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Alan Apter M.D Feinberg Child Study Center Schneider Childrens Medical Center suicide.

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1 Alan Apter M.D Feinberg Child Study Center Schneider Childrens Medical Center suicide

2 Suicidal Behaviour: a Major Public Health Problem in Europe In many European countries suicide is the leading cause of death among young people – more common than death from road accidents

3 SUICIDE DEFINITIONS EPIDEMIOLOGY AETIOLOGY/RISK FACTORS CLINICAL CONSIDERATIONS

4 SUICIDE PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION

5 DEFINITIONS

6 Suicide Spectrum Suicidal ideation "Thoughts of serving as the agent of ones own death. Suicidal ideation may vary in seriousness depending on the specificity of suicide plans and the degree of suicidal intent" Suicidal threats Suicidal gestures "Suicidal behaviors judged to be non-serious in intent or medical lethality"

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8 Suicide Spectrum Deliberate self harm: Willful self-inflicting of painful, destructive, or injurious acts without intent to die Suicide attempts: Self-injurious behavior with a nonfatal outcome accompanied by evidence (either explicit or implicit) that the person intended at some level to kill him/her

9 Suicide Spectrum Interrupted attempt: The person is interrupted (by an outside circumstance) from starting the self-injurious act

10 Continuum Theory Of Suicide Suicidal Thoughts leads to Suicidal Threats Leads to

11 Suicidal Gestures Leads to Suicide Attempts leads to Failed Suicide leads to Completed Suicide

12 Discontinuity Theory Suicidal Ideation Suicidal Threats Suicidal Gestures Suicide Attempts Serious Suicide Attempts Discontinuity Theory Suicidal Ideation Suicidal Threats Suicidal Gestures Suicide Attempts Serious Suicide Attempts

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14 Suicide attempts Completed suicide

15 Consequences of Suicidal Behavior School dropout Leaving home Motor accidents Police arrest Whole spectrum of high risk behavior

16 EPIDEMIOLOGY

17 EPIDEMIOLOGY SEX AGE GEOGRAPHY SOCIECONOMIC STATUS ETHNICITY RELIGION COHORT STATUS

18 EPIDIMIOLOGY OF SUICIDE 300% rise in fatal suicide >700% rise in non fatal suicidal behavior % of adolescents think seriously about suicide

19 Attempted Suicide Between 100 and 300 per 100,000 Preponderance of females in all countries 50 percent of attempters under 30 Excess of divorced persons

20 Attempted Suicide Rates Lower social classes overrepresented Depression in 35 to 79 percent of cases Females aged 15 to 19 - highest rates 1 in 100 in this group attempt suicide each year Highest rate for males is in aged 25 to 29 1 in 200 attempts suicide each year

21 Suicide Suicide rates increase with age Male suicides peak after age 45 Females peak after age 55 Rates of 40 per 100,000 men > 65

22 Suicide Males at all ages commit suicide more often than females Male: female suicide ratios range from 2:1 to 7:1 Males use more violent methods, like hanging, shooting, and jumping

23 Suicide Females more often overdose or drown Ethnic and minority groups tend to be more cohesive and have lower suicide rates Rate of suicide among whites is nearly twice that among nonwhites (in the US)

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25 Attempted suicide by age and sex – Holon-Bat Yam

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27 Suicide by age

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29 SUICIDE IN INDIA

30 Homicide and suicide rates by year

31 Source: World Health Statistics Annuals (WHO). Latest available year. Wasserman, D., Jiang, GX. Total suicide rates per 100,000 for 15 year olds and over in European countries

32 Change in percentage of suicide rates for males aged 15 years and over in European countries between and Source: World Health Statistics Annuals (WHO). Latest available year. Wasserman, D., Jiang, GX.

33 EPIDEMIOLOGY ELDERLY COMMIT/YOUNG ATTEMPT PROTESTANTS>CATHOLICS> JEWS>MUSLIMS POOR ATTEMPT/RICH COMMIT BLACKS

34 AETIOLOGY/RISK FACTORS

35 PSYCHIATRIC ILLNESS ALCAHOLISM & SUBSTANCE ABUSE PHYSICAL AND SEXUAL ABUSE FAMILY AND GENETICS

36 Risk Factors (ii) CONTAGION AVAILABILITY OF MEANS PERSONALITY FACTORS BIOLOGY

37 PSYCHIATRIC ILLNESS DEPRESSION SCHIZOPHRENIA ANXIETY DISORDERS DISSOCIATIVE DISORDERS

38 PSYCHIATRIC ILLNESS CONDUCT DISORDER ANOREXIA NERVOSA BULIMIA NERVOSA PERSONALITY DISORDERS

39 Risk factors for youth suicide Psychiatric disorder/Affective disorder Personality disorder- especially BPD Psychiatric illnesses – dangerous when more than one illness is present

40 Four co-morbid constellations The combination of schizophrenia, depression and substance abuse Substance abuse, conduct disorder and depression Affective disorder, eating disorder and anxiety disorders Affective disorder, personality disorder and dissociate disorder

41 ALCAHOLISM & SUBSTANCE ABUSE SELF MEDICATION INCREASES IMPULSIVITY AFFFECTS JUDGEMENT EXACERBATES DEPRESSION PROVIDES COURAGE

42 Personality Factors Adolescents committing suicide while doing their military service in the IDF Clinical work on an adolescent psychiatric inpatient unit Work in the ER

43 Three sets of personality constellations Narcissism, perfectionism and the inability to tolerate failure Impulsive and aggressive characteristics combined with over sensitivity Hopelessness often related to underlying depression

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45 The narcissistic perfectionist constellation (case 1) David told us that since age 8 he had been concerned by thoughts of death. At 11 he told his friends that he would kill himself on the day of his Bar-Mitzvah. A week before the event he wrote an elaborate suicide note addressed to his parents in which he stated that he did not believe in the hereafter and that he would just cease to exist.

