
number of different functions
33. Emotion Relief (92%, at least one)
• To stop bad feelings (immediate relief)
• To stop feeling angry or frustrated or enraged
• To relieve anxiety or terror
• To relieve feelings of aloneness, emptiness or isolation
• To stop feeling self-hatred, shame
• To obtain relief from a terrible state of mind
• To control feelings (to exert control)
34. Physical pain distracts from emotional pain
• To disassociate from intolerable feelings
• To transfer emotional pain into physical pain
• Physical pain is easier to deal with than emotional pain
• There is a positive statistical correlation between self-harm and
emotional abuse [Meltzer, Howard; et al. (2000)]
35. • Means of communicating distress
• Make internal wounds external (visible)
• Event markers (memorial for traumatic events)
• Creates euphoria.
• Wanting to fit in
• Feeling emotionally dead inside
• Self harm feels alive and confirms existence
• Coping strategy
36. To punish yourself (63% of non-suicidal self-injury)
• Replicates earlier abuse
• Only 13 % wanted to punish someone or make someone feel guilty
A functional approach to the assessment of self-mutilative behavior. Journal of
Consulting and Clinical Psychology 72: 885-890.
37. Emotional pain vs brain
• Emotional pain activates the same regions of the brain as physical
pain
• So emotional stress can be a significantly intolerable state for some
people
• The sympathetic nervous system controls arousal and physical
activation (e.g., the fight-or-flight response)
• The sympathetic nervous system innervates (e.g., is physically
connected to and regulates) many parts of the body involved in stress
responses.
38.
39. Warning signs
• Unexplained, frequent injuries including cuts and bruises
• Wearing of long pants/sleeves in warm weather
• Low self-esteem
• Overwhelmed by feelings
• Inability to function at home, school or work
• Inability to maintain stable relationships
40. Immediate consequences
• Feels alive, functioning, able to act
• Clears the mind, helps to focus
• Release of endorphins
• Tension reduction
• Relief from stress or feelings
• Calmness
• Relaxation
• Sleep
41. Late consequences
• Feel of Guilt, shame or stigma
• Feelings of isolation and
• Abandonment
• Infection either from wounds or sharing tools
• Severe, possibly fatal injury
• Permanent scars or disfigurement.
43. Course and prognosis
• Repetition is one of the core characteristics of suicidal behaviour.
• Among DSH patients ‘repeaters’ are more common than ‘first-evers’.
• Between 30 and 60 per cent of DSH patients engaged in previous acts,
and between 15 and 25 per cent did so within the last year.
• Psychosocial characteristics of repeaters are substance abuse,
depression, hopelessness, personality disorders, unstable living
conditions/living alone, criminal records, previous psychiatric
treatment, and a history of stressful traumatic life events.
44. Facts
• Self injury behaviors are found in about 75% of borderline personality
disorder.
• The frequency with which self destructive behaviors occur (e.g.,
unprotected sex with strangers, drinking while taking antabuse)
would increase this rate into 90% range.
• A common belief regarding self-harm is that it is an attention-
seeking behavior; however, in many cases, this is inaccurate.
• Many self-harmers are very self-conscious of their wounds and scars
and feel guilty about their behavior, leading them to go to great
lengths to conceal their behavior from others.
45. • Studies of individuals with developmental disabilities (such
as intellectual disability) have shown self-harm being dependent on
environmental factors such as obtaining attention or escape from
demands [Iwata, B. A.; et al. (1994)]
• Such self-injurious acts occur in people who have histories of suicidal
attempts (62%), with an average frequency of about three attempts
46. ICD 10 Criteria of DSH
• In annexure under - other conditions from ICD-10 often
associated with mental and behavioural disorders.
• It covers the associated diagnoses most likely to be
encountered in ordinary clinical practice.
• It covers 21 chapters in which,
• Chapter XX – external causes of morbidity and mortality.
