Suicide ,self harm , and violence
presentation
Prepared by :
Mr. Ayman El Ghouty
Supervised by :
Dr. Abed Alkareem Radwan
Suicide
What do we know about it?
How can we prevent it?
Background Information
Suicide: Intentionally causing one’s own
death.
Sometimes difficult to determine intention
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High speed, 1 car accidents
Auto-erotic hangings
Reluctance to label as suicide because of stigma
Life Insurance myth: Suicidal deaths are
covered if the death occurs 2 years after
policy was purchased.
Risk Factors
Adults
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Depression, alcohol abuse, cocaine use,
separation or divorce.
Youth
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Depression, alcohol and drug use, aggressive
and/or disruptive behavior in school.
Suicide Prevention
Warning Signs
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Signs are often not verbal.
Giving away beloved objects.
Changes in eating or sleeping habits.
Displaying a sense of calmness after a period
of agitation.
Practical Measures for
Helping
Characteristic
Guideline
Unbearable pain
Frustrated needs
Seeking a solution
Hopelessness
Cognitive tunnel
vision
Communication of
intention
Reduce the pain
Fill needs
Provide alternatives
Provide hope
Increase options
Listen, involve others
SUICIDE: A MULTI-FACTORIAL EVENT
Psychiatric Illness
Co-morbidity
Personality
Disorder/Traits
Neurobiology
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness
Family History
Access To Weapons
Life Stressors
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
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
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
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.
CHARACTERISTICS OF A SUICIDE PLAN
Risk / Rescue Issues:
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Method
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Time
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Place
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Available means
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Arranging sequence of events
Jacobs (1998)
PSYCHIATRIC SYMPTOMS
ASSOCIATED WITH SUICIDE
Hopelessness
Impulsivity / Aggression
Anxiety
Command hallucinations
DETERMINE TREATMENT SETTING AND PLAN
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Attend to issue of patient’s safety.
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Assess treatment plan/setting/alliance.
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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
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Psychotherapeutic intervention – widely viewed as helpful for suicidal
patients, evidence is limited
Provide education to patient and family.
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Monitor psychiatric status and response to treatment.
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Reassess for safety and suicide risk frequently.
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SOMATIC TREATMENTS
ECT
Evidence for short-term reduction of suicide,
but not long-term.
Benzodiazepines
May reduce risk by treating anxiety
Antidepressants
A mainstay treatment of suicidal patients with
depressive illness / symptoms. No conclusive
evidence of suicide reduction
Lithium and
Anti-Convulsant
Lithium has a demonstrated anti-suicide effect;
anticonvulsants do not
Antipsychotics
Evidence for Clozapine reducing suicidality in
schizophrenia and schizo-affective disorders
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.)
So when, therefore is self harm a
problem?
Define self harm
To do so, differentiate between self injury and
suicide and what about para-suicide?
Self Injury is the “ Deliberate damaging of
Body Tissue without the conscious
attempt to commit suicide” DSM IV TR
3 types
Self harm
Any harmful act to
the self, or
omission, in which
the direct intent is
not to die Smith 2003
What then are the intents in self
harm if it is not to die?
To survive
To communicate
To cope
To feel better
To get help
Transfer emotional
pain to physical
To show I am different
To heal
To see blood
To check I’m alive
To feel something
I deserve it/punish
self
To punish others
To dissociate
To control something
Its complex!!
Self Injury in psychiatry
The three types referred to are:Major self Mutilation
Stereotypic self mutilation
Superficial or moderate self
mutilation Singular, Episodic, Repetitive
So where are we now?
Classifying self harm
• 1st separate the pathological from the
culturally sanctioned
Classifying self harm
• Culturally sanctioned
– Rituals Reflect community tradition, underscored
by deep symbolism, link person to community,
done to heal, express spiritual enlightenment,
marks social order
• Practises
– Little underlying meaning, may be fad or fashion,
ornament, link to cultural group, medical-hygiene
reasons
What forms of self harm are
culturally acceptable?
Neck stretching
Tattooing
Facial scarring
Crucifixion
Lip plates
Piercing
Flagellation
Starvation (fasting)
What forms of self harm then are
acceptable as fashions?
Tattooing
Piercing
Heroin?
Food
Body modification
Cosmetic surgery
Tongue splitting
So how can we assess severity
and when to intervene?