46 Contd Despite being popular at school it soon became clear that David had no intimate friendships. After one year of therapy and extensive psychological testing and observation no axis I diagnosis could be made.

47 Case 2 Jonathan was a 20 year old officer when he killed himself. His family was achievement oriented and had high moral standards. Their ideals stressed controlling ones emotions and living up to high standards. Jonathan was a natural leader and popular with his teachers and peers. In the army he excelled and was selected as an instructor for new recruits. His superior commended him for his ability to perform under stress.

48 Case 2 He became totally involved in his new duties. His platoon of trainees did rather well, although their overall performance rating was only average. Following the course ceremony Jonathan went to his room and shot himself.

49 Features of psychological post mortem soldiers Strong narcissistic and perfectionist patterns Schizoid traits in personality The will to prove their worth High self – expectations and hopes Termed by being private/isolated people

50 THESE FEATURES ARE OFTEN COMPLICATED BY STRONG ISOLATIVE TRAITS

51 Distribution Of Axis II Diagnoses Within Complete Suicide Group

52 Case features No turning for help or support Better death than shame Minor setbacks spiral into disaster

53 THE IMPULSIVE AGGRESSIVE CONSTELLATION

54 Case material – case 1 Deborah had always been impulsive and oppositional from an early age. At about the age of 11 she developed anorexia nervosa probably as a result of her being an accomplished dancer in a ballet troop. With the onset of adolescence she developed very severe bulimia.

55 Her first admission to a psychiatric unit was occasioned by a suicide note, which she wrote to her teacher at school. In the unit she was an impossible patient. By the time she was 22 she had made over 100 suicide attempts. She received all kinds of psychosocial and biological therapies but to no avail, although with age (now 25) there is some tempering of her emotional instability.

56 Case material – case 2 Amit, an 18 year old soldier killed himself a few months after joining the army. He had grown up under conditions of economic deprivation. The home atmosphere consisted of his mothers angry accusations and fathers passive silences.

57 Case 2 (contd.) Amit did poorly in elementary school, however managed to complete a vocational high school with fairly good grades. During high school his behavior changed and he became more compliant. Amit looked forward to his army service, feeling that it would make a man out of him and requested a frontline unit. He was a highly motivated recruit but tended to become flustered under stress.

58 Case 2 (cont.) Once when returning late from a home pass, he was told that his next leave was cancelled. He became irritable and angry. When the teaching staff on the base broached the possibility of him being unsuitable for a front-line unit he became upset and insisted on continuing. While resting after a training exercise the other recruits began taunting him, Amit lost his temper and attacked his tormenter. When the 2 were separated, he ran to his tent and shot himself with his weapon.

59 Personality constellation There are certain individuals who, when faced with relatively minor life stressors will react with anger and anxiety and then develop a secondary depression which is often accompanied by suicidal behavior.

60 Van Praag (1997) serotonin-related anxiety/aggression stressor precipitated depression

61 Thanatos A tendency towards impulsive aggression may predispose suicidal behavior The risk increases when psychiatric disorder and impulsive aggressive personality traits co-occur (Kety, 1986) The wish to die; the wish to kill and the wish to be killed (Freuds death instinct)

62 Adults vs. youngsters There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among adults Specifically, there is more impulsivity, substance abuse and other personality disorders in younger completed suicides

63 Genetics of suicidal behavior Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior Higher familial loading for suicidal behavior was found in those attempters and completers who made more dangerous attempts and who were more aggressive

64 Serotonin, suicide and aggression Finding the link between altered serotonergic neurotransmission, suicidal behavior and impulsive violence Orders of magnitude have been noted in the correlations between measures of serotonin, suicide attempts, aggression and impulsive risk taking

65 Borderline personality disorder (BPD) Traditionally associated with non fatal attempts and intentional self-damaging acts One of the critical symptoms is affective instability Most adolescent patients require psychiatric help and often suffer from major depression

66 Borderline personality disorder (BPD) Anger and Violence - related symptoms. Co morbid conditions: conduct disorder, multi-impulsive bulimia and substance abuse About 9% of patients eventually kill themselves

67 Impulsivity The adolescent period in contemporary Western society is characterized by a distinctive pattern of morbidity and mortality Suicidal behavior and completed suicide are more common in adolescence than in any other developmental epoch (save, for males, in old age)

68 Impulsivity Leading causes of adolescent deaths ( in the West) – accidents, homicide, and suicide-- are preventable Associated with life-styles characterized by impulsivity, recklessness, and substance or alcohol use

69 Impulsivity Adolescence in the industrialized world characterized by increased health- threatening behaviors Tobacco, alcohol, and drug use; unprotected sex; fighting; reckless driving; and weapon-carrying (Centers for Disease Control and Prevention, 2000)

70 Continuum of Self Destructiveness" Covert (e.g. substance use, unprotected and precocious sexual activity, reckless driving) Overt (e.g. self-mutilation and suicide attempts) Suicidal behaviors and other risk behaviors share an association with psychiatric diagnoses such as mood, disruptive, substance use, and anxiety disorders

71 MENTAL-ILLNESS DEMORALIZATION – HOPLESSNESS CONSTELLATION

72 Case material – case 1 David, aged 18, came from a family with a distinguished military background. He appeared to have had a poor self image during his school years, with intermittent periods of depression, insomnia, and weight loss.

