2.4.1 Suicide, Attempted Suicide, and Self-Harm

All Aspects of Suicide, Attempted Suicide, and Self-Harm including Risk Assessment and Risk Management

Suicide, attempted suicide, and self-harm are complex and multifaceted issues that have significant implications for psychiatric practice. Suicide is defined as intentionally ending one’s life, while attempted suicide involves intentionally causing self-harm with the intent to die. Self-harm refers to intentional self-injury that is not intended to result in death. Psychiatric practice plays a vital role in the assessment, management, and prevention of suicidal behaviour.

Risk assessment and risk management are essential aspects of suicide prevention. Risk assessment involves evaluating the patient’s current level of risk for suicidal behaviour, while risk management involves implementing strategies to reduce the risk of suicide. It is important to consider both clinical and non-clinical risk factors, such as age, sex, previous suicide attempts, psychiatric diagnosis, substance abuse, and social support.

Aspects of Suicide	Clinical Aspects	Psychiatric Aspects	Theoretical Aspects
Risk Assessment	Evaluation of current level of risk for suicidal behavior	Identification of clinical and non-clinical risk factors	Interpersonal-Psychological Theory of Suicidal Behavior, which proposes that suicidal behavior results from a combination of perceived burdensomeness, thwarted belongingness, and acquired capability for suicide
Risk Management	Implementation of strategies to reduce the risk of suicide, such as safety planning, medication management, and psychotherapy	Development of a collaborative treatment plan that addresses the patient’s unique needs and preferences	Crisis theory, which proposes that suicidal behavior is the result of a crisis that the individual perceives as overwhelming and intolerable
Self-harm	Assessment and management of self-injurious behavior, such as psychoeducation, cognitive-behavioural therapy, and dialectical behavior therapy	Identification and treatment of underlying psychiatric conditions, such as borderline personality disorder	Emotion Regulation Theory, which proposes that self-harm is a maladaptive coping strategy used to regulate intense emotional experiences

Risk Assessment:

The primary goal of risk assessment is to identify individuals who may be at risk of harm to themselves or others. This can be accomplished through a combination of clinical assessment, structured assessment tools, and collateral information from family members, caregivers, and other healthcare professionals.

There are several key domains that are typically assessed in the context of psychiatric risk assessment, including:

1. Historical risk factors: This includes a patient’s past history of violence or self-harm, as well as any relevant family history or psychosocial stressors.
2. Clinical factors: This includes a patient’s current psychiatric symptoms, medication status, and overall level of functioning.
3. Environmental factors: This includes the patient’s living situation, level of social support, and access to healthcare.
4. Protective factors: This includes any factors that may mitigate the patient’s risk, such as engagement in treatment, positive social supports, or a supportive living environment.

Structured risk assessment tools, such as the HCR-20, PCL-R, and SAD PERSONS Scale, can also be helpful in providing a standardized approach to assessing risk.

The HCR-20, PCL-R, and SAD PERSONS Scale are assessment tools used in the field of psychiatry and psychology to evaluate specific aspects of individuals’ behavior and risk:

1. HCR-20: This stands for “Historical, Clinical, Risk Management-20.” It is a structured professional judgment tool for the assessment of violence risk. The “20” refers to the 20 items or factors that are assessed. These items are divided into three categories: historical (past behavior and experiences), clinical (current symptoms and conditions), and risk management (future scenarios and factors).
2. PCL-R: This stands for “Psychopathy Checklist-Revised.” It is a diagnostic tool used to measure psychopathic personality traits in individuals. The checklist is comprised of 20 items that are scored to determine the presence and severity of psychopathic traits. The PCL-R is often used in forensic settings to assess the risk of recidivism in criminal offenders and to provide insight into their behavior patterns.
3. SAD PERSONS Scale: This is an acronym used as a mnemonic to remember ten major risk factors for suicidal behavior. The factors are:
   • Sex (male)
   • Age (younger or older age groups)
   • Depression
   • Previous suicide attempt or psychiatric care
   • Excessive ethanol or drug use
   • Rational thinking loss
   • Separated, divorced, or widowed
   • Organized or serious suicide attempt
   • No social support
   • Stated future intent (to attempt suicide again)

These tools aid clinicians in understanding, diagnosing, and managing risk factors associated with violent behavior, psychopathy, and suicide.