Assessing risk and safety in self
harm (SHARS)
Risk and safety should be
jointly considered based on
the 5 domains of self harm
Self Harm Assessment of Risk &
Safety (SHARS)
About Judgement
Considering 5
domains
Professional, client
and carers opinion
Agreeing the
dialectical approach
5 domains of self harm
• Directness
• Intent
• Potential lethality
• Repetitiveness/frequency
• Control/distress
Self harm is still not yet a diagnosis
in itself it is associated with:•
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1.1.2
Post Traumatic Stress Disorder
Dissociative Identity disorder
Eating disorders
Character or personality traits (BPD)
Substance abuse
Clinical depression
Psychosis (coping & bargaining)
So what are the common life experiences
of those who self harm
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Childhood physical or sexual abuse
Violence at home
Stormy parental relationships or broken homes
Loss of a parent through death or divorce
Lack of emotional warmth from
parents/neglect
2.1.1
So what are the common life
experiences of those who self harm
• Hypercritical fathers
• A history of medical procedures or illnesses
resulting in significant hospitalisation in childhood
• Parental depression or substance abuse
• Confinement in residential establishments
• Work in the paramedical fields
2.1.2
And what personality factors are
associated with self harm by
psychiatry
• Perfectionist tendencies
• Dislike of body shape
• Inability to tolerate intense
feelings
• Inability to express emotional
needs or experiences
• Prone to rapid mood swings
2,2.1
Other life events associated :• Loss or abandonment
• Social isolation, confinement
or helplessness
• Rejection
• Failure
• Anger
• Guilt
3,1.1
How many people self harm
1.4% lifetime
incidence
1,400 per 100,000
population
Prisoners with PD
24%
Institutionalised
people 13.6%
FE students 12%
Bulimia 40.5%
Anorexia 35%
MPD/DID 43%
Dysphoria
People who self-injure tend to be
dysphoric -- experiencing a
depressed mood with a high degree
of irritability and sensitivity to
rejection and some underlying
tension -- even when not actively
hurting themselves Herpertz (1995)
“Self harmers in psychiatric
services are seen as attention
seeking, are disliked by staff and
are seen as in control of
manipulative behaviour”.
Institutional wisdom perceives
these “performances” as the
maladaptive attention seeking
malignancy of untreatable
psychopaths.
5,2.1
Recent studies have suggested some alarming links between
sexual abuse and the development of mental distress in later
life, many of these links made by the self harmer themselves.
Romme & Escher (1993) Boevink (1995) . In their study
Diclemente et al (1991) found that amongst adolescents in a
psychiatric service who reported childhood sexual abuse,
83% cut themselves.
This mental distress is believed to be a common factor which
may manifest itself in many ways. The commonest of these ways
is in some form of self harm.
7,4.1
Self injury is quite an obvious response to abuse.
The need to “get rid of the filth” is often reported by
survivors of abuse who cut themselves to get rid of
internalised feelings of shame
Dianne Harrison (1994)
7,4.2
A systematic model for making sense
of your experiences and working
toward your recovery
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Turning points
Identifying
Exploring
Understanding
Resolving and moving
on
Turning point
• A clear turning point which may be a result of
an event or an individuals inspiration which
results in you resolving to move on and
determining to conquer barriers to you living
your life. Topor et al (1998)
Turning point activities
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Give information
Inspire
Offer opportunities
Meet others
Have hope
Self help
Alternative belief systems DES, survival
Focus upon recovery not maintenance
Values and perceptions
Write down, brainstorm all the different
ways you use to cope with life
As a group decide which are positive or
negative coping strategies
Negative
Positive
Neutral
Identifying your experiences
• Identifying and forming a clear view in your
own language about what your experiences
actually have been, how they have changed,
when they happened and what were the effects
upon you.
Activities to identify your
experiences
• Life history
• write the three most important things
in your life!!
• Interviewing
• Guiding
• Specific questions
• When did it start
• What was happening
• Why
Exploring your experiences
• Exploring in depth why and how you have
become distressed including any things that
trigger your current experiences, relating it
beyond yourself to your social system such as
the responses of mental health services. What
has helped, what hinders, who helps.
Activities to explore your
experiences
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Explore in depth
Look at dissociation
Look at how you feel before and after
How has it changed from 1st experience &
why
• What has helped you, what hasn’t
• What are the real problems, is it self harm
or other things or other people?
• Most recent experience
Activities to explore your
experiences
Others reactions
Triggers
Links to your feelings
Understanding your experiences
• Links, are your voices/beliefs/harm related to
anything in your life. Can you do anything
about this, do you want to. What are your
beliefs or frame of reference for your
experience
Activities to understand your
experiences
• Create an ego document
• Get advice from others and alternate
explanations
• Medical, trauma, dissociation, addiction,
• AHP axis, impulse control,
learning,coping, survivor
• Be clear what you believe
• Get support
• Get direction (therapy)
Resolving & moving on with your
experiences
• What will help you, what coping mechanisms
can you learn, can you resolve or accept any
past issues in your life that are significant,
where can you get the things that can help.
