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					 Suicide ,self harm , and violence
           presentation

Prepared by :
          Mr. Ayman El Ghouty

Supervised by :
      Dr. Abed Alkareem Radwan
      Suicide
What do we know about it?
 How can we prevent it?
         Background Information
Suicide: Intentionally causing one’s own
death.
Sometimes difficult to determine intention
   High speed, 1 car accidents
   Auto-erotic hangings
   Reluctance to label as suicide because of stigma
Life Insurance myth: Suicidal deaths are
covered if the death occurs 2 years after
policy was purchased.
              Risk Factors
Adults
   Depression, alcohol abuse, cocaine use,
    separation or divorce.
Youth
   Depression, alcohol and drug use, aggressive
    and/or disruptive behavior in school.
         Suicide Prevention
Warning Signs
   Signs are often not verbal.
   Giving away beloved objects.
   Changes in eating or sleeping habits.
   Displaying a sense of calmness after a period
    of agitation.
  Practical Measures for
         Helping
Characteristic       Guideline
Unbearable pain      Reduce the pain
Frustrated needs     Fill needs
Seeking a solution   Provide alternatives
Hopelessness         Provide hope
Cognitive tunnel     Increase options
vision               Listen, involve others
Communication of
intention
      SUICIDE: A MULTI-FACTORIAL EVENT
                             Psychiatric Illness
                               Co-morbidity
          Personality                              Neurobiology
         Disorder/Traits
                                                               Impulsiveness
  Substance
  Use/Abuse
                                                                   Hopelessness

Severe Medical                    Suicide
    Illness                                                       Family History


Access To Weapons                                         Psychodynamics/
                                                      Psychological Vulnerability

                 Life Stressors           Suicidal
                                          Behavior
           PROTECTIVE FACTORS


 Children in the home, except among those with
  postpartum psychosis
 Pregnancy
 Deterrent religious beliefs
 Life satisfaction
 Reality testing ability
 Positive coping skills
 Positive social support
 Positive therapeutic relationship
  AFFECTIVE DISORDERS AND SUICIDE


High-Risk Profile:
    • Suicide occurs early in the course of illness
    • Psychic anxiety or panic symptoms
    • Moderate alcohol abuse
    • First episode of suicidality
    • Hospitalized for affective disorder secondary
      to suicidality
    • Risk for men is four times as high as for
      women except in bipolar disorder where
      women are equally at risk
    PERSONALITY DISORDERS
                AND SUICIDE
Borderline Personality Disorder
    Lifetime rate of suicide - 8.5%
    With alcohol problems -19%
    With alcohol problems and major affective disorder -38%
     (Stone 1993).
 A comorbid condition in over 30% of the suicides.
    Nearly 75% of patients with borderline personality
     disorder have made at least one suicide attempt in their
     lives.

Antisocial Personality disorder
    Suicide associated with narcissistic injury / impulsivity.
CHARACTERISTICS OF A SUICIDE PLAN


    Risk / Rescue Issues:
         Method

         Time

         Place

         Available means

         Arranging sequence of events
                                    Jacobs (1998)
 PSYCHIATRIC SYMPTOMS
ASSOCIATED WITH SUICIDE

Hopelessness
Impulsivity / Aggression
Anxiety
Command hallucinations
DETERMINE TREATMENT SETTING AND PLAN
    Attend to issue of patient’s safety.

    Assess treatment plan/setting/alliance.

    Somatic treatment modalities:

         ECT – used to treat acute suicidal behavior
         Benzodiazepines – may reduce risk by treating anxiety
         Antidepressants
         Lithium, Anticonvulsants
         Antipsychotics, recent study on Clozapine

    Psychotherapeutic intervention – widely viewed as helpful for suicidal
     patients, evidence is limited
    Provide education to patient and family.

    Monitor psychiatric status and response to treatment.

    Reassess for safety and suicide risk frequently.
      SOMATIC TREATMENTS
ECT               Evidence for short-term reduction of suicide,
                  but not long-term.