Risk management Once a patient has been identified as being at risk, the next step is to develop a risk management plan. This may involve a range of interventions, including pharmacotherapy, psychotherapy, behavioural interventions, and social interventions.

There are several key principles of effective risk management in psychiatry, including:

1. Collaborative decision-making: Risk management plans should be developed in collaboration with the patient and their family members or caregivers, as well as other healthcare professionals involved in the patient’s care.
2. Tailored interventions: Risk management plans should be tailored to the specific needs and circumstances of the patient, taking into account their individual risk factors and protective factors.
3. Continuity of care: Risk management plans should be integrated into the patient’s overall treatment plan, with ongoing monitoring and adjustment as needed.
4. Proactive approach: Risk management plans should be proactive, rather than reactive, with a focus on preventing harm before it occurs.
5. Ethical considerations: Risk management plans should take into account ethical considerations, such as the patient’s right to autonomy and privacy, as well as the duty of care to protect the patient and others from harm.

The Interpersonal-Psychological Theory (IPT) of Suicidal Behaviour:

The IPT of suicidal behaviour proposes that suicidal behaviour results from a combination of perceived burdensomeness, thwarted belongingness, and acquired capability for suicide. This theory suggests that suicidal behaviour can be prevented by addressing these three factors through targeted interventions, such as cognitive-behavioural therapy and interpersonal therapy.

The IPT is a theoretical model that was developed to explain the psychological mechanisms underlying suicidal behaviour. The theory suggests that suicidal behaviour arises from the interaction between three key factors: perceived burdensomeness, thwarted belongingness, and acquired capability for suicide.

Perceived burdensomeness refers to the belief that one is a burden to others. This can arise from a variety of factors, including financial difficulties, chronic illness, or feeling like one’s presence is unwanted. Thwarted belongingness refers to a sense of social isolation or disconnection from others. This can arise from factors such as loss of a loved one, relocation to a new community, or social rejection.

According to the IPT, when individuals experience both perceived burdensomeness and thwarted belongingness, they may begin to develop suicidal thoughts and ideation. However, these thoughts alone are not sufficient to lead to suicidal behaviour. A third factor, acquired capability for suicide, is also necessary. Acquired capability for suicide refers to the individual’s ability to overcome the natural aversion to self-harm and to engage in suicidal behavior. This is often developed through repeated exposure to painful or life-threatening experiences, such as physical abuse or combat.

The IPT proposes that the development of suicidal behavior involves a process of desensitization to the fear and pain associated with self-harm. This desensitization occurs through the repeated exposure to painful or life-threatening experiences, which leads to a reduced fear of death and increased capability for suicide.

The IPT has been supported by a growing body of empirical research. For example, studies have found that higher levels of perceived burdensomeness and thwarted belongingness are associated with increased risk of suicidal behavior, while acquired capability for suicide has been found to predict the lethality of suicidal behavior.

The IPT has important implications for suicide prevention and treatment. The theory suggests that interventions aimed at reducing perceived burdensomeness and thwarted belongingness, as well as preventing the development of acquired capability for suicide, may be effective in reducing suicidal behavior. This can be achieved through targeted interventions such as cognitive-behavioural therapy and interpersonal therapy.

The IPT provides a valuable theoretical framework for understanding the psychological mechanisms underlying suicidal behavior. By identifying the key factors that contribute to the development of suicidal behavior, the IPT can inform the development of effective interventions and treatments for suicide prevention.

Crisis Theory:

Crisis theory provides a framework for understanding the immediate triggers of suicidal behavior. According to this theory, suicidal behavior is the result of a crisis that the individual perceives as overwhelming and intolerable. Crisis intervention involves providing immediate support and assistance to the individual to help them manage their distress and develop coping strategies.

Crisis theory is a theoretical framework that seeks to explain the nature and dynamics of a crisis, as well as how individuals and systems respond to crises. It is based on the idea that a crisis is a time-limited event that disrupts the normal functioning of an individual or system and requires an immediate response.

According to crisis theory, crises are characterized by three key features: a perceived threat, a loss of coping abilities, and a lack of resources or support. These features can lead to a state of psychological disequilibrium, where an individual feels overwhelmed and unable to cope with the situation at hand.

