Module Ten OTHER PSYCHIATRIC SUBJECTS

Module TenOTHER PSYCHIATRIC SUBJECTS • Lesson 1: Suicide and intentional injury of self • Lesson 2: Mental disorders and aggressive, violent and illegal behavior

Lesson 1 SUICIDE AND INTENTIONAL DAMAGE OF SELF

Step 1: Introduction • Suicide refers to the case where the person achieves to kill oneself, while intentional injury of self to the people that attempt to hurt their selves, but not kill oneself. • Even though these two groups complete one another, there are serious reasons to distinguish them. • In the second case is usually used the term suicide attempt, which is recently replaced by the term intentional injury of self, because a large group of persons that belong in this category has no intention to commit suicide.

Step 2: Theory presentation Suicide • The registration of deaths caused by suicide differ from country to country. • Suicides occur all over the world, but there are great variation of rates between countries or social groups. • The World Health Organization estimates that 135.000 people commit suicide in Europe. • Generally in North Europe the percentages of suicides are higher than those in Southern Europe. • Lately, there was observed an increase in suicide’s percentages of younger persons in Europe. • Internationally 2.000 people suicide daily. • Suicide is more common to men. • It is also more frequent to people aged > 65 years old.

Step 3: Who commits suicide • People who has a specific profession • People who belong in the higher or the lower class. • Unemployed • Singles, widower, separated or divorced • People with mental disorders • People with history of suicide attempt or suicide in family history • People who suffer from a severe physical disease or invalidation , like cancer, AIDS or chronic pain.

Step 3 (continued) What are the reasons for committing suicide? • Physical or mental disease • Personal factors – social support, position towards suicide, impulsiveness • Stressful events and difficulties – loss of a job, separation, rejection, widowhood, divorce • Changes in cultural environment • Easy access to suicide means

Step 4: Brainstorming In what ways usually persons commit suicide? • Hanging (mostly men) • Drugs (mostly women) • Exhaust pipe • Guns • Fall of height The way of suicide depends on the easy access to the means, the facility these can be used and the prevailing “trend”.

Step 5: Theory presentation Intentional injury of self • This term refers to a large group of people that attempted suicide and failed, some who have taken action to suicide and others that only intended to injure themselves for minimizing their tension. • It is not quite clear in which way is related the intentional injury of self and suicide. If it is about different manifestations of the same problem or if these are different but similar problems. There are for sure important differences.

Step 5 (continued) • It is 10 times more frequent than suicide. • Usually attempted from young persons, mainly under 35 years old. • They usually come from economically lower class. • In opposition to suicide it is twice more frequent in women. • The most common way is drug taking (poisoning) followed by cut of wrist veins.

Step 5 (continued) • About one fifth of persons that injured themselves, repeat it within a year. It is estimated that 1% of people who attempted will complete it within a year. That means that suicidal intentional injury is an important factor to suicide.

Step 6: Slide projection Slide 10.1.1: differences between suicide and intentional injury of self Aim SUICIDE: death INTENTIONAL INJURY OF SELF : death or injury

Step 6 (continued) Reasons SUICIDE: physical or mental disease, Personal factors, Stressful events, Changes in wider cultural environment, Easy access to suicide means. INTENTIONAL INJURY OF SELF : possibly all the reasons of suicide plus: desire of managing the environment, tensions relief, communication of a message, avoid responsibilities.

Step 6 (continued) Rate of incidence SUICIDE: about 2- 60 every 100.000 INTENTIONAL INJURY OF SELF : 10 times more frequent than suicide

Step 6 (continued) Gender SUICIDE: mostly men INTENTIONAL INJURY OF SELF : mostly women

Step 6 (continued) Age SUICIDE: usually more than 65 years old. INTENTIONAL INJURY OF SELF : usually under 35 years old

Step 6 (continued) Method SUICIDE: Hanging, (mostly men), Drugs (mostly women), exhaust pipe, guns, fall from height INTENTIONAL INJURY OF SELF : drug (poisoning), cutting wrist veins

Prevention of suicide • Educational programs for first aid doctors, so that they are able to point out person in danger of committing suicide. • Therapy for persons with psychiatric problems. • Observation after hospitalization. • Center for suicide Prevention where persons with suicidal ideas can call.