Benzodiazepines   May reduce risk by treating anxiety

Antidepressants   A mainstay treatment of suicidal patients with
                  depressive illness / symptoms. No conclusive
                  evidence of suicide reduction


Lithium and       Lithium has a demonstrated anti-suicide effect;
Anti-Convulsant   anticonvulsants do not

Antipsychotics    Evidence for Clozapine reducing suicidality in
                  schizophrenia and schizo-affective disorders
             Psychotherapy
Regardless of theoretical basis, key element is a
  positive and sustaining therapeutic relationship
Recommended (primarily from clinical consensus)
  To target issues
    Denial of symptoms

    Lack of insight

  To manage high risk symptoms
    Hopelessness

    Anxiety




Effective treatment in high risk diagnoses
    Depression

    Personality disorders (use of D.B.T.)
So when, therefore is self harm a
           problem?
            Define self harm




To do so, differentiate between self injury and
suicide and what about para-suicide?
Self Injury is the “ Deliberate damaging of
    Body Tissue without the conscious
    attempt to commit suicide” DSM IV TR




                          3 types
               Self harm
Any harmful act to
the self, or
omission, in which
the direct intent is
not to die Smith 2003
What then are the intents in self
   harm if it is not to die?
 To survive           To heal
 To communicate       To see blood
 To cope              To check I’m alive
 To feel better       To feel something
 To get help          I deserve it/punish
 Transfer emotional   self
 pain to physical     To punish others
 To show I am         To dissociate
 different            To control something
                      Its complex!!
Self Injury in psychiatry
The three types referred to are:-

Major self Mutilation

Stereotypic self mutilation

Superficial or moderate self
 mutilation Singular, Episodic, Repetitive
So where are we now?
           Classifying self harm
• 1st separate the pathological from the
  culturally sanctioned
          Classifying self harm

• Culturally sanctioned
  – Rituals Reflect community tradition, underscored
    by deep symbolism, link person to community,
    done to heal, express spiritual enlightenment,
    marks social order

• Practises
  – Little underlying meaning, may be fad or fashion,
    ornament, link to cultural group, medical-hygiene
    reasons
    What forms of self harm are
      culturally acceptable?
Neck stretching
Tattooing
Facial scarring
Crucifixion
Lip plates
Piercing
Flagellation
Starvation (fasting)
What forms of self harm then are
acceptable as fashions?
Tattooing
Piercing
Heroin?
Food
Body modification
Cosmetic surgery
Tongue splitting
So how can we assess severity
   and when to intervene?
Assessing risk and safety in self
        harm (SHARS)

Risk and safety should be
jointly considered based on
the 5 domains of self harm
Self Harm Assessment of Risk &
        Safety (SHARS)
About Judgement
Considering 5
domains
Professional, client
and carers opinion
Agreeing the
dialectical approach
       5 domains of self harm

• Directness
• Intent
• Potential lethality
• Repetitiveness/frequency
• Control/distress
   Self harm is still not yet a diagnosis
      in itself it is associated with:-
        •   Post Traumatic Stress Disorder
        •   Dissociative Identity disorder
        •   Eating disorders
        •   Character or personality traits (BPD)
        •   Substance abuse
        •   Clinical depression
        •   Psychosis (coping & bargaining)
1.1.2
So what are the common life experiences
        of those who self harm

•   Childhood physical or sexual abuse
•   Violence at home
•   Stormy parental relationships or broken homes
•   Loss of a parent through death or divorce
•   Lack of emotional warmth from
    parents/neglect


2.1.1
     So what are the common life
  experiences of those who self harm
 • Hypercritical fathers
 • A history of medical procedures or illnesses
   resulting in significant hospitalisation in childhood
 • Parental depression or substance abuse
 • Confinement in residential establishments
 • Work in the paramedical fields



2.1.2
    And what personality factors are
     associated with self harm by
              psychiatry
• Perfectionist tendencies
• Dislike of body shape
• Inability to tolerate intense
  feelings
• Inability to express emotional
  needs or experiences
• Prone to rapid mood swings

 2,2.1
         Other life events associated :-
        • Loss or abandonment
        • Social isolation, confinement
          or helplessness
        • Rejection
        • Failure
        • Anger
        • Guilt


3,1.1
 How many people self harm
1.4% lifetime       FE students 12%
incidence           Bulimia 40.5%
1,400 per 100,000   Anorexia 35%
population          MPD/DID 43%
Prisoners with PD
24%
Institutionalised
people 13.6%
           Dysphoria
People who self-injure tend to be
dysphoric -- experiencing a
depressed mood with a high degree
of irritability and sensitivity to
rejection and some underlying
tension -- even when not actively
hurting themselves Herpertz (1995)
  “Self harmers in psychiatric
 services are seen as attention
seeking, are disliked by staff and
    are seen as in control of
   manipulative behaviour”.
        Institutional wisdom perceives
         these “performances” as the
         maladaptive attention seeking
          malignancy of untreatable
                  psychopaths.