In response to a crisis, individuals may experience a range of emotional and physical reactions, such as anxiety, depression, anger, or physical symptoms. The individual’s ability to cope with the crisis is influenced by a variety of factors, including their personality, past experiences, social support, and available resources.

Crisis theory proposes that crises can be categorized into three broad types: developmental, situational, and existential. Developmental crises are predictable and occur at predictable times in an individual’s life, such as adolescence, midlife, or retirement. Situational crises are unpredictable and arise from specific events, such as a natural disaster, divorce, or loss of a job. Existential crises are related to questions of meaning and purpose in life, and may arise in response to a major life change or traumatic event.

Crisis theory has important implications for crisis intervention and management. Crisis intervention involves providing immediate and targeted support to individuals in crisis, with the goal of stabilizing the individual and restoring a sense of equilibrium. Crisis management involves the coordination of resources and services to address the underlying causes of the crisis and prevent further crises from occurring.

Crisis intervention and management can be delivered through a variety of settings and modalities, including crisis hotlines, emergency departments, mobile crisis teams, and crisis residential programs. Effective crisis intervention and management involve a collaborative and coordinated approach that addresses the individual’s immediate needs, as well as their long-term recovery and resilience.

Crisis theory provides a valuable framework for understanding the nature and dynamics of crises, as well as how individuals and systems respond to them. By identifying the key features of a crisis and the different types of crises that can occur, crisis theory can inform the development of effective crisis intervention and management strategies.

Emotion Regulation Theory (ERT):

ERT provides a theoretical framework for understanding self-harm. According to this theory, self-harm is a maladaptive coping strategy used to regulate intense emotional experiences. Treatment for self-harm often involves psychoeducation, cognitive-behavioural therapy, and dialectical behavior therapy, which focus on developing alternative coping strategies and emotion regulation skills.

ERT is a theoretical framework that seeks to explain how individuals regulate their emotions in response to different situations and stimuli. This theory proposes that individuals use a variety of cognitive, behavioral, and physiological strategies to regulate their emotional experiences, with the goal of achieving a desired emotional state or outcome.

ERT is based on the idea that emotions serve adaptive functions, such as communicating information about the environment, motivating behavior, and promoting social interaction. However, emotions can also be disruptive and interfere with effective functioning, particularly when they are intense, prolonged, or inappropriate to the situation. Therefore, individuals engage in emotion regulation to modulate the intensity, duration, and expression of their emotions, in order to optimize their adaptive functioning.

Emotion regulation strategies can be categorized into several broad types, including cognitive strategies, such as reappraisal, distraction, and acceptance; behavioral strategies, such as avoidance, suppression, and expression; and physiological strategies, such as relaxation, breathing exercises, and physical exercise. These strategies can be used to alter the cognitive, behavioral, and physiological components of emotional experiences, such as the appraisal of a situation, the expression of emotions, and the physiological arousal associated with emotions.

ERT has important implications for clinical practice, particularly in the treatment of mood and anxiety disorders. Dysregulated emotions are a hallmark of these disorders, and effective treatment often involves teaching individuals adaptive emotion regulation strategies. Cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT) are two examples of psychotherapeutic approaches that incorporate emotion regulation strategies into their treatment protocols.

ERT also has implications for understanding the role of emotions in social and interpersonal processes. For example, research has shown that individuals who are better able to regulate their emotions tend to have more positive social interactions and relationships, and are less likely to experience social rejection and isolation.

ERT provides a valuable framework for understanding how individuals regulate their emotions in response to different situations and stimuli. By identifying the different types of emotion regulation strategies and their underlying cognitive, behavioral, and physiological mechanisms, emotion regulation theory can inform the development of effective clinical interventions and shed light on the role of emotions in social and interpersonal processes.

In conclusion, suicide, attempted suicide, and self-harm are complex issues that require a comprehensive and multidisciplinary approach to assessment, management, and prevention. Psychiatric practice plays a vital role in these areas, and theoretical frameworks can help inform effective interventions and treatments.

Reference:

1. Joiner, T. E., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., … & Rudd, M. D. (2009). Main predictions of the interpersonal-psychological theory of suicidal behavior: Empirical tests in two samples of young adults. Journal of abnormal psychology, 118(3), 634-646.