This document discusses suicide and deliberate self harm. It begins by noting that suicide is among the top 10 causes of death globally and the second leading cause of death among young people. For every suicide, 30 episodes of non-fatal self harm occur. Depression, substance abuse and other mental illnesses are common in those who engage in deliberate self harm. The risk of suicide is greatly increased in the year following an episode of self harm. The document then examines the definition of suicide, common methods, warning signs, and risk factors like sociodemographic variables, psychiatric disorders and psychological traits. It provides details on assessing risk and managing suicide at different risk levels.

1. Suicide and deliberate self harm

2. Introduction
• Among the ten leading causes of death in most countries.
• the second cause of death in young people (Hawton, 2012).
• For every suicide more than 30 non-fatal episodes of self-harm
occur.
• Depression, substance misuse, and other mental illness are
common in people with deliberateself harm (DSH).
• The rate of suicide in the year following an episode of deliberate
self-harm (DSH) is some 60–100 times that of the general
population (Hawton et al., 2003).

3. The act of suicide
• An act with a fatal outcome, deliberately initiatedand performed in
the knowledge or expectation of its fatal outcome.
• In England and Wales, according to the Office for National Statistics
in 2008, hanging was the most commonly used method for suicide
by men (53%), followed by drug overdose (16%), self-poisoning by
car exhaust fumes, drowning, and jumping.
• The commonestmethods for women were drug overdose (36%),
hanging (34%), and drowning (Wasserman and Wasserman, 2009).
• In the USA, gunshot and other violent methods are more frequent
than in the UK.

4. The act of suicide
• Most completed suicides have been planned.
• Precautions against discovery are often taken—for example,
choosing a lonely place or a time when no one is expected.
• However, in most cases a warning is given.
• In a US study, suicidal ideas have been expressed by more
than two-thirds of those who die by suicide.
• Clear suicidal intent by more than one-third.
• Often the warning had been given to more than one person.

5. The act of suicide
• Over 40% of people who committed suicide had consulted
their general practitioner in the preceding weeks (Pirkis and
Burgess, 1998).
• Data from the National Confidential Inquiry into Suicide and
Homicide (2015) suggest that 25–29% of suicides have been in
recent contact with mental health services.

6. Definition
• Suicide :Successful attempt to kill one self
• Parasuicide :suicidal gestures, risky behavior likely to result in
death, or unsuccessful suicide attempts

7. The epidemiology of suicide
• Accurate statistics about suicide are difficult to obtain because
information about the exact cause of a sudden death is not
always available.
• It is accepted that official statistics underestimate the true
rates of suicide.
• Local culture and customs, in particular the stigma attached
to suicide and the procedure and requirements for classifying a
death as suicide have a marked effect (Hawton and van
Heeringen, 2009).

8. The epidemiology of suicide
• Global mortality rate is 16:100,000
• 9th cause of death inUSA
• In Japan 25:100,000in Moslems and catholic is less than
10:100,000
• Suicide attempts is 20 times more frequent than successful
suicide

9. Risk factors of suicide
• Sociodemographic factors.
• Activating events
• Physical health
• Psychiatric disorders

10. Sociodemographic factors
• Suicide is about three times as common in men as in women.
• The highest rates of suicide in both men and women are in the
elderly.
• Suicide rates are lower among the married than among those who
have never been married, and increase progressively through
widows, and the divorced.
• Rates are higher in the unemployed.
• Rates are particularlyhigh in certain professions, particularlythose
with access to lethal materials. veterinary surgeons, pharmacists
and it is also higher in doctors, particularlyfemale doctors

11. Activating events
• Stressful life events
• Grief
• Hopelessness
• Alcohol and substance abuse
• Availability of methods

12. • Epilepsy
• Cancer
• AIDS
• Head injuries
Physical health

13. • 95% of all people commit suicide have mental illness
• Depression 15-25%
• Schizophrenia up to 10%
• Alcohol dependency up to 15%
• Personality disorders
Psychiatric disorders

14. Rates of mental disorders in five psychological autopsy studies on
completed suicides using DSM-III or DSM-III-R criteria
• Depressive disorders 36–90%
• Alcohol dependence or abuse 43–54%
• Drug dependence or abuse 4–45%
• Schizophrenic disorders 3–10%
• Organic mental disorders 2–7%
• Personality disorders 5–44%

15. Social factors
• Areas with high unemployment, poverty (Gunnell et al., 1995),
divorce, and social fragmentation (Whitley et al., 1999) have
higher rates of suicide.
• Media coverage of suicide. Suicide and attempted suicide rates
were shown to increase after television programmes and films
depicting suicide (Stack, 2003).
• The precise nature of the media content may also be influential
in increasing or decreasing the risk of imitative behaviour
(Niederkrotenthaler et al., 2010).

