F 1 BAPTIST HEALTH SCHOOL OF NURSING NSG 3037: PSYCHIATRIC MENTAL HEALTH Safety: Suicidal Crisis Lecture Objectives: 1. Discuss epidemiological statistics and risk factors related to suicide. 2. Describe predisposing factors implicated in the etiology of suicide. 3. Differentiate between facts and fables regarding suicide. 4. Apply the nursing process to individuals exhibiting suicidal behavior. Reading Assignment: Townsend, Chapter 18 Key Terms: Egoistic suicide Altruistic suicide Anomic suicide 1. Introduction A. Definition Suicide is not a diagnosis or a disorder, it is a behavior. More than 90% of suicides are committed by individuals who are psychiatrically ill at the time of the suicide II. Historical Perspectives A. Ancient Greece: suicide was an offense against the state, and individuals who committed suicide were denied burial in community sites. B. Imperial Roman Army: in this culture, individuals sometimes resorted to suicide to escape humiliation or abuse. C. Middle Ages: suicide was viewed as a selfish or criminal act. D. Renaissance era: the view became more philosophical, and intellectuals could discuss suicide more freely. th th E. 17 and 18 Century philosophers condemned suicide, but some individuals began to associate suicide with mental illness. F. Suicide was illegal in England until 1961, and only in 1993 was it decriminalized in Ireland. G. Most religions consider suicide a sin against God.
F 2 III. Epidemiological Factors A. 30,000 people end their lives in the United States each year by suicide. B. th 8 leading cause of death among adults in the United States. C. rd 3 leading cause of death in young Americans ages 15 to 24. IV. Risk Factors: A. Marital Status 1. The suicide rate for single people is twice that of married people. B. Gender 1. Women attempt suicide more often, but more men succeed. 2. Men commonly choose more lethal methods than women. C. Age 1. Risk of suicide increases with age, particularly among men. 2. White men older than the age of 80 years are at the greatest risk of all age/gender/race groups. 3. rd Suicide is the 3 leading cause of death (after motor vehicle accidents and homicide) in the 15-24 year old age group. D. Religion 1. Protestants have significantly higher rates of suicide than Catholics or Jews. E. Socioeconomic Status 1. Individuals in the very highest and lowest social classes have high suicide rates Than those in the middle classes. F. Ethnicity 1. Whites are at highest risk for suicide, followed by Native-Americans, African- Americans, Hispanic-Americans, and Asian-Americans. G. Other Risk Factors 1. Psychiatric illness a. Mood disorders are the most common psychiatric illnesses that precede suicide. 2. Severe insomnia is associated with increased risk. 3. Homosexual individuals have a high risk rate 4. Chronic pain or disabling illness. Those afflicted with either have an increased risk. 5. Family history of suicide, particularly a same-sex parent, increases the risk. 6. Previous attempts increased the risk of a subsequent attempt. 50-80% of those who ultimately commit suicide have a history of a previous attempt. 7. Loss of loved one through death or separation is a risk factor. 8. Unemployment and increased financial burden increased the risk. V. Predisposing Factors: Theories of Suicide We will study three: Psychological, Sociological and Biological
F 3 A. Psychological Theories 1. Anger turned inward. Freud believed that suicide was a result of an earlier repressed desire to kill someone else. Anger that was previously directed to another person was turned inward on the self. 2. Hopelessness. Studies indicate a high correlation between feelings of hopelessness and suicide. 3. Desperation and guilt Desperate feelings occur when an individual recognizes the need for change but feels helpless to bring about that change. Guilt and self-recrimination are other aspects of desperation. 4. History of aggression and violence. Rage and violent behavior have been identified as important psychological factors underlying suicidal behavior. 5. Shame and humiliation. Some individuals view suicide as a face-saving mechanism after a social defeat such as a sudden loss of status or income. 