73 case 1 David really looked forward to his army service, hoping that success there would redeem his low self esteem. He applied to join an elite commando unit but was turned down by the unit psychologist.

74 case 1 However, after advanced training David was posted to a combat unit. He seemed to do well but complained to his parents of being unable to cope. His parents alerted the unit mental health officer, who interviewed David. During the examination David denied experiencing any depression or suicidal thoughts, but David was reassigned. The reassignment made David feel like a failure soon thereafter he fatally shot himself.

75 Case material – case 2 (The case of Ellen West) Ellen West was the daughter of wealthy Jewish parents who had great control over her. Her father interfered twice when she became engaged, and when she finally married it was to a cousin.

76 Ellen West From age 19 she developed the fear of becoming fat and by 21 had developed Anorexia Nervosa. She was hospitalized but this only increased her suicidal thoughts. She was discharged from the sanatorium at the request of her family.

77 The case of Ellen West On the third day after returning home she appeared to be a changed person; she ate and enjoyed a walk with her husband. That evening she took a lethal dose of poison.

78 Eating disorders Adolescents with Bulimia Nervosa highly prone to suicidal behaviors Impulsive and unstable life style. Often make serious suicide attempts, which sometimes succeed. Multi-impulsive bulimia was coined to describe the increasingly more common association between bulimia, BPD, substance abuse, depression and conduct disorder. Although most patients with this co-morbid constellation of disorders are women, they are nevertheless at risk of repeated Para-suicide and fatal suicide.

79 The Canterbury suicide project A case control study. It was found that there was an elevated risk for mood disorder, substance disorder and conduct disorder. The study looked at male and female Finnish adolescents 10 years after having received outpatient psychiatric care. They found that 16 male subjects but no female subjects had died.

80 Study findings Current suicidal ideation and suicide attempts, poor psychosocial functioning and a recommendation for psychiatric hospitalization during the index treatment were associated with male mortality and suicidality. The study found that 10% of male adolescent inpatients and about 1% female inpatients eventually kill themselves.

81 Study at psychiatric unit One group recently surveyed admissions to our adolescent unit for a period of 24 months Most suicidal patients suffered from Affective and Conduct disorder, others had eating disorders or anxiety disorders The recent upsurge of drug and alcohol abuse in our country has led to an even higher incidence of suicidal patients in our ward

82 Depression Major depression appears acutely in a previously healthy child. Many other difficulties such as attention disorder or separation anxiety disorder before becoming depressed Mood disorders tend to be chronic In some cases they may be psychotic and have hallucinations and delusions of guilt

83 Bipolar disorder Approximately 20% of all patients have their first episode during adolescence (bet.15-19) Lack of clinician awareness has led to under diagnosis or misdiagnosis in children and adolescents

84 Unique clinical characteristics associated with the early-onset form : Manic or depressive episodes Increased risk for completed suicides. Strober et al (1995) Subjects made at least one medically significant suicide attempt. Depressive and manic depressive disorders. Patients who are male or in the depressed phase are at higher risk. A major clinical problem is that severe depression is common in almost all the patients and its difficult to determine what is primary and what is secondary.

85 Schizophrenia A common psychiatry disorder of adolescence Some clinicians are hesitant to make this diagnosis which denies the child and family access to appropriate treatment When the diagnosis is made the patient must be followed longitudinally to ensure accuracy

86 Patients and families should be educated about these issues Many patients are depressed and suicidal. About 10%-15% of patients eventually commit suicide Most victims are unmarried men who have made previous suicide attempts (often shortly after discharge) Many adolescent patients also abuse drugs and alcohol - sometimes an attempt at self medication

87 Study Participants : 32 adolescent inpatients with affective disorders (16 suicidal and 16 non-suicidal) 33 adolescent inpatients diagnosed with BPD (17 suicidal and 16 non- suicidal )

88 All subjects were diagnosed using the Hebrew version of the childrens version of K-SDADS. The subjects were examined on 8 measures relevant to suicidal behavior: The BDI; BHS; SPS; SIS; ICS; OAS; MAI; SRM. Three dimensions were found on factor analysis: 1. Anger-impulsivity-aggression 2. Depression and hopelessness 3. Suicidality

89 Anger Anger in subjects was examined via a two way analysis of variance (diagnosis/suicidality) Only diagnosis was found to significantly be associated with anger (F1,61=17.31;p>0.0001) being significantly higher in the BPD subjects than in the depressive adolescents The pair-wise Scheffe however showed that anger was significantly higher in the BPD suicidals than in the depressed non-suicidals

90 Impulsivity Impulsivity in subjects was examined by a two way analysis of variance (diagnosis/suicidality). Only diagnosis was found to significantly be associated with impulsivity (F1,61=33.66;p<0.0001), with anger being significantly higher in the BPD subjects than in the depressive adolescents. There was also a strong inter-action between impulsivity suicidality and diagnosis (F1,61=4.47;p<0.039). Thus impulsivity was higher in BPD than in depressive and in suicidal BPD compared to non-suicidal BPD. There was no difference between depressive suicidals and depressive non-suicidals. In addition BPD non- suicidal subjects were more impulsive than depressive suicidal subjects. Thus impulsivity does not appear to play an important role in suicidal depression in adolescents.