16. Biological factors
• A family history of suicide increases the risk at least twofold (Qin et al., 2003),
and genetic factors account for 45% of variance in suicidal behaviour (Bondy et
al., 2006).
• The genetic mechanism may be largely independent of mechanisms giving rise to
psychiatric disorders (Roy et al., 2000),but related to impulsivity and aggression.
• Suicidal behaviour has been linked to decreased activity of brain 5-HT pathways.
Markers of 5-HT function, such as cerebrospinal fluid (CSF) 5-HIAA and the
density of 5-HT transporter sites, are lowered in suicide victims.
• The association between underactivity of 5-HT pathways and suicidal behaviour
appears to extend across diagnostic boundaries, and may be related to increased
impulsivity and aggression in those with low brain 5-HT function.

17. Psychological factors
• Psychological factors in suicide have been derived mainly by
extrapolation from studies of non-fatal DSH, but the factors
may not be the same.
• Research has indicated that hopelessness, impulsivity,
dichotomous thinking, cognitive constriction, problem-solving
deficits are all associated with suicidal behaviour.
• All of these could act by predisposing an individual to act
impulsively (Williams and Pollock, 2000).

18. Older people
• In most countries the highestrate of suicide is among people aged over 75
years. The most frequentmethods are hanging among men, and drug
overdose among women (Harwood et al., 2000).
• In additionto active self-harm, some older adults die from deliberateself-
neglect (e.g. by refusingfood or necessary treatment).
• As in younger age groups, depressionis a strong predictorof suicide in the
elderly.
• Other risk factors are social isolation,bereavement,and impaired physical
health (Harwood et al., 2006).
• Personality is also important,especiallyanxious and obsessionaltraits
(Harwood et al., 2001).

19. Children
• Suicide is rare in children. In 1989, the suicide rate for children aged 5–14 years
was estimated to be 0.7 per 100,000in the USA and 0.8 per 100,000in the UK.
• Little is known about the factors that lead to suicide in childhood, except that it
is associated with severe personal and social problems.
• Children who have died by suicide have usually shown antisocial behaviour.
• Suicidal behaviour and depressive disorders are common among their parents
and siblings (Shaffer, 1974).
• Shaffer distinguished two groups of children. The first group consisted of children
of superior intelligence who seemed to be isolated from less educated parents.
Many of their mothers were mentally ill. Before death, the children had
appeared depressed and withdrawn, and some had stayed away from school.
• The second group consisted of children who were prone to violence,and
resentful of criticism (Shaffer et al., 2000).

20. Adolescents
• Suicide rates among adolescents have increased in recent years.
• In England and Wales the increase has mainly been in male adolescents aged 15–19 years
(McClure,2000).
• Hanging, and poisoning with car exhaust fumes (Hawton et al., 1999).
• The risk factors are similar to those in adults, with high rates of comorbid psychiatric
disorders (Bridge et al., 2006).
• A psychological autopsy study (Houston et al., 2001)showed that about 70% of adolescents
who killed themselves had had psychiatric disorders, mainly depressive and personality
disorders, which were sometimes comorbid.
• Many of them had misused alcohol or drugs.
• The suicide was often the culmination of long-term difficulties with relationships and other
psychosocial problems.
• Approximately two-thirds of these individuals had made a previous suicide attempt.

21. Assessment
1) The history of the current episode of self harm.
2) Assess risk factors for suicide.
3) Assess the patients mood.
4) Will the patient be returning to the same situation?
5) What does the patient think about the future?
6) Ask about current suicide thoughts

22. The history of the current episode of self harm
• What precipitated the attempt?
• Was it planned?
• What method did they use?
• Was a suicide note left?
• Was the patient intoxicated (drugs/alcohol)?
• Was the patient alone?
• Were there any precautions against discovery (e.g. waited until house
empty)?
• Did the patient seek help after the attempt or were they found and brought
in by someone else?
• How does the patient feel about the episode now? (regret? do they wish that
they had succeeded?)