Step 8: Questions and comments

Lesson 2 MENTAL DISORDERS WITH AGGRESSIVE, VIOLENTAND /OR ILLEGAL BEHAVIOUR

Step 1: Slide projection Slide 10.2.1: Characteristics of aggression and violence Aggression • The term expresses the intention to hurt somebody or show that the person is more important. • It does not only includes physical traumatism. • There might be specific motives or no motives at all. • It is not always considered as negative behavior, except if the receptor is involved involuntary. • This characterization constitutes subjective judgment of a third person and it’s thus influenced by his / her personal values.

Step 1 (continued) Violence • This term refers to the use of power for causing physical damage. • Usually there is a negative motive, except from cases where is considered from both involved parts that there is internal acknowledge. • Even if it is considered as negative behaviour, in some cases is socially legalized (e.g., in case of self-defense).

Step 2: Causes of violence in mentally ill people • Dirty and untidy environment • Inflexible everyday life • Personnel’s nervousness • Insufficient contact between personnel and patients • Impossibility of the personnel to understand the fear of the patient that comes from personal experiences (e.g. delusions)

Step 3: Theory presentation (10΄) Even though there are different opinions regarding the participation of people with mental disorders, these people are responsible only for a small percentage of violent actions in society. The relation between mental disorders and violence is resumed as follows: • One in ten persons hospitalized in psychiatric departments has a history of violence. • Among these persons the diagnosis is most of the times Schizophrenia and follow Organic Mental Disorders, Manic Disorder, Substance use, Antisocial Personality Disorder.

Step 3 (continued) • In Schizophrenia violence is related to the existence of hallucinations or delusions and the consumption of alcohol or other substances. • In Manic disorder is usually manifested during the first period of the treatment. • In substance users is because they are free of inhibitions, or secondary because of delirium, or is related to personality. It is usually related to alcohol and cocaine.

Step 4: Slide projection Slide 10.2.2: Dangerousness factors • History of violence • Use of alcohol or other substances • Organic brain disease • Rapes • Pathologic jealousy • Violence menaces • Recurrent violent behaviour when drunk • Attend of stressful events • Easy access to the victims • Lack of guilt • Aggressive behaviour since childhood (maltreatment of animals, fire-raising) • Sadistic fantasies • Obvious fear in presence of the examiner

Step 5: Slide projection Slide 10.2.3: Treatment of violent behaviour • Call for help • Protection of other patients • Direct evaluation of mental state and subjective experiences • Take away or face causing factors (e.g. alcohol, substances, provocations, metabolic disorders) • Evaluation of how valuable or risky verbal interventions are • Avoiding making promises orGiving medication • Limitation

Step 6: Theory presentation Homicides • In about 50% of cases there is alcohol abuse. • Half of the people who commit homicide are disordered persons, mainly regarding personality.

Step 6 (continued) Indictable offences • These are related to law violations and concern mainly persons under 21 years old. • These are mostly related to circumstances and occasions than to personality. • Blaming for: • Having Mediocre IQ. • The family (big family, tough parents) • Social environment (a company that encourage such actions). • Personal characteristics (disobedient child, aggression, absence from school).

Step 6 (continued) Rapes Usually committed from persons under 25 years old, with no partner with history of no sexual violations, with no mental disorder.

Step 6 (continued) Fire – raising • 8 % of the people arrested for fire – raising are schizophrenic persons who acted under the influence of delusions or aberrant ideas. • For fire- raisers with Mood Disorders the cause might be melancholic ideas or manic emotional attack. • Fire – raising also commit persons with psychoses due to alcohol or other substances use, as well as persons with Dementia or Mental Retardation.

Step 6 (continued) Petty thefts Usually committed by two categories of persons: • Young, socially isolated, opportunists that feel no guilt. • Middle aged persons with Depression or physical disturbances.

Step 7: Questions and comments (5΄)

Module Ten OTHER PSYCHIATRIC SUBJECTS