91 Overt Aggression Aggression in subjects was examined by two way analysis of variance (diagnosis/suicidality). Diagnosis was found to significantly be associated with impulsivity (F1,61=19.14;p<0.0001) as was suicidality (F1,61=18.75;p<0.0001), with anger being significantly higher in the BPD subjects than in the depressive adolescents. Aggression was significantly higher in the BPD suicidals than the BPD non-suicidals but did not differentiate between the depressed suicidals and the depressed non-suicidals. Thus impulsivity does not appear to play an important role in suicidal depression in adolescents.

92 Depressive symptoms and Hopelessness Depressive symptoms (BDI) in subjects was examined by two way analysis of variance (diagnosis/suicidality). Only suicidality was found to significantly be associated with depressive symptoms (F1,61=31.99;p<0.0001), with depressive symptoms being significantly higher in the suicidal subjects than in the non-suicidal adolescents in both diagnostic categories. Exactly the same findings were shown for hopelessness (F1,61=26.31;p<0.0001).

93 Suicide Intent SIS was significantly higher in the depressed subjects than in the BPD subjects (t(31)=2.69p<0.011). SIS correlated negatively and significantly with impulsivity and aggression.

94 Suicide Risk Was higher for suicidal than non-suicidal subjects but did not differentiate between BPD and depressive suicidals.

95 Conclusions Suicidal behavior in depressed adolescents differs from that of BPD adolescents and the recognized connection between impulsivity, aggression and suicidality may well relate to BPD and conduct disorder only. This has important implications for adolescent suicide research in general since additional findings regarding the association with trauma, sex abuse, broken families, dissociation and drug abuse may also be related to only one specific type of suicide. Suicidal behavior can no longer be regarded as on homogenous group of behaviors and although the non-nosological approach developed by Van Praag et al (1997) has been a very fruitful one, diagnostic and personality differences may well have a part to play in the understanding of suicide.

96 Canterbury Suicide Project

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98 Clinical Settings Primary Care settings (family or pediatric practices) Mental health outpatient departments (OPD) Emergency rooms (ER) Intensive care units (ICU) Residential treatment programs

99 Primary Care Early Detection of Internalizing Disorders Early Treatment of Internalizing Disorders Early Referral of Internalizing Disorders Referral of Externalizing Disorders

100 Early Detection Education regarding Childhood Depression and Anxiety Routinely Examining for Childhood Depression and Anxiety Routine Screening for suicidal ideation ( Gould et al., 2005 )

101 Early Treatment Psycho education ( Harrington, 2003 ) Psychopharmacology (TADS, 2005 ) Attenuation of Psychosocial Risk Factors (e.g. reporting abuse)

102 Early Referral Psychotherapies are best before complications set in Obviates long waiting lists for urgent cases Facilitates secondary prevention

103 Internalizing Disorders- Summary Gatekeeper education in terms of pediatricians is much under-researched In adult primary care Depression and other psychiatric disorders are under-recognized and under-treated in the primary care setting There is an opportunity for prevention because up to 83% of those who die by suicide have had contact with a primary care physician (PCP) within a year of their death, and up to 66% within a month.

104 Internalizing Disorders- - Summary PCPs lack of knowledge about and/or failure to screen patients for depression may contribute to non-treatment seen in most suicides Therefore, improving physicians' recognition of depression and suicide risk is a component of most national suicide prevention plans However the special role of the pediatrician is still neglected

105 Externalizing Disorders PCP often called upon to deal with those externalizing disorders that highly predispose to suicidal behavior. Include conduct disorders, attention deficit disorders and psychosexual disorders. Diagnosis is often all too evident and the primary role of PCP is to alert and mobilize the appropriate social, educational and legal authorities.

106 Externalizing Disorders Pediatricians and specialists in adolescent medicine need to be trained in the diagnosis of sexual and physical abuse, the early stages of drug and alcohol abuse and to learn to look for the physical signs of self cutting and disordered eating practices

107 Emergency Room Management Establish relationship with suicidal individual and family Stress importance of treatment Admit suicide attempters with persistent wish to die or clearly abnormal mental state. Obtain information from third-party.

108 Emergency Room Management Availability and presence in the home of firearms and lethal medication must be determined parents must be explicitly told to remove firearms and lethal medication. warn about the dangerous disinhibiting effects of alcohol and other drugs.

109 Emergency Room Value of "no-suicide contracts" is not known. The child or adolescent might not be in a mental state to accept or understand the contract, and both family and clinician should know not to relax their vigilance just because a contract has been signed. An appointment should be scheduled for the child or adolescent to be seen for a fuller evaluation before discharge from the emergency room.

110 Emergency Room Management available to the patient and family (for example, receive and make phone calls outside of therapeutic hours) have adequate physician coverage if away have experience managing suicidal crises have support available for him or herself

111 AFTER CARE No after care was recommended to 28.5% of the boys and 25.7% of the girls A negative attitude towards care and treatment staff is not unusual among young people

112 AFTER CARE It is also common not only for adults, but also for young people to deny suicide acts with great vehemence (Spirito 1996). Parents lack of involvement, ignorance of the suicide attempt, possibly negative attitude of their own towards care and desire to trivialize the suicide attempt make it easier for a teenager to turn down an offer of treatment.

113 Intensive Care Units The Canterbury Suicide Project Almost equal numbers of males and females made serious suicide attempts Severe psychiatric disturbance

114 Intensive Care Units (Apter A, et al., Compr. Psychiatry 42 (1) :70-75, 2001) 80 subjects 20 ICU suicidal,20 non-ICU suicidal, 20 psychiatric non –suicidal and 20 control subjects ICU subjects had significant lower levels of self disclosure

115 Mental Health OPD PCP - secondary prevention. Are expected to detect those young people who are at risk for suicide OPD -children who have already attempted suicide Tertiary prevention

116 Mental Health OPD No treatment has been proven fully effective in an outpatient setting depression is the most common diagnosis behavioral disorders common. (Kerfoot et al.,1996). Also PTSD, eating disorders and schizophrenia (Herrington & Saleem, 2003).