• Under which comes intentional self harm (X60 – X84)
47. DSM V criteria of Non suicidal self injury
A. In the last year, the individual has, on 5 or more days, engaged in
intentional self-inflicted damage to the surface of his body or sort
likely to induce bleeding, bruising or pain with the intention that
injury will lead to only minor or moderate physical harm(i.e., there
is no suicidal intent)
B. The individual engaging self-injurious behavior with one or more of
the following expectations
1. To obtain relief from a negative feeling or cognitive state
2. To resolve an interpersonal difficulty
3. To induce a positive feeling state
48. C. The intentional self injury is associated with at least one of the
following
1. Interpersonal difficulties or negative thoughts or feelings
depression, anxiety, tension, anger
2. Prior to engaging in the act, a period of preoccupation with the
intended behavior that is difficult to control
3. Thinking about self injury that occurs frequently, even when it is not
acted upon.
49. D. The behavior is not socially sanctioned (e.g.,
body piercing, tattooing, part of religious or cultural ritual)
and is not restricted to picking a scab or nail biting.
E. The behavior or its consequences cause clinically significant distress
or interference in interpersonal, academic or other important areas of
functioning
F. The behavior does not exclusively occur during psychotic episodes,
delirium, substance intoxication, or substance withdrawal. The
behavior is not better explained by other mental disorders.
50. Assessment scales of DSH
• The Deliberate Self-Harm Inventory
• General Self-Harm Questionnaire
• Clinician-administered rating scale of self-destructive behavior
• Self-harm behavior survey (Favazza)
• Functional assessment of self-mutilation (Lloyd)
51. The Deliberate Self-Harm Inventory
• The Deliberate Self-Harm Inventory (Gratz, 2001) is a 17-item self-
report questionnaire developed to assess deliberate self-harm.
• It is behaviorally based and assesses aspects of deliberate self-harm
such as frequency, severity, duration, and type of self-harming
behavior.
52. General Self-Harm Questionnaire
• This is a brief questionnaire containing some of the common items
traditionally used in the literature to measure deliberate self-harm.
• It is used to assess the construct validity of the DSHI
53. Treatment
Pharmacotherapy
As many psychiatric disorders are associated with a higher risk of self-
harm, pharmacological treatment of these conditions documented
should be considered.
• For depression –SSRIs, SNRIs, TCAs or MAO (NICE, 2009a)
• For anxiety -
1. Offer a selective serotonin reuptake inhibitor (SSRI) and
psychotherapy
2. Do not offer a benzodiazepine or antipsychotic ( NICE, 2011a)
54. • For schizophrenia (NICE, 2009b) - oral antipsychotic medication such
as
1. Risperidone (Risperdal, Janssen),
2. Olanzapine (Zyprexa, Eli Lilly),
3. Quetiapine (Seroquel, AstraZeneca), (Geodon, Pfizer)
4. Aripiprazole
5. Offer clozapine who have an inadequate or no response to
treatment despite the sequential use of adequate doses of at least
two different antipsychotic drugs
55. Psychotherapy
• Two long-term–based treatments :
1. Cognitive behavioral therapy (CBT)
2. Dialectical behavioral therapy (DBT)
• Others therapies include - Developmental group
therapy, Psychodynamic therapy, and In-home
Interpersonal Psychotherapy.
56. Borderline personality disorder
• Psychotherapy is considered the primary treatment for borderline
personality disorder (BPD).
• Currently, there are four comprehensive psychosocial treatments for
BPD.
• Two of these treatments are considered psychodynamic in nature:
mentalization-based treatment and transference-focused
psychotherapy.
• The other two are considered to be cognitive-behavioral in nature:
dialectical behavioral therapy and schema-focused therapy.
57. Mentalization-based treatment
• Bateman and Fonagy developed mentalization-based treatment
(MBT) for patients with BPD.
• This treatment aims to increase a patient's curiosity about and skill in
identifying his or her feelings and thoughts and those of other people
as well.
• They speculate that this difficulty in mentalization arouse because of
difficulties in early attachment.
58. Transference-focused psychotherapy.
• TFP is based on Kernberg's conceptualization of the core problem of
BPD .
