3. Introduction
Situations considered to be psychiatric emergencies
include patients who are:
Suicidal
Agitated and out of control
Threatening, combative or disruptive
4. suicide
is derived from the Latin word for “self-murder.”
Primary psychiatric emergency
Unpredictable
Impact on survivor and treating physician
Proposed to be caused mostly by mental illness-
depression
6. epidemiology
Over 800,000 people die by suicide each year i.e every
40 seconds a person dies by suicide
More than 20 million attempt suicide each year i.e
every 1.5 seconds some one attempt suicide
Suicide rate 11.4 per 100,000 population.
Occurs in all regions of the world and throughout life
span and account 1.4 % of all deaths word wide
ranking as 15th leading cause of death.
Ethiopia 7.7/100,000
7. Causes / risk factor
Socio-demographic factors
Gender difference
men> women
Method to commit suicide:= firearms, hanging, drugs,
pesticides, and jumping from high places
Age
Men >45, women >55
Most suicides now are among those aged 35 to 64
8. Race :- white> black
Religion :- protestant high risk, Muslim low risk
Marital status :-
single , never-married, divorced, widows and widower
Social isolation and FHx
Homosexual > heterosexual
Occupation:
Physical health
Loss of mobility, disfigurement and chronic intractable pain
10. Psychological factors
Hopelessness
Impulsivity
Poor problem solving skill
Protective factors
strong religious affiliation
Married, children at home, pregnancy
Responsibility to family
Good social support
good coping skills
11. Etiological theories
Sociological factors
Durkheim’s theory:-
divided suicides into three social categories
egoistic, altruistic, and anomic
1 egoistic suicide- applies to those who are not
strongly integrated into any social group.
2 Altruistic suicide -applies to those susceptible to
suicide stemming from their excessive integration into
a group.
12. Etio theories cont…
Anomic suicide - applies to persons whose
integration into society is disturbed so that they
cannot follow customary norms of behavior.
also refers to social instability and a general
breakdown of society’s standards and values.
13. Cont…
Psychological factors
Freud’s theory- Freud stated his belief that suicide
represents aggression turned inward against an
Introjected, ambivalently cathected love object.
also doubted that there would be a suicide without an
earlier repressed desire to kill someone else.
Menninger’s Theory – man against himself
conceived of suicide as inverted homicide because of a
patient’s anger toward another person.
14. Recent Theories
Fantasies about what would happen and what the
consequences would be if they commit suicide.
Such fantasies often include
wishes for revenge, power, control, or punishment
atonement, sacrifice, or restitution
escape or sleep
rescue, rebirth, reunion with the dead; or
a new life.
A study by Aaron Beck showed that hopelessness was one
of the most accurate indicators of long-term suicidal risk.
15. Biological Factors
Post mortem neurochemical studies have reported modest
decreases in serotonin itself or 5-HIAA in either the
brainstem or the frontal cortex of suicide victims.
Postmortem receptor studies have reported significant
changes in presynaptic and postsynaptic serotonin
binding sites in suicide victims.
Together, these CSF, neurochemical, and receptor studies
support the hypothesis that reduced central serotonin is
associated with suicide.
Recent studies also report some changes in the
noradrenergic system of suicide victims.
Low concentrations of 5-HIAA in CSF also predict future
suicidal behavior.
16. Genetic Factors
Suicidal behavior tends to run in families.
In psychiatric patients, a family history of suicide
increases the risk of attempted suicide and that of
completed suicide in most diagnostic groups.
Concordance =monozygotic>dizygotic
17. Parasuicidal Behavior
Parasuicide is a term introduced to describe patients who
injure themselves by self-mutilation (e.g., cutting the
skin), but who usually do not wish to die.
Most cut delicately, not coarsely, usually in private with a
razor blade, knife, broken glass, or mirror.
The wrists, arms, thighs, and legs are most commonly
cut; the face, breasts, and abdomen are cut infrequently.
Most persons who cut themselves claim to experience no
pain and give reasons, such as anger at themselves or
others, relief of tension, and the wish to die.
18. RISK ASSESSMENT
Clinical Interview
In suicide risk assessment, the most important
instrument is clinical inquiry.
The inquiry should be clear, empathetic, free from
prior criticism, and focus on facts and patients’
emotional and communication style.
Interview with the family or significant others is an
important source of information
19. Interview should be in systematic way
Begin with questions that address the patients feeling
about living
Follow on with specific questions that ask about
thoughts of death, self-harm, or suicide
Ask whether individuals had repeated suicidal thoughts
or attempts
For individual with psychosis, ask specifically about
hallucinations and delusions
Assess pts potential to harm others in addition to
himself or herself.