6. Developmental stressors. Certain life stressors that occur during various developmental levels have been identified as precipitating factors to suicide. B. Sociological Theory 1. Durkheim believed that suicide was correlated to the cohesiveness of a society in which the individual lived. He described three social categories of suicide. a. Egoistic suicide: the response of the individual who feels separate and apart from the mainstream of society. Integration is lacking. b. Altruistic suicide: the opposite of egoistic. Individuals are excessively integrated into the group. And allegiance to the group is so strong that they will sacrifice their own lives for the group. c. Anomic suicide: occurs in response to changes in the individual s life that disrupt feelings of relatedness to the group. The interruption in the customary norms of behavior instills feeling of separateness and fears of being without support from the formerly cohesive group. C. Biological Theories 1. Genetics. Twin studies have indicated a possible genetic predisposition toward suicidal behavior. 2. Neurochemical Factors. Some studies have revealed decreased levels of Serotonin in depressed clients who attempted suicide. VI. Application of the Nursing Process with the Suicidal Patient
F 4 A. Assessment 1. The aspects of information that are gathered during a suicidal assessment include: a. Demographics (1) Age (2) Gender (3) Ethnicity (4) Marital status (5) Socioeconomic status (6) Occupation (7) Lethality and availability of the method (8) Religion (9) Family history of suicide b. Presenting symptoms/medical-psychiatric diagnosis c. Suicidal ideas or acts (1) Seriousness of intent (2) Plan (3) Means (4) Verbal or behavioral clues d. Interpersonal support system e. Analysis of the suicidal crisis (1) The precipitating stressor (2) Relevant history (3) Life-stages issues f. Psychiatric/medical family history g. Coping strategies B. Diagnosis and outcome identification 1. Nursing diagnoses for the suicidal patient may include the following:: a. Risk for suicide b. Hopelessness C. Planning and implementation 1. Care plan for the hospitalized suicidal patient 2. Guidelines for treatment of the outpatient suicidal patient a. Do not leave the person alone. b. Establish a no-suicide contract with the patient c. Enlist the help of family and friends d. Schedule frequent appointments. e. Establish rapport and promote a trusting relationship. f. Be direct and talk matter-of-factly about suicide. g. Discuss the current crisis situation in patient s life. h. Identify areas of control. i. Give antidepressant medication.
F 4 3. Guidelines for family and friends of the suicidal patient a. Take any hint of suicide seriously. b. Do not keep secrets. c. Be a good listener. d Express to the client feelings of personal worth. e. Know about suicide intervention resources. f. Restrict access to firearms or other means of self-harm. 4.. Interventions with family and friends of suicide victims a. Encourage them to take about the suicide. b. Discourage blaming and scapegoating. c. Listen to feelings of guild and self-persecution. d. Talk about personal relationships with the victim. e. Recognize differences in styles of grieving. f. Assist with the development of adaptive coping strategies. g. Identify resources that provide support. D. Evaluation of the suicidal patient is an ongoing process accomplished through continuous reassessment of the patient, as well as determination of goal achievement. Once the immediate crisis has been resolved, extended psychotherapy may be indicated. Individual and or Group psychotherapy: Long term and short term goals. 1. Develop and maintain a more positive self-concept. 2. Learn more effective ways to express feelings to others. 3. Achieve successful interpersonal relationships. 4. Feel accepted by others and achieve a sense of belonging. A suicidal person feels worthless and hopeless. These goals serve to instill a sense of self-worth, while offering a measure of hope and a meaning for living. VII. Summary FACTS and FABLES about Suicide 1. Suicide is an inherited trait. 2. Gunshot wounds are the leading cause of death amount suicide victims. 3. Most people give clues and warnings about their suicidal intentions. 4. If a person has attempted suicide, he or she will not do it again. 5. Suicide is the act of a psychotic person. 6. Once a person is suicidal, he or she is suicidal forever. 7. Most suicides occur when the severe depression has started to improve.
F 5 8. Most suicidal people have ambivalent feelings about living and dying. 9. If a suicidal person is intent on dying, he or she cannot be stopped. 10. People who talk about suicide don t commit suicide. Answers: 1. F 2. T 3. T 4. F 5. F 6. F 7. T 8. T 9. F 10. F Revised and prepared by: Sandra Kahler, MS R.N. from original outline and th Townsend 4 edition March, 2006