• Kernberg suggests that excessive early aggression has led the young
child to split his or her positive and negative images of him or herself
and his or her mother.
• In either case, the pre-borderline child is unable to merge his or her
positive and negative images and attendant affects to achieve a more
realistic and ambivalent view of him or herself and others.
• The primary goal of TFP is to reduce symptomatology and self-
destructive behavior through the modification of representations of
self and others as they are enacted in the here and now transference
59. Dialectical behavioral therapy
• Linehan(1993) has suggested that the core feature of BPD is
emotional dysregulation.
• She suggests that this lability may be due to both inborn biological
vulnerabilities and an invalidating childhood environment.
• In any case, the person with BPD is easily upset, becomes extremely
upset very rapidly, and takes a good deal of time to calm down.
60. • This treatment consists of skills groups, individual therapy as well as
phone coaching for patients, and a consultation team for clinicians
treating them.
• DBT resulted in a significantly better retention rate and significantly
greater reductions of self-mutilating and self-damaging impulsive
behaviors, particularly among those with a history of frequent self-
mutilation
61.
62.
63. Schema-focused therapy
• Borderline patients are thought to have four dysfunctional life
schemas that maintain their psychopathology and dysfunction:
detached protector, punitive parent, abandoned/abused child, and
angry/impulsive child.
• Change is achieved through a range of behavioral, cognitive, and
experiential techniques that focus on the therapeutic relationship,
daily life outside therapy, and past experiences (including traumatic
experiences).
64. Supportive Telephone Calls and Letters
• Treatments consisting of supportive telephone calls, SMS, or written
contacts after discharge of the suicidal patient from the emergency
department or hospital showed preventive effects.
• Involving community resources with the goal that the social
intervention should give support to the patient in breaking through
loneliness and finding social networks, and in this way, enhancing a
sense of meaning in their lives is essential.
65. Self mutilation
“Self mutilation refers to intentional,
non lethal, repetitive body harm or
disfigurement that is socially
disagreeable”.
(Pearson, 2011)
67. Major :
• Extreme acts that occur suddenly and cause considerable damage
• Associated with the psychotic state or intoxication.
Stereotypic :
• Repetitive, often rhythmic self-injurious
• Found in autistic, mentally retarded, and in about a third of
individuals with Tourette’s syndrome.
68. Moderate or superficial :
• Type that mental health professional are most likely to encounter
• Includes hair pulling, skin scratching, picking, cutting and carving.
Eg – trichotillomania
69. Can be :
1. Compulsive – repetitive, ritualistic behavior that occurs many times
in a day
2. Episodic – occasional and usually a symptom of another disorder
3. Repetitive – addictive and part of their identity
70. Attempted Suicide - definition
• Attempted suicide is self injury with a desire to end one's life but does
not lead to death.( Nazem et al.,2008;23:1573–9)
• Suicide attempt can be defined as a non-fatal self-directed potentially
injurious behavior with an intent to die (Krug E. Vol. 1. Genèva: World
Health Organization; 2002)
71. Historical facts of suicide
• Suicides played prominent roles in ancient
legend and history, like Ajax the Great who
killed himself in the Trojan War,
and Lucretia whose suicide around 510 B.C.
initiated the revolt that displaced the Roman
Kingdom with the Roman Republic.
72. • One early Greek historical person to commit
suicide was Empedocles around 434 B.C. One
of his beliefs was that Death was a
transformation. It is possible this idea
influenced his suicide. Empedocles died by
throwing himself into the Sicilian volcano,
Mount Etna.
Empedocles
73. • In the Middle Ages, the Christian church excommunicated people
who attempted suicide and those who died by suicide were buried
outside consecrated graveyards.
• In ancient times, suicide sometimes followed defeat in battle, to avoid
capture and possible subsequent torture, mutilation, or enslavement
by the enemy.
• During the Cultural Revolution in China (1966–1976), numerous
publicly known figures, especially intellectuals and writers, are
reported to have committed suicide, typically to escape persecution
74. • The WHO report “Preventing suicide: a global imperative” published
in 2014 estimates that over 800,000 people die by suicide, and more
than 20 million attempt suicide each year.