20. Psychometric Scales
SAD PERSONS Scale
S : male sex
A: age (<19 or >45)
D : depression
P : previous attempt
E : ethanol abuse
R : rational thinking loss
S : social support lacking
O : organized plan
N : no spouse
S : sickness
Score 0–2: Low risk.
Discharge and outpatient
follow-up.
Score 3–4: Moderate risk.
Close monitoring as
outpatient. Consider
admission.
Score 5–6: High risk.
Admission is advised,
especially if support from
environment seems
uncertain.
Score 7–10: Very high risk of
suicide. Admission required
21. Management principles of suicide
Assessing suicidal risk :- SAD PERSONS scale
Assessing treatment needs :- outpatient vs inpatient
Pharmacological treatments
Psychological therapies
suicide prevention
22. Outpatient Treatment
Suicide intent _
Severity of symptoms _
Social support +
Full assessment of patient .
Organization of adequate social support
Regular review of suicidal risk
Safe psychiatric treatment using drugs with less toxicity
Small prescriptions
Involve relative in safe keeping of tablets
Immediate access to extra help
23. Inpatient Treatment
Suicide intent +
Severity of symptoms +
Social support _
Assessment of mental capacity
Safe ward environment
Adequate number of well-trained nursing staff
Good working relationship between staff and between
staff / patients
24. Pharmacological Treatments
Use of antipsychotics
Use of antidepressants
Psychological Therapies
Problem oriented therapy
dialectical behavior therapy (DBT) for BPD
cognitive behavioral therapy
Group therapy (multiple attempters) (Adolescent)
25. Suicide Prevention
Improved care for high risk groups
Better and more available psychiatric services
Restricting the means of suicide
Encouraging responsible reporting
Educational programmes
26. VIOLENT BEHAVIOR
The media exaggerated the link between violence and
mental illness
Increase fear by the public
Stigma experienced by psychiatric patients
Most mentally ill persons are nonviolent
27. Violent Behavior
Patients with the following diagnoses are more likely
to become violent than others:
Schizophrenia
Mania
Cognitive disorders (delirium, dementia)
Drug or alcohol intoxication
Mental retardation
28. Violent Behavior
Violence is difficult to predict in long-term
Clinical data that indicate patient’s potential for
violence
Diagnosis
Past behavior
A history of violent behavior is the best predictor of
future dangerousness
Predictions are more accurate in the short-term
29. Etiology and Pathophysiology:
Substance abuse: Stimulants, sedatives hallucinogens
Activities to obtain the drugs
Alcohol is strongly associated with violence because of
its tendency:
To cause disinhibition
To decrease perceptual & cognitive alertness
To impair judgment
30. Etiology ….
Childhood aggression – one of the strongest predictors
of adult violence
Childhood abuse
PD- like ASPD/Antisocia personality d/o
Low socio-economic status
Availability of firearms
Low CSF serotonin metabolite levels
31. Remain calm and speak softly
Avoid judgmental comments & questions
Nonjudgmental, e.g. “you seem upset; can you tell
me why you feel that way?”
Seats should be arranged allowing personal
distance between the two patient & clinician
Avoid direct eye contact
Patient & clinician should have access to exits
Interview others: family, friends, police, etc.
Assessing Risk for Violence
32. Risk assessment…
Review of clinical variables: thorough history and
careful MSE
Ask:
“have you ever thought of harming someone else?”
“have you ever seriously injured another person?”
“What is the most violent thing you have ever done?”
Assessment should be updated frequently
Careful differential diagnosis – for treatment
33. Clinical variables associated with violence
A history of violent acts
Inability to control anger
History of impulsive behavior (reckless)
Paranoid ideation or frank psychosis
Lack of insight in psychotic patients
Command hallucinations
The stated desire to hurt or kill a person
Acting out PD (Antisocial, Borderline)
Presence of dementia, delirium or intoxication
34. Managing the Violent Patient
Hospital or clinical setting:
Staff:
Sufficient in number
Well trained in seclusion & restraint techniques
Seclusion & restraint is a measure to prevent injury to
the patient and other, not a punishment!!
35. Managing the Violent Patient
How to restrain?
Clear the area of other patients
Approach the patient with a back up of four other
team members
Tell the patient that he is being restrained
because of uncontrolled behavior
Ask the patient to walk to seclusion area
Staff members take a limb each in a plan agreed
beforehand.
Apply restraints & take the pt to seclusion room
36. Managing the Violent Patient
Search the patient for potentially dangerous items that
need to be removed
Dress the patient in hospital gown
Medication can be oral or injection
If patient is agitated, Haloperidol 2-5mg &
diazepam 10mg can be combined
Repeat medication every 30 min until the patient
calms down
Keep documentation & observe closely
