😵Abnormal Psychology Unit 9 – Suicide and Self–Injury

Definition and Overview

• Suicide involves intentionally ending one's own life through self-directed injurious behavior with the intent to die
• Suicidal behavior encompasses a range of actions, including suicidal ideation, suicide attempts, and completed suicide
• Suicidal ideation refers to thoughts, fantasies, or preoccupations with death and suicide, which can be passive or active
• Suicide attempts are non-fatal, self-inflicted, potentially injurious behaviors with an intent to die (overdose, self-harm)
• Completed suicide results in death and is often associated with a history of previous attempts and untreated mental health conditions
• Self-injury, also known as non-suicidal self-injury (NSSI), involves deliberate self-harm without suicidal intent (cutting, burning)
• Suicide and self-injury are complex phenomena influenced by a combination of biological, psychological, social, and environmental factors

Risk Factors and Warning Signs

• Risk factors increase an individual's vulnerability to suicidal behavior and can be categorized as static or dynamic
  • Static risk factors are unchangeable (family history of suicide, previous suicide attempts)
  • Dynamic risk factors can potentially be modified (substance abuse, access to lethal means)
• Warning signs are observable behaviors or symptoms that indicate heightened risk for suicide in the near term
• Verbal warning signs include talking about feeling hopeless, being a burden, or having no reason to live
• Behavioral warning signs encompass increased substance use, isolation, giving away possessions, and searching for methods online
• Mood-related warning signs involve depression, anxiety, irritability, humiliation, and sudden improvement after a depressive episode
• Demographic risk factors include male gender, older age, and belonging to certain ethnic or sexual minority groups
• Psychiatric risk factors comprise mental disorders (depression, bipolar disorder, schizophrenia), substance use disorders, and personality disorders

Types of Suicidal Behavior

• Suicidal behavior can be classified based on the level of intent, lethality, and frequency of the actions
• Suicidal ideation is categorized as passive (wish to die without a specific plan) or active (thoughts of taking action to end one's life)
• Suicide attempts vary in their level of lethality, ranging from low-lethality (superficial cutting) to high-lethality (jumping from heights) methods
• Aborted suicide attempts occur when an individual prepares to attempt suicide but does not follow through due to external intervention or change of mind
• Interrupted suicide attempts are stopped by someone else or an external circumstance before the individual can engage in the behavior
• Suicide rehearsals involve practicing or rehearsing the intended method without causing injury (holding a gun without pulling the trigger)
• Suicide pacts are agreements between two or more people to die by suicide, often at the same time and place
• Suicide clusters refer to a series of suicides that occur in close temporal and/or geographical proximity, often among adolescents and young adults

Self-Injury: Forms and Motivations

• Self-injury, or non-suicidal self-injury (NSSI), is the deliberate, self-inflicted destruction of body tissue without suicidal intent
• Common forms of self-injury include cutting, burning, scratching, hitting, and interfering with wound healing
• Cutting is the most prevalent method of self-injury, often involving sharp objects (razors, knives) to create superficial wounds on the skin
• Self-injury is more common among adolescents and young adults, with a typical onset between ages 12 and 14
• Motivations for self-injury are diverse and can serve intrapersonal and interpersonal functions
  • Intrapersonal functions include emotion regulation, self-punishment, and distraction from emotional pain
  • Interpersonal functions encompass seeking attention, communicating distress, and influencing others' behavior
• Self-injury can become a maladaptive coping mechanism for dealing with overwhelming emotions, traumatic experiences, or interpersonal conflicts
• Although self-injury is distinct from suicidal behavior, it is a significant risk factor for future suicide attempts