• This implies that every 40 seconds, a person dies by suicide
somewhere on the globe, and every 1.5 seconds, someone will
attempt to take his/her own life.
• Annual global suicide rates are 15 for males, 8 for females, and 11.4
per 100,000 population.
Epidemiology
75. Epidemiology
• Suicide occurs in all regions of the world and throughout the life span,
and it accounts for 1.4 percent of all deaths worldwide, by that,
ranking as the 15th leading cause of death.
• Among young people 15 to 29 years of age, suicide is the second
leading cause of death globally
76. Etiology of suicidal behavior
Psychiatric disorders
• Major depressive disorder (MDD),
• Bipolar disorders,
• Anxiety disorders,
• Alcohol and Substance misuse,
• Schizophrenia,
• Eating / personality disorders,
• Different types of trauma,
• Chronic somatic disorders, and
• Current stressful life events
77. Epigenetics
• Exposure to early-life maltreatment can affect molecular mechanisms
involved in the regulation of behavior through methylation and
histone modification
• This induce behavioral deviations during the early development, and
possibly later in life. This mechanism is called epigenetics.
• Childhood abuse and other detrimental environmental factors seem
to target the epigenetic regulation of genes involved in the synthesis
of neurotrophic factors and neurotransmission.
78. Biological aspects :
Serotonergic system
• Serotonin is involved in brain development, behavioural regulation,
modulation of sleep, mood, anxiety, cognition, and memory and is
shown to be disturbed in various psychiatric disorders.
• Asberg and colleagues observed that depressed individuals who had
either attempted suicide by violent means or subsequently died by
suicide in the study follow-up period were more likely to have lower
CSF 5-HIAA levels.
79. • 5-hydroxyindoleacetic acid (5-HIAA) is the major metabolite of
serotonin and level of CSF 5-HIAA is a guide to serotonin activity in
parts of the brain.
• Multiple postmortem studies of suicide, report lower brainstem levels
of 5-HIAA and serotonin
• In depressed and non-depressed suicides there is evidence that
5-HT2A receptors are upregulated
• Aggressive/ impulsive traits, related to serotonergic dysfunction, are
potentially an aspect of the diathesis for suicidal behaviour.
80. Noradrenergic system
• Investigating the functioning of stress response systems in suicidal
individuals is important for elucidating neurobiological concomitants
of suicidal behavior
• The noradrenergic system and the HPA axis are two key stress
response systems.
81. • Lower functional reserve of the noradrenergic system, which if
accompanied by an exaggerated stress response with greater release
of noradrenaline
• It may result in norepinephrine depletion leading to depression and
hopelessness, both of which are contributory factors to suicidal
behavior.
• Noradrenergic and HPA axis responses to stress in adulthood appears
to be greater in those reporting an abusive experience in childhood.
82. Other biological changes
• There is a well-documented relationship between thyroid dysfunction
and depression
• Abnormal TSH response to challenge tests has also been associated
with poor response to antidepressant treatment and a higher relapse
rate, which may increase risk for suicidal behavior.
• Long chain polyunsaturated fatty acids, particularly omega-3, may
also be a mediating factor in the relationship between low cholesterol
and increased risk for depression and suicidal behavior.
83. Suicide after DSH
• Suicide is one of the major outcomes of DSH.
• Prospectively, DSH patients have a high risk of dying by suicide.
Between 10 and 15 per cent eventually die because of suicide.
• The connection between DSH and suicide lies between 0.5 and 2 per
cent after 1 year and above 5 per cent after 9 years.
• Mortality by suicide is higher among DSH patients who have engaged
in previous acts of DSH.
84. Warning signs of suicidal ideation
•Isolating yourself from your loved ones
•Feeling hopeless or trapped
•Talking about death or suicide
•Giving away possessions
•An increase in substance use or misuse
•Increased mood swings, anger, rage, and/or irritability
•Engaging in risk-taking behavior like using drugs or having
unprotected sex
•Accessing the means to kill yourself, such as medication, drugs, or a
firearm
•Acting as if you're saying goodbye to people
85. Suicidal ideation
• Suicidal ideation means wanting to take your own life or thinking
about suicide.