5,2.1
 Recent studies have suggested some alarming links between
 sexual abuse and the development of mental distress in later
 life, many of these links made by the self harmer themselves.
 Romme & Escher (1993) Boevink (1995) . In their study
 Diclemente et al (1991) found that amongst adolescents in a
 psychiatric service who reported childhood sexual abuse,
 83% cut themselves.

 This mental distress is believed to be a common factor which
 may manifest itself in many ways. The commonest of these ways
 is in some form of self harm.

7,4.1
        Self injury is quite an obvious response to abuse.

        The need to “get rid of the filth” is often reported by
        survivors of abuse who cut themselves to get rid of
        internalised feelings of shame

        Dianne Harrison (1994)




7,4.2
A systematic model for making sense
  of your experiences and working
       toward your recovery

                •   Turning points
                •   Identifying
                •   Exploring
                •   Understanding
                •   Resolving and moving
                    on
                Turning point
• A clear turning point which may be a result of
  an event or an individuals inspiration which
  results in you resolving to move on and
  determining to conquer barriers to you living
  your life. Topor et al (1998)
         Turning point activities
•   Give information
•   Inspire
•   Offer opportunities
•   Meet others
•   Have hope
•   Self help
•   Alternative belief systems DES, survival
•   Focus upon recovery not maintenance
    Values and perceptions
Write down, brainstorm all the different
ways you use to cope with life

As a group decide which are positive or
negative coping strategies
                     Negative
Positive