Psychological Theories and Models

• Psychological theories and models aim to explain the underlying mechanisms and risk factors associated with suicidal behavior and self-injury
• The interpersonal theory of suicide (Joiner, 2005) posits that suicidal desire arises from the combination of perceived burdensomeness and thwarted belongingness
  • Perceived burdensomeness is the belief that one's existence burdens family, friends, or society
  • Thwarted belongingness is the experience of social alienation and lack of reciprocal care
• The three-step theory (3ST; Klonsky & May, 2015) proposes that suicidal ideation develops through a series of steps:
  1. Experiencing pain and hopelessness
  2. Having no connectedness to hold back suicidal ideation
  3. Possessing the capacity to attempt suicide through dispositional, acquired, and practical factors
• The integrated motivational-volitional (IMV) model (O'Connor, 2011) describes the transition from suicidal ideation to behavior through motivational and volitional phases
  • The motivational phase involves the development of suicidal ideation through defeat, humiliation, and entrapment
  • The volitional phase encompasses factors that facilitate the transition from ideation to attempts (impulsivity, access to means)
• The four-function model (Nock & Prinstein, 2004) proposes that self-injury serves four primary functions:
  1. Automatic negative reinforcement (reducing negative emotions)
  2. Automatic positive reinforcement (generating positive feelings)
  3. Social negative reinforcement (avoiding interpersonal demands)
  4. Social positive reinforcement (gaining attention or support from others)

Assessment and Diagnosis

• Assessment of suicidal behavior and self-injury involves a comprehensive evaluation of risk factors, warning signs, and protective factors
• Structured clinical interviews, such as the Columbia-Suicide Severity Rating Scale (C-SSRS), assess the presence and severity of suicidal ideation and behavior
• Self-report measures, like the Beck Scale for Suicide Ideation (BSS) and the Suicide Behaviors Questionnaire-Revised (SBQ-R), provide additional information on suicidal thoughts and risk
• Assessment of self-injury typically includes the Self-Injurious Thoughts and Behaviors Interview (SITBI) or the Deliberate Self-Harm Inventory (DSHI)
• Diagnosis of suicidal behavior and self-injury is based on the presence of specific symptoms and criteria outlined in the DSM-5 and ICD-11
  • Suicidal behavior disorder is a proposed diagnosis in the DSM-5 characterized by a suicide attempt within the past 24 months
  • Non-suicidal self-injury is a proposed disorder in the DSM-5 involving repeated self-inflicted damage to the surface of one's body without suicidal intent
• Risk assessment involves evaluating the likelihood of future suicidal behavior based on static and dynamic risk factors, as well as protective factors (social support, reasons for living)

Prevention Strategies and Interventions

• Prevention strategies for suicide and self-injury aim to reduce risk factors, enhance protective factors, and promote mental health and well-being
• Universal prevention targets entire populations through public education campaigns, media guidelines, and means restriction (limiting access to firearms, drugs)
• Selective prevention focuses on high-risk groups, such as individuals with mental disorders or a history of trauma, through screening and early intervention programs
• Indicated prevention targets individuals showing early signs of suicidal behavior or self-injury through crisis intervention, safety planning, and referral to treatment
• Evidence-based interventions for suicidal behavior include cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and the collaborative assessment and management of suicidality (CAMS)
  • CBT addresses maladaptive thoughts and behaviors related to suicide through cognitive restructuring and problem-solving skills
  • DBT combines individual therapy, group skills training, and phone coaching to enhance emotion regulation and distress tolerance
  • CAMS is a therapeutic framework that emphasizes collaboration between the clinician and patient in assessing and managing suicidal risk
• Interventions for self-injury focus on teaching alternative coping strategies, improving emotion regulation, and addressing underlying psychological distress
• Pharmacotherapy, such as antidepressants and lithium, may be used in conjunction with psychotherapy to manage underlying mental health conditions and reduce suicidal risk

Ethical and Legal Considerations

• Ethical principles, such as autonomy, beneficence, non-maleficence, and justice, guide the assessment and treatment of suicidal behavior and self-injury
• Mental health professionals have a duty to protect clients who are at imminent risk of suicide by taking appropriate steps to ensure their safety (hospitalization, emergency services)
• Confidentiality may be breached when a client poses a clear and present danger to themselves or others, as mandated by the Tarasoff ruling and similar laws
• Informed consent involves discussing the limits of confidentiality, the risks and benefits of treatment, and the client's right to refuse or withdraw from treatment
• Involuntary hospitalization may be necessary when a client is deemed to be a danger to themselves or others and is unwilling or unable to seek voluntary treatment
• Assessing decision-making capacity is crucial in determining a client's ability to make informed decisions about their care and safety
• Documentation of risk assessments, safety plans, and treatment decisions is essential for ensuring continuity of care and protecting against legal liability
• Collaboration with family members, healthcare providers, and community resources is important in managing suicide risk and promoting long-term recovery