• However, there are two kinds of suicidal ideation: passive and active.
• Passive suicidal ideation occurs when you wish you were dead or
that you could die, but you don't actually have any plans to commit
suicide.
• Active suicidal ideation, on the other hand, is not only thinking about
it but having the intent to commit suicide, including planning how to
do it.
86. Prevalence of suicidal ideation
• The lifetime prevalence of suicidal ideation for the general world
population is about 9% and about 2% within a 12-month period.
• According to the 2017 National Survey on Drug Use and
Health (NSDUH) by the Substance Abuse and Mental Health Services
Administration (SAMHSA), 4.3% of U.S. adults ages 18 and older had
thoughts about suicide, with the highest prevalence among adults
ages 18 to 25.
87. Suicidal intent
• Intent refers to the desire to end one’s life, and includes the person’s
knowledge of the risk and the means to achieve the desired outcome
(O'carroll PW, 2007 )
• Suicide intent is a complicated construct that comprises 2 major
elements:
• The level of planning and forethought preceding an act of suicide
(objective planning), and
• The intended outcome and perceived lethality of the act (perceived
intent
88. • Low intent suicide – with less or no intent to kill oneself.
• High intent suicide – with strong desire to kill oneself.
• Suicidal intent correlates highly with medical lethality when the
attempter has sufficient knowledge to assess properly the probable
outcome of his attempt
(Haw C et al., Suicide and Life-Threatening Behavior. 2003;33:353–364)
89. Lethality
• Lethality is the inherent danger and the potential for death associated
with the suicidal act (Berman, Shepard, & Silverman, 2003).
• A minimal association between the degree of suicide intent and the
extent of medical lethality has been found, indicating that suicide
intent and lethality are independent dimensions of suicide attempt
behavior.
• the lethality of a suicide attempt may be determined less by their
intent to die than by their access to lethal methods (Spirito &
Overholser, 2003).
93. Psychometric scales used in suicide risk assessment.
• The Suicide Intent Scale (SIS),
• Scale for Suicidal Ideation (SSI-C),
• The Beck Hopelessness Scale,
• The Columbia Suicide Severity Rating Scale (C-SSRS).
94. The Suicide Intent Scale (SIS)
• The suicide intent scale was developed by Aaron T. Beck and his
colleagues at the University of Pennsylvania for use with patients who
attempt suicide but survive.
• It is important to understand a patient's will to die in order to assess
the severity of the suicide attempt.
• Some attempted suicides are carried out with little to no intention of
cessation of life, while others clearly have no other goal
• The suicide intent scale is an attempt to redefine the meaning of
attempted suicide, placing them on a scale based on intent.
95. Treatment
• Treatment in prevention of suicide requires a complex approach of
psychosocial, psychotherapeutic, and psychopharmacological
interventions
• The choice of treatment depends on the condition of the patient.
• The combination of pharmacological treatment with psychotherapy
should always be taken into consideration as part of a complex
treatment strategy
96. Pharmacological
Antidepressants
• Selective serotonin reuptake inhibitors (SSRIs) are nowadays widely
used in the treatment of suicidal patients with MDD and related
conditions
• Adverse outcomes in some patients during treatment with SSRI
antidepressants like agitation, restlessness, irritability, dysphoria,
anger and insomnia can worsen the suicide risk in these patient.
97. Mood stabilizers
• Meta-analyses shows that long term lithium treatment is associated
with a substantial reduction of the risk for suicide and attempted
suicide in patients with bipolar spectrum disorders
• In bipolar depression, other mood stabilizers, such as anticonvulsants
or second-generation antipsychotics have beneficial effects on
suicidal behavior. However, lithium is noted to be significantly
superior in reducing suicidal behaviors
98. Antipsychotics
• Suicidal symptoms in schizophrenic patients require, in addition to
the standard treatment of the schizophrenia with antipsychotics, an
additional medication to control anxiety or agitation.