23. Assess risk factors for suicide
• Are they male?
• Is their age greater than 45 years?
• Are they unemployed?
• Are they divorced, widowed or single?
• Do they have a physical illness?
• Do they have a psychiatric illness?
• Do they have a history of substance misuse?
• Have they had previous suicide attempts?
• Do they have a family history of depression, substance misuse or
suicide?

24. Individual Risk Factors
1. Previous suicide attempt
2. History of depression and other mental illnesses
3. Serious illness such as chronic pain
4. Criminal/legal problems
5. Job/financial problems or loss
6. Impulsive or aggressive tendencies
7. Substance misuse
8. Sense of hopelessness

25. Step 03
• Assess the patients mood.
Particularly note if they are depressed or angry.
Step 04
• Assess whether the patient will be returning to the same
situation, such as issues at home?

26. Management of suicide
• Low risk :wish of death but no plan: give support and focus on
positive strength
• Medium risk: suicidal thoughts but no detailed plan:
alternatives to suicide, contact family, make a contract
• High risk: has definite plan, has the means to do it: do not
leave the patient alone, remove the mean, make a contract,
contact family and hospitalization

27. Management of suicide
• Hospitalization:
o If risk is high then involuntary admission may be required with
resistant patient
o Outpatient treatment can be applied only with low risk of
suicide and good support network of the patient

28. Management of suicide
• Management of primary diagnosis
• Mood stabilizers specially lithium and atypical antipsychotics
specially clozapine are effective in suicidal patients
• ECT is effective with rapid onset

29. Suicide prevention
• Better and more accessible psychiatric services
• Restriction of the means of suicide
• Encouragement of responsible media reporting
• Educational programmes
• Improved care for high-risk groups
• Crisis centres and telephone ‘hotlines’

30. Deliberate self-harm
• Parasuicide, and deliberate self-harm—wereintroduced to describe
episodes of intentional self-harm that did not lead to death and
may or may not have been motivated by a desire to die
• The Royal College of Psychiatrists encourages the use of the term
‘self-harm’, and ‘non-suicidal self-injury’ (NSSI)
• It should be rememberedthat, among people who have been
involved in DSH, the suicide rate in the subsequent 12 months is
about 100 times greater than in the general population. It remains
high for many years, with over 5% committingsuicide within 9
years (Owens et al., 2002). Therefore DSH should not be regarded
lightly.

31. Terms for non-fatal self-inflicted harm
• Attemptedsuicide: Used widely (especially in North America) for episodes
where there was at least some suicidal intent,or sometimes without
referenceto intent.Repetitivebodily harm may be excluded.
• Deliberateself-harm: Used in UK for all episodes survived, regardless of
intent.North American usage refers to episodesof bodily harm without
suicidal intent,especially if repetitive.Usually excludes overdoses and
methods of high lethality.
• Parasuicide: Episodessurvived, with or without suicidal intent(especiallyin
Europe) or episodeswithout intent.Repetitivebodily harm may be
excluded.

32. Terms for non-fatal self-inflicted harm
• Self-poisoning or self-injury: Self-harm by these methods
regardless of suicidal intent.
• Self-mutilation: Serious bodily mutilation (such as enucleation
of eye) without suicidal intent. Repetitive superficial bodily
harm without suicidal intent (synonymous with North
American term ‘deliberate self-harm’). Also known as self-
injurious behaviour, self-wounding. Sometimes the term is
used to describe both the above meanings and also
stereotypical self-harm in intellectually disabled people.

33. Methods of deliberate self-poisoning
• In the UK, about 90% of the cases of DSH that are referred to general hospitals involve a
drug overdose, and most of them present no serious threat to life.
• The type of drug used varies with age, local prescription practices, and the availability of
drugs.
• The most commonly used drugs are
• the non-opiate analgesics, such as paracetamol and aspirin. Paracetamol is particularly
dangerous because it damages the liver and may lead to the delayed death of patients who
had not intended to die.
• It is particularly worrying that younger patients, who are usually unawareof these serious
risks, often take this drug.
• Antidepressants (both tricyclics and SSRIs) are taken in about 25% of episodes.
• About 50% of people consume alcohol in the 6 hours before the act (Hawton et al., 2007).

34. Methods of deliberate self-injury
• Deliberate self-injury accounts for about 10% of all DSH
presenting to general hospitals in the UK.
• The commonest method of self-injury is laceration, usually
cutting of the forearms or wrists; it accounts for about 80% of
the self-injuries that are referred to a general hospital.
• Other forms of self-injury include jumping from a height or in
front of a train or motor vehicle, shooting, and drowning.
These violent acts occur mainly among older people who
intended to die (Harwood and Jacoby, 2000).

