suicide

1. suicide Alan Apter M.D Feinberg Child Study Center Schneider Children’s Medical Center

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 one’s 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"

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 toSuicide Attempts leads to Failed Suicideleads toCompleted Suicide

12. Discontinuity TheorySuicidal IdeationSuicidal ThreatsSuicidal GesturesSuicide AttemptsSerious Suicide Attempts

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 10- 30% 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)

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

27. Suicide by age

29. SUICIDE IN INDIA

30. Homicide and suicide rates by year

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

32. Change in percentage of suicide rates for males aged 15 years and over in European countries between 1989-90 and 1995-96. 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<WHITES • HISPANICS AND S.EUROPEANS ATEMPT

34. AETIOLOGY/RISK FACTORS

35. AETIOLOGY/RISK FACTORS • 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

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 one’s 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