117 Psychosocial treatments domiciliary oriented outreach programs motivational enhancement methods, Both non-effective in preventing suicide ( Raj, Kumaraiah & Bhide, 2001 ).

118 Psychosocial treatments Dialectical behavior therapy effective in reducing suicide rate in a 6 month follow- up, non-significant in a 1-year follow-up (Linehan, Armstrong, Suarez et al., 1991) Problem-solving skills training effective to a certain extent in decreasing psychological distress and the number of suicide attempts (Salkovskis, Atha & Storer, 1990 ).

119 Consequences of Suicidal Behavior School dropout Leaving home Motor accidents Police arrest Whole spectrum of high risk behavior

120 Treatment Poor compliance Is Emergency room intervention enough? Mandatory hospitalization as a policy

121 Suicidal Behavior Suicide and suicide attempts are frequently associated with: Axis I disorder Depression Co-morbid conditions

122 Risk factors beyond psychopathology One of the most pressing clinical research questions is to determine what factors predispose suicide.

123 Risk factors for suicidal behavior Social factors: Unemployment Poverty Availability of guns National character Biological factors Personal factors

124 Adults vs. youngsters There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among adults. Specifically, there is more impulsivity, substance abuse and other personality disorders in younger completed suicides.

125 Genetics of suicidal behavior Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior. Higher familial loading for suicidal behavior was found in those attempters and completers who made more dangerous attempts and who were more aggressive.

126 Serotonin, suicide and aggression Finding the link between altered serotonergic neurotransmission, suicidal behavior and impulsive violence. Orders of magnitude have been noted in the correlations between measures of serotonin, suicide attempts, aggression and impulsive risk taking.

127 Borderline personality disorder (BPD) Traditionally associated with non fatal attempts and intentional self-damaging acts. One of the critical symptoms is affective instability Most adolescent patients require psychiatric help and often suffer from major depression. Anger and Violence - related symptoms. Co morbid conditions: conduct disorder, multi- impulsive bulimia and substance abuse. About 9% of patients eventually kill themselves.

128 MENTAL-ILLNESS DEMORALIZATION – HOPLESSNESS CONSTELLATION

129 Case material – case 1 David, aged 18, came from a family with a distinguished military background. He appeared to have had a poor self image during his school years, with intermittent periods of depression, insomnia, and weight loss. David really looked forward to his army service, hoping that success there would redeem his low self esteem. He applied to join an elite commando unit but was turned down by the unit psychologist. However, after advanced training David was posted to a combat unit. He seemed to do well but complained to his parents of being unable to cope. His parents alerted the unit mental health officer, who interviewed David. During the examination David denied experiencing any depression or suicidal thoughts, but David was reassigned. The reassignment made David feel like a failure soon thereafter he fatally shot himself.

130 Case material – case 2 (The case of Ellen West) Ellen West was the daughter of wealthy Jewish parents who had great control over her. Her father interfered twice when she became engaged, and when she finally married it was to a cousin. From age 19 she developed the fear of becoming fat and by 21 had developed Anorexia Nervosa. She was hospitalized but this only increased her suicidal thoughts. She was discharged from the sanatorium at the request of her family. On the third day after returning home she appeared to be a changed person; she ate and enjoyed a walk with her husband. That evening she took a lethal dose of poison.

131 Types of Self-Harm Superficial self-injurious behavior (SIB) such as self-cutting, scraping, burning (associated with Cluster B personality disorders, eating disorders, stress disorders) Repetitive Stereotypical Behavior such as head banging and self biting (associated with intellectual disability, e.g. MR, autism) Major self mutilation such as self blinding and castration (rare; occurs in psychotic disorders and substance intoxication) Harris, JC, 2005

132 SIB as a stress related disorder SIB as a stress related disorder – Common in laboratory animals, and domestic animals under stress, neglect, or isolation Acral lick syndrome in dogs, feather plucking in birds, self-biting in rhesus monkeys – Prevalence in normal human development: 3.6 to 6.5% head banging rate at 8-36 months; associated with teething, ear infections. Generally terminates by 36 mos. Harris, JC (2005) 15% head banging rate at 9-18 mos. (Hammock et al, 1995)

133 Prevalence of SIB Among patients with eating disorders, 34.6% had a life-time rate of SIB (N=376). (Paul et al, 2002) Community samples in the U.S. vary in estimates from 4% to 38% of adolescents. Canadian study found 13.9% of urban and suburban high school students had self-injured (Ross & Heath, 2002). A British report noted a 65% increase in SIB disclosures to national childrens hotlines from 1999 to 2004.

134 Distinguishing SIB from Suicidal Behavior Suicidal behavior is distinct from SIB in terms of motivation, intent, and lethality. Suicidal behavior is accompanied by some degree of wish to die and intent to die; i.e. the patient believes that the behavior will possibly, or will definitely, result in death. Carefully assess motivations (to die, to escape, to influence someone, to communicate feelings, to relieve emotional distress, and intent (what was the expected outcome of the behavior?)

135 Suicide Continuum Passive Death Wish Suicidal Ideation, no method Suicidal Ideation with method Gesture AttemptCompletion

136 Assessing Current Safety Assess the presence or absence of suicidality and the degree of severity (frequency, intensity, duration) over the past 48 hours or since last visit. Negotiate No-Suicide/No Harm Safety Plan. Collaborate and review this plan with family. If family conflict is a common precipitant to suicidality or self harm, help teen and family negotiate a truce.