35. Deliberate self-laceration
There are three forms of deliberate self-laceration:
• 1. Deep and dangerous wounds inflicted with serious suicidal
intent, more often by men.
• 2. Self-mutilation by schizophrenic patients (sometimes in
response to hallucinatory voices)
• 3. Superficial wounds that do not endanger life, more often
inflicted by women.

36. Deliberate self-laceration
• Usually, the act of laceration is preceded by increasing tension and irritability,which
diminish afterwards. After the act, the patient often feels shame and disgust.
• Some of these individuals report that they lacerated themselves while in a state of
detachment from their surroundings, and that they experienced little or no pain.
• The lacerations are usually multiple, made with glass or a razor blade, and inflicted
on the forearms or wrists. Some also injure themselves in other ways (e.g. by
burning with cigarettes, or inflicting bruises).
• Self-cutters who attend hospital are more often men (Hawton et al.,2004c).
• People who cut themselves superficially do not always seek help from the medical
services, and many of these people are young females, often with problems of low
self-esteem, and sometimes impulsive or aggressive behaviour, unstable moods,
difficulty in interpersonal relationships, and problems with alcohol and drug misuse.

37. The epidemiology of deliberate self-harm
• DSH is the main risk factor for completedsuicide. Although there is no
national DSH register,there are several local registersthat track its
incidence.
• DSH is more common among younger people, with the rates declining
sharply in middle age.
• The peak age for men is older than that for women. For both sexes, rates
are very low under the age of 12 years.
• DSH is more prevalent in those of lower socioeconomic statusand who live
in more deprived areas.
• Rates are higher for both men and women among the divorced, and
among teenagewives, and younger single men and women (Hawtonet al.,
2003).

38. Causes of deliberate self-harm
Precipitatingfactors
• People who harm themselves deliberately report more stressful life
events, especially quarrels with a partner, girlfriend, or boyfriend.
Predisposing factors
• Familial and developmentalfactors may predispose to DSH. The
whole range of adverse early circumstances (abuse, parental
divorce, parental discord, or mental illness) is associated with an
increased risk, particularlyin adolescents and young patients
(Beautrais, 2000; Brent et al.,2002).

39. Causes of deliberate self-harm
• Personality disorder is identified in almost 50% of patients who
deliberately self-harm.
• Borderline personality disorder has been reported to be
common, but other studies have found anxious, anankastic
(obsessional), and paranoid personality disorders more
frequently (Haw et al., 2001).
• Impulsiveness, and poor skills in solving interpersonal
problems, may also predispose to DSH.

40. Causes of deliberate self-harm
• if standardized assessments are used, psychiatric disorder has
been detected in about 90% of patients who DSH who are seen
in hospital (Suominen et al., 1996; Haw et al., 2001).
• Depressive disorder is the most frequent diagnosis in both
sexes, followed by alcohol and drug abuse in men, and anxiety
disorders in women.
• Comorbidity is frequent, especially between psychiatric
disorder and personality disorder.

41. Motivation and deliberate self-harm
• The motives for DSH are usually mixed and often difficult to
identify with certainty.
• Even when patients know their own motives, they may try to
hide them from other people.
• For example, people who have taken an overdose in response
to feelings of frustration and anger may feel ashamed and say
instead that they wished to die.
• Conversely, people who truly intended to kill themselves may
deny it with the intention of repeating it.

42. Motivation and deliberate self-harm
A study in 13 European countries found similar reported motives in all
of the study sites (Hjelmeland et al., 2002)
• To die
• To escape from unbearable anguish
• To obtain relief
• To change the behaviour of others
• To escape from a situation
• To show desperation to others
• To get back at other people/make them feel guilty
• To get help

43. The outcome of deliberate self-harm
A) Repetition of self-harm
• In the weeks after DSH, many patientsreport changes for the better. Those
with psychiatricsymptoms often report that they have become less
intense.
• This improvementmay result from help provided by professionals,or from
improvementsin the person’s relationships,attitudes,and behaviour.
• Some people do not improve and harm themselvesagain, systematic
review of 90 studies (Owenset al., 2002) concludedthat, among people
who have engaged in DSH:
• about one in six repeatsthe DSH within 1 year
• about one in four repeats the DSH within 4 years.

