3. Suicide Background
• Third leading cause of death for teens and
young adults
• Persons more likely to commit suicide
-Older adolescents
• -Males (4x more than females)
• Persons more likely to attempt suicide
-females
4. Etiology and Pathogenesis
• Normal stresses of adolescence
-Biological
-Psychological
• -Social/environmental
• Society’s view of adolescence
• Role of socioeconomic factors
6. Predisposing Factors
• Abuse – Physical/Sexual
• Chronic Diseases
• Chronic substance abuse, teen/parent
• Family disorganization
• Poor school performance
• Family hx of suicide
• Age/ firearm in the house
8. Acute Stressors
• Early/Late psychological maturation
• Sexuality
Anxiety about beginning sex
homosexuality
• pregnancy
• Death of someone close
• Recent loss (person/relationship)
9. Acute Stressors (cont.)
• Changes in school performance
• Victimization, assault,rape
• Substance use experimentation
• Major changes in social environment
• Onset of psychiatric disorder
• Media
10. Vulnerable Adolescent
• Late adolescent
• Depression
• Low self esteem coupled with multiple
failures
• Not fitting in, no friends
11. Signs of suicide
• Changes eating/sleeping habits
• Withdrawal
• Chronic drug use
• Frequent somatic complaints
• Giving away favorite possessions
• Feelings of hopelessness,guilt,poor
concentration,boredom,school grade drop
12. Case
Jessie is a 17 y.o. female who you are seeing
in the ER at 4PM on a Saturday afternoon.
She presents with a known Tylenol
overdose earlier that day. She ‘s somewhat
drowsy, but is coming to and able to answer
basic questions. She is medically stable. Her
mother comes with the Tylenol bottle and
states that it was recently brought and that
13. Case (cont.)
10 pills were missing (325mg each). After 4
hours, Tylenol levels are in a safe zone, and
you have to determine her disposition.
What specific points from the hx are
important to ask Jessie?
What criteria should you use to hospitalize?