           Neutral
     Identifying your experiences
• Identifying and forming a clear view in your
  own language about what your experiences
  actually have been, how they have changed,
  when they happened and what were the effects
  upon you.
     Activities to identify your
            experiences
• Life history
        • write the three most important things
          in your life!!
• Interviewing
• Guiding
• Specific questions
   • When did it start
   • What was happening
   • Why
      Exploring your experiences
• Exploring in depth why and how you have
  become distressed including any things that
  trigger your current experiences, relating it
  beyond yourself to your social system such as
  the responses of mental health services. What
  has helped, what hinders, who helps.
      Activities to explore your
             experiences
• Explore in depth
• Look at dissociation
• Look at how you feel before and after
• How has it changed from 1st experience &
  why
• What has helped you, what hasn’t
• What are the real problems, is it self harm
  or other things or other people?
• Most recent experience
   Activities to explore your
          experiences
Others reactions
Triggers
Links to your feelings
   Understanding your experiences
• Links, are your voices/beliefs/harm related to
  anything in your life. Can you do anything
  about this, do you want to. What are your
  beliefs or frame of reference for your
  experience
   Activities to understand your
            experiences
• Create an ego document
• Get advice from others and alternate
  explanations
   • Medical, trauma, dissociation, addiction,
   • AHP axis, impulse control,
     learning,coping, survivor
• Be clear what you believe
• Get support
• Get direction (therapy)
  Resolving & moving on with your
            experiences
• What will help you, what coping mechanisms
  can you learn, can you resolve or accept any
  past issues in your life that are significant,
  where can you get the things that can help.
  What can mental health services do to help
  you, how can you develop alliances.
       Activities to move on
Where do you want to go
PCP
Deal with problems
Find yourself not guilty
Path
Essential lifestyle plans
Getting unstuck
Recovery planning (Coleman et al)
WRAP
Harm reduction
Finding for yourself less harmful ways of coping
How can you help people to hurt
       themselves less
Write down all the things you can think of
     Coping angry, frustrated,
            restless
Try something physical and violent, something not directed at a living thing:
Slash an empty plastic soda bottle or a piece of heavy cardboard or an old shirt or
sock.
Make a soft cloth doll to represent the things you are angry at. Cut and tear it
instead of yourself.
Flatten aluminum cans for recycling, seeing how fast you can go.
Hit a punching bag.
Use a pillow to hit a wall, pillow-fight style.
Rip up an old newspaper or phone book.
On a sketch or photo of yourself, mark in red ink what you want to do. Cut and tear
the picture.
Make Play-Doh or other clay models and cut or smash them.
Throw ice into the bathtub or against a brick wall hard enough to shatter it.
Break sticks.
These things work even better if you rant at the thing ur cutting/tearing/hitting.
Start out slowly, explaining why I you are hurt and angry, sometimes end up
swearing and crying and yelling. It helps a lot to vent like that.
Crank up the music and dance.
Clean your room (or your whole house).
Go for a walk/jog/run.
Stomp around in heavy shoes.
Play handball or tennis.
Coping sad, soft, melancholy,
   depressed, unhappy
Do something slow and soothing, like
taking a hot bath with bath oil or bubbles,
curling up under a quilt with hot cocoa and
a good book, looking after yourself
somehow. Do whatever makes you feel
taken care of and comforted. Light sweet-
smelling incense. Listen to soothing music.
Smooth body lotion into the parts or
yourself you want to hurt. Call a friend
and just talk about things that you like.
Make a tray of special treats and tuck
yourself into bed with it and watch TV or
read. Visit a friend.
  Helpful responses to self harm
• Show that you see and care about the person
• Show concern for the injuries themselves,
  the person may be ashamed, frightened and
  vulnerable at this time.
• Make it clear that its okay to talk about the
  self injury
• Convey respect for the persons efforts to
  survive
  Helpful responses to self harm
• Help them to make sense of their self injury
• Acknowledge how frightening it is to think
  of life without self injury.
• Encourage them to see the injury as a
  metaphor rather than as a problem in itself
• Help them to build up supportive networks
• Don’t see stopping the injury as the goal
• It takes time!
What do people who self harm
think that a service should do?
   Not confuse it with       Accept us
    suicide?                  Help us see future
   Help us look at life      Explore our feelings
   Accept our view           listen
   Look at our               Help find solutions
    relationships             Keep us safe
   Help us make
    decisions/choices
   Relieve distress
          What type of support
   Information about         Something different
    alternatives              Value us as people
   Publicity explaining      Non judgmental
    Self Harm                 Choices
   Specialised services      Talking treatments
   Opportunity for           Self help
    anonymity
   Someone to talk to
          What type of support
   Staff to realise they    Cares about its staff
    cant make it better      Offers supervision to
   Staff to be human         staff
   Help us in recovery      Professions to be
   Person centered           aware
   Be honest about          No labeling
    barriers
   Do with not for
What Is Workplace Violence?

Workplace violence is any physical
assault, threatening behavior, or verbal
abuse occurring in the work setting
           Definition
Workplace violence is any physical
assault, threatening behavior, or verbal
abuse occurring in the work setting
A workplace may be any location either
permanent or temporary where an
employee performs any work-related
duty
 Workplace Violence Includes:
Beatings        Threats or obscene
                phone calls
Stabbings
                Intimidation
Suicides
                Harassment of any
Shootings       nature
Rapes           Being followed,
Near-suicides   sworn or shouted at
Psychological
traumas
Types of Workplace Violence

Violence by    Violence by co-
strangers      workers
Violence by    Violence by
customers or   personal relations
clients
           Risk Factors
Contact with the public
Working late night or early morning
Exchanging money with the public
Working alone or in small numbers
Uncontrolled access to the workplace
Having a mobile workplace such as a
police cruiser, fire fighter or ambulance
service
    Methods Used For Hazard
     Prevention and Control
Could Include:
 Make high risk areas more visible
 Install more lighting
 Use drop safes, decrease cash on hand
 Post signs – stating limited cash
 Train employees on conflict resolution
 Need a system to respond
  Management Commitment
  and Employee Involvement
Complementary and essential
Management commitment provides the
motivating force to deal effectively with
workplace violence
Employee involvement and feedback-enable
workers to develop and express their
commitment to safety and health

				
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