44. The outcome of deliberate self-harm
Factors associatedwith risk of repetition of self harm
• Previous attempt(s)
• Personality disorder
• Alcohol or drug abuse
• Previous psychiatric treatment
• Unemployment
• Lower social class
• Criminal record
• History of violence
• Age 25–54 years

45. The outcome of deliberate self-harm
B) Suicide following deliberate self-harm
• People who have intentionally harmed themselves have a
much increased risk of later suicide. The same systematic
review (Owens et al., 2002) concluded that among these
people:
• ● between 1 in 200 and 1 in 40 commit suicide within 1 year
• ● about 1 in 15 commits suicide within 9 years or more.

46. The outcome of deliberate self-harm
Risk factors for suicideafter self-harm
• Older age
• Male sex
• Past psychiatric care
• Psychiatric disorder
• Social isolation
• Repeated self-harm
• Avoiding discovery at time of self-harm
• Medically severe self-harm
• Strong suicidal intent
• Substance misuse (especially in young people)
• Hopelessness
• Poor physical health

47. The assessment of patients after deliberate self-
harm
General aims
• Assessment is concerned with three main issues:
1. The immediate risks of suicide.
2. The subsequent risks of further DSH.
3. Current medical or social problems.

48. The assessment of patients after deliberate self-
harm
The interview should address five questions.
• 1. What were the patient’s intentions when they harmed
themself?
• 2. Do they now intend to die?
• 3. What are their current problems?
• 4. Is there a psychiatric disorder?
• 5. What helpful resources are available?

49. What were the patient’s intentions when they harmed
themself?
• Was the act planned or carried out on impulse?
• Were precautions taken against being found?
• Did the patient seek help?
• Was the method thought to be dangerous?
• Was there a ‘final act’ (e.g. writing a suicide note or making a
will)?

50. Do they now intend to die?
• The interviewer should ask directly whether the patient is
pleased to have recovered or wishes that they had died.
• If the act suggested serious suicidal intent and if the patient
now denies such intent, the interviewer should try to find out
by tactful questioning whether there has been a genuine
change of resolve.

51. What are their current problems?
• The review of problems should be systematic and should cover
the following:
• ● intimate relationships with the partner or another person
• ● relationships with children and other relatives
• ● employment, finances, and housing
• ● legal problems
• ● social isolation, bereavement, and other losses
• ● physical health.

52. Is there a psychiatric disorder?
• It should be possibleto answer this questionfrom the history and from a
brief but systematic examination of the mental state.
• Particularattentionshould be directedto depressivedisorder, alcoholism,
anxiety disorder, and personality disorder.
• Schizophreniaand dementiashould also be considered
• Adjustmentdisorders are diagnosedin many individualsin responseto
major life changes and stresses(e.g. bereavement,relationshipbreak-up,
migration).
• The presence of an obvious precipitatingevent does not rule out the
presenceof a psychiatric disorder.

53. What helpful resources are available?
• These include capacity to solve problems, and the help that
others are likely to provide.
• The best guide to patients’ abilities to solve future problems is
their record of dealing with difficulties in the past—for
example, the loss of a job or a broken relationship.
• The availability of help should be assessed by asking about
friends and confidants, and about any support the patient is
receiving or can be expected to receive from the general
practitioner, social workers, or voluntary agencies.

54. Management after the assessment
Patients’needs fall into three groups:
• 1. A small minority need admission to a psychiatric unit for treatment.
• 2. About one-third have a psychiatricdisorder that requirestreatmentin
primary care, or from a psychiatric team in the community.
• 3. The remainder need help with various psychosocialproblems, and
assistancewith improving their ways of coping with stressors.
• This help is needed even when the risk of immediatesuicide or non-fatal
repetitionis low, as continuingproblems increase the risk of later
repetition.
• Apart from practical help, problem-solvingis usually the best approach,
startingwith the problems identifiedduring the assessmentinterview.

55. General principles of care after self-harm
• Monitor patient for further suicidal or self-harm thoughts
• Identify support available in a crisis
• Come to a shared understanding of the meaning of the
behaviour and the patient’s needs
• Treat psychiatric illness vigorously
• Attend to substance abuse
• Help patient to identify and work towards solving problems

56. General principles of care after self-harm
• Enlist support of family and friends where possible
• Encourage adaptive expression of emotion
• Avoid prescribing quantities of medication that could be lethal
in overdose
• Assertive follow-up in an empathic relationship
• Affirm the values of hope and of caring for oneself