137 Formulating the Safety Plan A collaborative process Includes the phone numbers of trusted adults, therapist, 24-hour emergency coverage Includes a set of coping strategies (written card containing specific emotion regulation skills, relaxation skills, social supports, coping statements, hope kit) A promise between teen, parents and therapist, that teen will contact a responsible adult or therapist before acting on suicidal impulses

138 Contract and Commitment Phase Establishing a commitment to treatment from both teen and family ___agrees to do whatever it takes to say alive during the period of this contract. This contract lasts from __ to__

139 Contract and Commitment Phase (continued ) Priorities for intervention are as follows: I.Decreasing life threatening behaviors cutting, overdosing, any tissue damage or other life threatening behavior II. Decreasing therapy interfering behaviors (any behavior that makes therapy less likely to occur) Refusing to bring in or get rid of razors or other dangerous objects Any other therapy interfering behaviors

140 Patient Agreements Stay in therapy for the specified time. Attend scheduled therapy sessions. Work toward reducing suicidal behaviors/self-injurious behaviors as a goal of therapy. Work on problems that arise that interfere with progress in therapy.

141 Therapist Agreements Make every reasonable effort to conduct competent and effective therapy. Obey standard ethical and professional guidelines. Be available for weekly therapy sessions, phone consultations, and provide needed therapy back- up when on vacation or away. Respect the integrity of and rights of the patient. Maintain confidentiality. Obtain consultation when needed.

142 Negotiating Treatment Contract Initially patients with history of self-cutting may not be able to agree to abstain entirely from SIB. Explore teens concerns about their SIB and negative consequences of the behavior to increase motivation for change. (remain non-judgemental.) Negotiate with teen to try specific emotion regulation strategies first, and to delay cutting for longer periods after the urge begins. Negotiate with teen to avoid triggers for self- injury.

143 Understanding Self-injurious Behavior SIB is identified by the patient as non- suicidal, and is typically aimed at relieving distress. It is marked by: – An irresistible impulse to self-harm – Mounting agitation – no escape from tension – Cognitive constriction- no alternatives considered – Rapid, temporary relief following the act of self injury

144 Functions Self-injury may Serve Escape or reduce painful emotions Distract from painful memories or thoughts Self-expression of emotions Punishment of self Tension reduction/Anger reduction Get attention, social support, or help To feel alive

145 Characteristics of Self-injurers The teen may have difficulties: – Labeling their emotions – Effectively regulating emotions – Trusting experiences as valid responses to events (therefore individual searches environment for cues about how to respond) – Tolerating distress – Effectively solving problems (Miller, 1999)

146 Emotional Vulnerability High sensitivity – Immediate reactions – Low threshold for emotional reaction High reactivity – Extreme reactions – High arousal dysregulates cognitive processing Slow return to baseline – Long lasting reactions – Creates high sensitivity to next emotional stimulus

147 Borderline Personality Disorder Many self-injurers display some of these traits: – Emotion dysregulation (affect lability) – Interpersonal dysregulation (chaotic relationships) – Self-dysregulation (identity disturbance) – Behavioral dysregulation (self-injury) – Cognitive dysregulation (paranoia)

148 What We See in the Teen Critical, hostile statements toward self and feelings of guilt, shame, anger when experiencing strong emotions These reactions serve to intensify the pain of the original emotion and further support the self-critical backlash

149 The Invalidating Environment Families may: – Indiscriminantly reject – Punish emotional displays and intermittently reinforce emotional escalation. – Over-simplify the ease of problem-solving and meeting goals – Indiscriminantly indulge

150 Creating a Validating Therapeutic Environment Therapist validates the emotional need behind the behavior. Therapist must non-judgmentally acknowledge destructiveness of teens behavior. Youre doing the best you can, and you can do better. Therapist refrains from criticizing the individual but instead elicits negative consequences about specific behaviors from teen.

151 Levels of Validation (Miller & Comtois, 2002) Unbiased listening and observing. Accurate reflection Articulating the unverbalized Validation in terms of past learning or biological dysfunction Validation in terms of present context Radical genuineness

152 Break Time for a 15 minute break!

153 Developing the Treatment Approach Protocol driven treatments (one size fits all, what to do instructions) work with severe and chronic Axis I problems Principle-driven treatments (based on principles that tell you how to figure out what to do) are needed with multi- diagnostic and/or Axis II patients Miller, 2002

154 Chain analysis as a Guide to Case Conceptualization A form of behavioral analysis Translation of the behavior problem (SIB) into links in the chain of emotions, events, behavior and consequences Assessing at a micro-level to reconstruct the sequence in time

155 Chain Analysis as a Guide Start by asking teen to walk you through the events that led up to the self-injury. Help teen identify vulnerability factors that may have contributed. Ask teen to describe in detail the precipitants, thoughts, images, and feelings they may have experienced as well as what was going on outside. Ask about (+) and (-) consequences of the SIB.

156 Links in the Chain Vulnerability factors Triggering event Emotions Thoughts (self-talk) Physical sensations Urges Behavior Consequences

157 Forming Conceptualization The specific vulnerabilities, self-statements, and feelings (internal factors), as well as the triggering events and consequences of the SIB (external factors), will help you to develop the case conceptualization and treatment plan.