• Sedating antipsychotics are mostly used in these cases.
Electroconvulsive Therapy
• Cases of depression with suicidality, which are difficult to treat by
other means, can be treated by ECT, which has a rapid onset of action
and relief of symptoms
99. Role of media
• Sensational and irresponsible reporting by different types of media
may precipitate or induce suicidal acts through imitation or
identification mechanisms in suicidal persons.
• The WHO issued guidelines on media coverage, describing how the
press and broadcasting media should report on suicide in order to
avoid copycat effects. It is essential to avoid the description of suicide
as courageous or desirable.
100. Legality of attempted suicide
Indian scenario
• According to Article 21 of the Indian constitution, “No person shall be
deprived of his life or personal liberty except according to procedure
established by the law”. While the constitution covers the right to life
or liberty, it does not include the ‘right to die’
• Section 309 of the Indian Penal Code (IPC) clearly states as follows:
“Whoever attempts to commit suicide and does any act towards the
commission of such offence, shall be punished with simple
imprisonment for a term which may extend to one year or with fine or
both.”
101. • The law commission, in its 210th report, recommended that attempt
to suicide warranted medical and psychiatric care and not
punishment.
• In view of the opinions expressed by the WHO, International
Association for Suicide Prevention, the Indian Psychiatric Society and
the representations received by the commission from various
persons, the commission resolved to recommend the government of
India to initiate steps for repeal of the anachronistic law contained in
section 309, IPC.
• Thus keeping in view the responses, it has been announced on
December 10, 2014, to delete section 309 of IPC from the statute
book.
102. International scenario
• During 19th and 20th century, most of the developed countries have
repealed criminalization of attempted suicide, but some countries
including India, continue to treat suicidal attempt as a criminal
offense.
• Attempted suicide has been decriminalized in Ireland as early as 1993
• Currently, World Health Organization identified 59 countries across
the world that have decriminalized suicide.
• The attempted suicide has been decriminalized in whole of Europe,
North America, much of South America and few parts of Asia.
103. • Decriminalization will reduce the trauma and potential prosecution in
the aftermath of a suicidal attempt.
• However, there is a need to improve the mental health coverage and
provide a framework to deliver essential mental health services to all
those who attempted suicide.
104. Self harm in animals
• Self-harm in non-human mammals is a well-established but not
widely known phenomenon
• Zoo or laboratory rearing and isolation are important factors leading
to increased susceptibility to self-harm in higher mammals, e.g.,
macaque monkeys.
• Non-primate mammals are also known to mutilate themselves under
laboratory conditions after administration of drugs.
• For example, pemoline, clonidine, amphetamine, and very high (toxic)
doses of caffeine or theophylline are known to precipitate self-harm
in lab animals.
105. • Captive birds are sometimes known to engage
in feather-plucking, causing damage to feathers
that can range from feather shredding to the
removal of most or all feathers within the bird's
reach, or even the mutilation of skin or muscle
tissue.
• In dogs, canine obsessive-compulsive disorder can
lead to self-inflicted injuries, for example
canine lick granuloma
Lick granuloma from
excessive licking
Feather plucking
in a Moluccan Cockatoo
106. Conclusion
• Deliberate self-harm is a major problem in many contemporary
societies.
• DSH seems to reflect the degree of powerlessness and hopelessness
of young people with low education, low income, unemployment,
and difficulties in coping with life stress
• There is a need for a better nationwide continuous registration of DSH
and related socio-economic conditions.
• There is also a need for better mental health care management of
DSH patients.
• Development of effective intervention, and prevention programs is a
key priority.
107. References
• Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition. Arlington,
VA: American Psychiatric Association, 2013.
• Benjamin James Sadock, Virginia Alcott Sadock, Comprehensive
textbook of psychiatry. 10th Ed. 2007,Philadelphia, chapter 32.
• Paul H et al., Oxford Textbook of Psychiatry. 2018. New Delhi. Ch
4,957-70.