15. Factor
PRECIPATATING EVENT
• LOW, argument with friend, teacher
• MODERATE, fight with close friend,school
failure,difficult home situation
• HIGH, break-up important
relationship,thrown out of home,pregnancy
discovery,death close relationship,thinking
disorder,hallucinations
16. FACTOR
INTENDED PURPOSE
• LOW, unknown, impulsive
• MODERATE, attention seeking, to
punish,escape,cannot face shame or failure
• HIGH,to be dead, no purpose in living, to
join deceased one
17. FACTOR
PLAN - PERCEIVED LETHALITY
• LOW, small amount of pills, perceived low
toxicity
• MODERATE,small amount of
pills,perceived as toxic, slash wrist
• HIGH, violent method, large amount of
pills, perceived toxic
18. FACTOR
PLAN – REAL LEATHALITY
• LOW, relative innocuous
• MODERATE.moderately harmful but
perceived recovery
• HIGH, significant potential for death
19. FACTOR
PLAN – SPECIFICITY
• LOW,no solid plan
• MODERATE, specific plan, not
rehearsed,several plans, method readily
available
• HIGH, one method chosen and steps in
place, may have rehearsed plan
20. FACTOR
PLAN - DISCOVERY POTENTIAL
• LOW,announces intent, someone at home
• MODERATE, someone expected at home,
calls someone, location highly visible
• HIGH, isolated location or situation,tells no
one
21. FACTOR
LIFE STRESSORS – CURRENT
• LOW, none
• MODERATE, environmental changes,
physical changes, failure to achieve
• HIGH, death of close individual, thrown out
of home, rejection by boyfriend
22. FACTOR
MOOD - AFFECT – BEHAVIOR
• LOW, optimistic, able to verbalize
• MODERATE, depressed,but mood
lightens,few friends
• HIGH, flat, distant affect, no friends, no
change in mood after talking
23. FACTOR
PAST COPING AND MENTAL HEALTH
• LQW, good coping and support, no mental
health issues
• MODERATE, distorts reality, impulsive,
uses peers for support, some
depression,mood swings
• HIGH. loose reality,victim of fate,depressed
24. FACTOR
FAMILY STRUCTURE – FUTURE PLANS
• LOW, supportive, good coping.,definite
future goals
• MODERATE, overburden family but tries
to be supportive,wants to be somebody but
no plans
• HIGH, overburden family,no coping,no
plans, alienated
25. SUMMARY
• PRECIPITATING EVENT
• INTENDED PURPOSE
• PLAN
METHOD-PRECEIVED LETHALITY
REAL LETHALITY
SPECIFICITY
DISCOVERY POTENTIAL
26. SUMMARY (cont.)
• LFE STRESSORS – CURRENT
• MOOD – AFFECT – BEHAVIOR
• PAST COPING AND MENTAL HEALTH
• FAMILY STRUCTURE/FUTURE PLANS
28. DRUGS OF ABUSE
• Illicit and nonillicit
• Combination of both
• Alcohol, #1 followed by smoking cigarettes
and marijuana
• Rise in stimulant use
• Inhalant use popular with early adolescents
• Cocaine, opiate, and othe drug use stable
29. CLASSES OF DRUGS
• Opioids – Depressants type 1
• Stimulants
• Sedatives,hypnotics –Depressants type2
• Inhalants – Depressants type 3
• Hallucinogens
• Marijuana
• Phencyclidine - PCP
30. CASE
Ann is a 17 y.o. who present in your clinic
with a 2 day hx of cough, rhinorhea, sore
throat, and generalized muscle aches. She
also has had abdominal pain with vomiting
and diarrhea. Her temp is normal and pulse
slightly elevated. She appears agitated. Her
P.E. is normal except for dilated pupils.
31. OPIOID CLASS
• Morphine
• Heroin
• Codeine
• Oxycodone and hydromorphone
• Merperedine and methodone
• Talwin, darvon, ultram
• Nsaids
32. OPIOID SYMPTOMS
• V.S. – depressed
• Mental Status – euphoria, stupor
• Physical – miosis, decreased reflexes,
analgesia,amnesia, constipation, pulmonary
edema, respiratory depression and coma
39. FLUMAZENIL
• Benzodiazepine antidote
• Use with caution
• May cause vomiting
• May not totally reverse respiratory depress.
• Seizures in physical dependence and mixed
overdoses
• Arrythmia with tricyclics and mixed
overdoses
43. HALLUCINOGEN
SYMPTOMS
• V.S. – increased
• Mental status – euphoria with hallucinations
• Physical – impaired senses,synesthesia,
sweating, dilated pupils,palpitations,tremors
and poor coordination
44. PHENYCYCLIDINE
• PCP
• V.S. – may be normal, increased B.P. ,temp,
• Mental status – confusion, anxiety, amnesia
• Physical – vertical nystgmus,and may see
horizontal or rotary, muscle rigidity.
Catatonia,ataxia,sweating, extreme muscle
strength, seizures
45. PREGNANCY - DIAGNOSIS
• LABORATORY
Urine HCG- + 7-10 days after conception
severe renal damage interferes
Serum HCG- + 6-12 days after ovulation
peaks 10-12 weeks
46. PREGNANCY-PHYSICAL
EXAM
• Always perform pelvic exam,including
GC/CHL
• Bimanual exam
Less than 12 weeks enlarged globularr
uterus below the symphysis pubis
16 weeks midway umbilicus/pubic bone
20 weeks umbilicus
47. PREGNANCY -
PSYCHOSOCIAL
• Concrete vs. abstract thinking
• Sexual history
• Parental knowledge
• Ability to communicate with parents
• Partner awareness and what pt. Wants to do
• Pregnancy outcome options
• Support status and safety to go home
48. RAPE
• Under age 18 and less than 72 hours – rape
kit,, family advocacy, commanding
officer,Dr. Craig’s group
• Over age 18 and less than 72 hours,above
but refer to SAVI, Cindy Stewart, 202 685-
1171,for navy family advocacy other
branches
49. RAPE
• Under age 18 and greater than 72 hours,do
standard STD work up,HEADDS, family
advocacy – central contact Jackie
Richardson, 202 685-1182 or county rape
crisis center
• Over age 18 and greater than 72 hours,
work up as above but refer to SAVI, contact
Cindy Stewart 202 685-1171
50. STATUTORY RAPE
• DC law, sexual acts or sexual contact
between a child under 16 and any person
four or more years older.
• Maryland, Sexual contact with another
person who is under 14 and the person
performing the sexual contact is four or
more years older than the victim or.
51. STATUTORY RAPE (cont.)
• A sexual act with another person who is 14
or 15 years of age and the person
performing the act is at least 21 years of age
• Or, vaginal intercourse with another person
who is 14 or 15 years of age and the person
performing the act is at least 21 years of
age
52. STATUTORY RAPE
VIRGINIA
Carnal knowledge of a child younger than 13
is automatically considered to be rape and
falls under the code of Virginia 18.2-61
An adult over age 17 who has sex with a child
over age 14, but under age 18, can be guilty
of contributing to the delinquency of a
minor