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160 Prioritize treatment needs Through chain analyses, the therapist decides which skill areas to target first: – Emotion regulation skills – Cognitive restructuring – Family Conflict – Communication skills – Problem-solving – Social skills/assertiveness skills

161 LUNCH BREAK !

162 Emotion Education Learning to be nonjudgmental toward self – Teach teen how to observe and describe different emotions, without labeling them as good or bad, but simply to be aware of them. – Emotion dysregulation results often because teen is overly harsh toward self for having strong feelings, and may often judge specific feelings as wrong, or invalid, and feel more distressing emotions in turn.

163 Emotion Education (continued) Action urges and choices – A negative emotion often leads to an irresistible urge to act in a self-destructive manner. – Important to teach teen that just because they have urge to act on a distressing emotion they are not obligated to act in this way. – Distinguish between urge to act and the action itself.

164 Reducing Vulnerability to Negative Emotion Parents and teens should be taught how to decrease vulnerability to emotion mind (Linehan, 1993). Emphasis on importance of maintaining regular sleep schedule. Eating balanced diet, treating physical illness, getting regular exercise, avoiding substance abuse and planning at least one activity a day that elicits a sense of competence and mastery.

165 HEAR ME Health (treat physical illness) Exercise regularly Avoid mood altering drugs Rest (balanced sleep) Mastery (one rewarding activity daily) Eating (balanced diet)

166 Emotions Thermometer

167 Mindfulness of current emotion Steps in the process: 1. Observe your emotion 2. Experience Your emotion 3. You are not your emotion 4. Practice Accepting your emotion

168 Mindfulness 1. Observe your emotion – Note its presence… just observe it – Step Back – Get Unstuck from the emotion

169 Mindfulness 2. Experience Your Emotion – As a wave, coming and going… – Try not to block or suppress the emotion – Dont try to get rid of the emotion – Dont push it away – Dont try to keep the emotion around – Dont hold on to it – Dont intensify it

170 Mindfulness 3. Remember: You are not your emotion – Do not necessarily act on your emotion (that is, let destructive action urges pass). – Remember times when you have felt different.

171 Mindfulness 4. Practice accepting your emotion – Do not judge your emotion as wrong, bad, too painful, unfair, embarrassing, etc. – Do not criticize yourself for feeling the emotion. – Accept your emotion as it is in the moment.

172 Chain Analysis as an Intervention: The Freeze Frame Technique (Wexler, 1991) Takes the chain analysis a step further – Recalls events as if reviewing a video replay and then freezing the frame at critical points. – Helps teen to slow time down (especially useful for teens who are impulsive and cant remember what happened).

173 Steps of Freeze Frame To review : – Teen is asked to describe in detail a situation in which he/she had a particularly strong emotional reaction and/or had adverse consequences. – These consequences should be both internal and external e.g. teen punched his door – consequence might be he/she has to pay for a new door and also feels guilty and ashamed of this behavior.

174 Freeze Frame (continued) In addition to who, what, where, when of the problem situation, sensory, interpersonal, affective, cognitive details are also recalled; negative self-talk is especially important to articulate. The teen should describe the vulnerability factors that made he/she more susceptible to negative emotions and problem behavior.

175 Freeze Frame (continued) The teen is instructed to slow time down as the scene approaches the moment when the problem emotion intensified or the uncontrollable behavior started (analogy of the instant replay can be used). At the moment just prior to the problem emotion or uncontrollable behavior is reached, the teen is instructed to FREEZE THE FRAME and describe thoughts, feelings, bodily sensations, and action urges at that moment.

176 Freeze Frame (continued) The next step is to ask the teen what NEEDS were you attempting to meet through the behavior, even if the results were negative? Once these needs have been identified, the therapist must help teen to develop self- respect for these needs (teach teen to validate these needs) and formulate alternative ways to take care of these needs.

177 Freeze Frame (continued) Needs-Important to teach teen that if they can identify their needs and learn different behaviors to get their needs met, they can have more power. Once you know the needs, you are smarter. Once you have new tools for handling the needs, you are more powerful (Wexler, 1993).

178 Freeze Frame (continued) The Freeze Frame differs from the chain analysis, and becomes an intervention with the final step: The teen replays the scene and replaces the problem behavior with the new coping skills, and then imagines a new outcome.

179 Educating Family about Freeze Frame The Freeze Frame approach is the basis for generating options and interventions with regard to emotion dysregulation. We can use this approach to examine emotion dysregulation that occurs interpersonally between family members.

180 Break Time for a 15 minute break!

181 Distress Tolerance Skills A crisis survival strategy Vital skill to teach teen as they will not always be able to decrease painful emotions, or get what they need interpersonally, so they will need to learn how to tolerate distressing emotions.

182 Distress Tolerance Skills Linehan (1993) Learning how to bear pain skillfully Teaching teens to suspend judgment – an emotion simply is Teaching teens to accept painful feelings vs. trying to get rid of them quickly

183 Distress Tolerance Skills 3 Myths about acceptance (Miller, 1997) – If you refuse to accept something, it will magically change. – If you accept your painful situation, you will become soft and just give up (or give in). – If you accept your painful situation, you are accepting a life of pain.

184 Distress Tolerance Skills CBT component of Distress Tolerance – Acceptance self-talk Learning to talk to yourself nonjudgmentally e.g. Im doing the best I can, I know if I can just get through this difficult time things will get better. Acceptance self-talk counters the negative, critical shoulds that often accompany painful emotions.

185 Distress Tolerance Skills Main emphasis is teaching teens how to soothe themselves. Teens may be resistant to this, as their relation to the world is predominantly action and other oriented. Self-soothing skills involve neither action in the external behavior sense nor an explicit relation with others.