What can mental health services do to help
you, how can you develop alliances.
Activities to move on
Where do you want to go
PCP
Deal with problems
Find yourself not guilty
Path
Essential lifestyle plans
Getting unstuck
Recovery planning (Coleman et al)
WRAP
Harm reduction
Finding for yourself less harmful ways of coping
How can you help people to hurt
themselves less
Write down all the things you can think of
Coping angry, frustrated,
restless
Try something physical and violent, something not directed at a living thing:
Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or
sock.
Make a soft cloth doll to represent the things you are angry at. Cut and tear it
instead of yourself.
Flatten aluminum cans for recycling, seeing how fast you can go.
Hit a punching bag.
Use a pillow to hit a wall, pillow-fight style.
Rip up an old newspaper or phone book.
On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear
the picture.
Make Play-Doh or other clay models and cut or smash them.
Throw ice into the bathtub or against a brick wall hard enough to shatter it.
Break sticks.
These things work even better if you rant at the thing ur cutting/tearing/hitting.
Start out slowly, explaining why I you are hurt and angry, sometimes end up
swearing and crying and yelling. It helps a lot to vent like that.
Crank up the music and dance.
Clean your room (or your whole house).
Go for a walk/jog/run.
Stomp around in heavy shoes.
Play handball or tennis.
Coping sad, soft, melancholy,
depressed, unhappy
Do something slow and soothing, like
taking a hot bath with bath oil or bubbles,
curling up under a quilt with hot cocoa and
a good book, looking after yourself
somehow. Do whatever makes you feel
taken care of and comforted. Light sweetsmelling incense. Listen to soothing music.
Smooth body lotion into the parts or
yourself you want to hurt. Call a friend
and just talk about things that you like.
Make a tray of special treats and tuck
yourself into bed with it and watch TV or
read. Visit a friend.
Helpful responses to self harm
• Show that you see and care about the person
• Show concern for the injuries themselves,
the person may be ashamed, frightened and
vulnerable at this time.
• Make it clear that its okay to talk about the
self injury
• Convey respect for the persons efforts to
survive
Helpful responses to self harm
• Help them to make sense of their self injury
• Acknowledge how frightening it is to think
of life without self injury.
• Encourage them to see the injury as a
metaphor rather than as a problem in itself
• Help them to build up supportive networks
• Don’t see stopping the injury as the goal
• It takes time!
What do people who self harm
think that a service should do?
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Not confuse it with
suicide?
Help us look at life
Accept our view
Look at our
relationships
Help us make
decisions/choices
Relieve distress
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Accept us
Help us see future
Explore our feelings
listen
Help find solutions
Keep us safe
What type of support
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Information about
alternatives
Publicity explaining
Self Harm
Specialised services
Opportunity for
anonymity
Someone to talk to
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Something different
Value us as people
Non judgmental
Choices
Talking treatments
Self help
What type of support
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Staff to realise they
cant make it better
Staff to be human
Help us in recovery
Person centered
Be honest about
barriers
Do with not for
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Cares about its staff
 Offers supervision to
staff
 Professions to be
aware
 No labeling
What Is Workplace Violence?
Workplace violence is any physical
assault, threatening behavior, or verbal
abuse occurring in the work setting
Definition
Workplace violence is any physical
assault, threatening behavior, or verbal
abuse occurring in the work setting
A workplace may be any location either
permanent or temporary where an
employee performs any work-related
duty
Workplace Violence Includes:
Beatings
Stabbings
Suicides
Shootings
Rapes
Near-suicides
Psychological
traumas
Threats or obscene
phone calls
Intimidation
Harassment of any
nature
Being followed,
sworn or shouted at
Types of Workplace Violence
Violence by
strangers
Violence by
customers or
clients
Violence by coworkers
Violence by
personal relations
Risk Factors
Contact with the public
Working late night or early morning
Exchanging money with the public
Working alone or in small numbers
Uncontrolled access to the workplace
Having a mobile workplace such as a
police cruiser, fire fighter or ambulance
service
Methods Used For Hazard
Prevention and Control
Could Include:
Make high risk areas more visible
Install more lighting
Use drop safes, decrease cash on hand
Post signs – stating limited cash
Train employees on conflict resolution
Need a system to respond
Management Commitment
and Employee Involvement
Complementary and essential
Management commitment provides the
motivating force to deal effectively with
workplace violence
Employee involvement and feedback-enable
workers to develop and express their
commitment to safety and health
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Suicide