186 Distress Tolerance Skills Some teens have belief that others should soothe them when distressed and have difficulty believing that they can depend on themselves. Others may feel that they dont deserve to be soothed and may feel guilty, ashamed, angry when they try to self-soothe (Linehan, 1993).

187 Distress Tolerance Skills Some teens have belief that others should soothe them when distressed and have difficulty believing that they can depend on themselves. Others may feel that they dont deserve to be soothed and may feel guilty, ashamed, angry when they try to self-soothe (Linehan, 1993).

188 Self-Soothing Through the Five Senses An accessible and easily taught self- soothing/distress tolerance skill is the use of the 5 senses: – Vision, hearing, smell, taste, touch Usually at least 2-3 of the five senses are engaged or capable of being engaged at any given moment as a distraction from distress.

189 Sensory Soothing (continued) Vision: Focus on an aspect of nature, or any visual detail Hearing: Music, nature sounds, relaxation tape, fan noise Smell Lotion, candle, perfume, favorite food cooking Taste Hot chocolate or tea, ice cream…taste slowly Touch Pet your dog, cat, soothing bath, hug, blanket

190 Helping Parents Regulate Their Emotions When in Conflict with Teen Teach trategies for changing the timing and process of confrontations. Important to educate parents that when teen attacks and parent becomes dysregulated then parent can no longer be effective in enforcing rules and consequences. Teens will escalate their behavior in an attempt to control outcome of mood and outcome of the interaction (Sells, 1998).

191 Creating a Validating Family Environment Help both parents and teen to understand how their reactions to each other may be invalidating. Kernel of Truth Coaching parents to become more aware of the ways in which their communication may be overly negative and critical. Validation isnt agreeing with and doesnt have to be warm and fuzzy.

192 Strategies to Help Parents Respond Calmly Strategies to help parents respond calmly and nonreactively to their teens provocations during conflict: – EXIT AND WAIT – STAYING SHORT AND TO THE POINT, USING DEFLECTORS

193 Communication Skills Active Listening (verbal and non verbal skills) Therapist models listening skills Sending clear messages ( use of I statements instead of you Practice/role play in session

194 Changing Emotion by Acting Opposite the Current Emotion Every emotion has an action associated with it. – Fear …………Run – Anger………….. Attack – Sadness………..Withdraw – Shame………….Hide

195 Changing Emotion by Acting Opposite the Current Emotion Opposite Action – Emotion is strongly influenced by our bodily posture and facial expressions. – By altering posture, behavior and facial expressions we can delay, interrupt or de- escalate the progression of a problematic emotion.

196 Opposite Action for Anger Keep ones palms open when inclined to punch. Whisper when inclined to scream. Breath deeply and slowly rather than angrily hyperventilating. Gently avoid the person you are angry with rather than attacking. Put yourself in the other persons shoes, and imagine sympathy or empathy for the person, rather than blame.

197 Opposite Action for Guilt or Shame Repair the mistake. – Say youre sorry – Make up for what you did to the person you offended Try to avoid making the same mistake in the future. Accept the consequences for what you did. Then let it go.

198 Opposite action for Sadness or Depression Get active Approach, dont avoid Do things that make you feel effective and self-confident Use the half-smile

199 Opposite Action for Envy Someone else has something that you think you WANT or NEED. (If you cant have it, they SHOULDNT.) Based on a fundamental belief that you are DEPRIVED. Radical Acceptance: you have to radically accept that you dont have it (opposite action).

200 Radical Self-Acceptance We must willingly accept all aspects of self. Remember that acceptance does not necessarily mean approval or agreement, but is simply the acknowledgement of what is. Accepting that you are human, that you have both failings and accomplishments in your life experiences, and that you are inherently both flawed and gifted is radical self-acceptance. Practice accepting insights, both what you like and dont like with an open-heart. Accept yourself wholeheartedly, without fear that doing so will make you worse.

201 Steps to practice using opposite action What emotion am I experiencing? What is the action (what is the emotion trying to get me to do)? Do I really want to reduce this emotion? What is the opposite action? DO the opposite action. Practice, practice, practice!

202 Relaxation Skills Deep Breathing with a Self-Statement, Counting Backward Deep Breathing with Pleasant Imagery Leaving the scene for a break Guided Imagery for Relaxation (Spaceship to the Moon and back; Falling Leaf…) Progressive Muscle Relaxation

203 Summary Important to assess most severe episode suicidal thoughts or behavior and evaluate the precipitants and motivations. Important to gather history of suicidal thoughts and behaviors in all patients. Gather current information and history of self-injurious behaviors or urges.

204 Summary (continued) Establish no harm/no suicide safety plan with teen and family. If conflict has been a precipitant, work with family to call a truce. Evaluate possible reinforcers for the teen to continue self-injurious behaviors (what does he/she get or gain). Remain non- judgmental.

205 Summary (continued) The essential Commitment Phase of treatment Decreasing vulnerability factors Teaching Use of Freeze Frame Emotion Regulation skills to teen and parents. Enhance Family Communication skills

206 Summary (continued) Self-soothing skills Helping parents regulate their emotions when in conflict. Strategies to help. Changing Emotion by opposite action technique Distress Tolerance Skills

207 Questions and Discussion

208 We acknowledge with gratitude the Pennsylvania Legislature for its support of the STAR-Center and our outreach efforts. This presentation may not be reproduced without written permission from: STAR-Center Outreach, Western Psychiatric Institute and Clinic, 3811 OHara Street, Pittsburgh, PA (412) All Rights Reserved, 2006


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