Suicide & Nonsuicidal Self Injury

Psych - Exam 2

Suicidal Self-Injury (SSI)

• Intent: To die or cause life-threatening harm

• Lethality: Typically high (firearms, hanging, overdose)

• Methods: Firearms, hanging, jumping, poisoning, overdose

• Frequency: Often single or few attempts

• Affect Before: Hopelessness, despair, psychic pain, desire to escape

• Affect After: If survived: ambivalence, relief, or regret

• Associated Diagnosis: MDD, bipolar, schizophrenia, substance use, PTSD

• Relationship: NSSI is a significant risk factor for future suicide attempts

Nonsuicidal Self-Injury (NSSI)

• Intent: To cope with emotional distress; NOT to die

• Lethality: Typically low (superficial cutting, burning, scratching)

• Methods: Cutting, burning, carving, hitting, scratching, interfering with wound healing

• Frequency: Often repetitive; may become habitual

• Affect Before: Intense negative emotion, numbness, dissociation, anger

• Affect After: Temporary relief followed by shame/guilt

• Associated Diagnosis: BPD, PTSD, depression, eating disorders, anxiety

Suicidal Ideation

• Thinking about, considering, or planning suicide

Suicide Attempt

• Engaging in potentially self-injurious behavior with intent to die - may result in death, injury, or no injury

Suicide

• Death caused by self-directed injurious behavior with intent to die

Nonsicidal self-injury

• Intentional damage to one's own body tissue WITHOUT conscious suicidal intent and for purposes NOT socially/culturally sanctioned

Suicidal gesture

• Self-harm behavior that appears suicidal but has low lethality and low intent - Avoid this term as it minimizes the behavior and is no longer clinically recommended

Completed suicide

• Use "died by suicide" -"committed" implies criminality; "completed" implies
  accomplishment. Use person-first, destigmatizing language

Suicide Risk & Assessnent framework

• Identify risk factors (demographic, clinical, biological, cultural, social)

• Identify protective factors (reasons for living, social support, coping, treatment engagement)

• Screen using standardized tools (C-SSRS, PHQ-9, ASQ)

• Assess lethality (specificity, lethality of method, access to means)

• Determine level of risk (low, moderate, high, imminent)

• Intervene based on risk level (safety plan → crisis intervention → hospitalization)

Epidemiology of Suicide

• Overall ranking: 11th leading cause of death in the U.S.

• Annual deaths: 49,449 (2022) — approximately 1 death every 10.6 minutes

• Leading causes ages 10-14 & 20-34: 2nd leading cause

• Leading cause ages 35-44: 4th leading cause

• Highest rate by age: Adults 85+ have the highest age-specific rate

• Gender paradox: Males die by suicide 4x more than females; females attempt 3x more than males

• Race/ethnicicty: White males account for ~70% of deaths; American Indian/Alaska Native
  populations have the highest rates

• Primary method: Firearms account for ~55% of all suicide deaths

• Military/veterans: Active-duty and veteran suicide rates exceed civilian rates

• Healthcare workers: Nurses have higher suicide rates than the general population (Olfson et al., 2023)

• ED visits: 470,000 ED visits related to suicide attempts/ideation annually

Freud Theory

• Suicide = aggression turned inward against the self

• Assess for internalized anger, self-directed hostility

Menninger Theory

• Three wishes: to kill (revenge), to be killed (guilt), to die (hopelessness)

• Assess for each component in suicidal patients

Beck Theory

• Hopelessness is the central emotional factor- more predictive of suicide than depression alone

• Beck Hopelessness Scale; hopelessness is a stronger predictor than depressed mood

Shneidman Theory

• "Psychache" - unbearable psychological pain that the person feels can only be escaped through death

• Assess perceived psychological pain; validate suffering while offering alternative solutions

Joiner Interpersonal Theory

• Three factors:

1. Thwarted belongingness ("I am alone"),

2. Perceived burdensomeness ("I am a burden"),

3. Acquired capability (habituation to pain/fear of death through prior
   exposure) - All three together = highest risk

• Assess social connection, perceived burden on others, and
  history of self-harm/violence exposure

Diathesis Stress Model

• Predisposition (genetics, biology, personality) + stressor (loss,
  trauma) = suicidal crisis

• Explains why not all depressed individuals become suicidal

Cognitive Rigidity

• All-or-nothing thinking; inability to generate alternatives; tunnel
  vision; perfectionism

• "Suicide is a permanent solution to a temporary problem" - help
  patient see alternatives

Contagion/Werther Effect

• Suicide clusters following publicized suicides; adolescents especially vulnerable due to immature prefrontal cortex

• Media guidelines; school-based postvention protocols

Individual and Biological Risk Factors for Suicide

• Psychiatric ~90% of people who die by suicide have a diagnosable psychiatric disorder. MDD, bipolar disorder, schizophrenia, PTSD, anorexia nervosa (highest mortality of any psych disorder), BPD

• Substance Use: Lowers inhibitions, increases impulsivity, impairs judgment; alcohol intoxication present in~25–50% of suicides

• Prior Attempts: SINGLE STRONGEST PREDICTOR of future suicide - prior attempt increases risk 40x

• Biological: Familial tendency (higher concordance in monozygotic twins); low serotonin levels in brainstem; lowered SKA2 gene expression; HPA axis dysregulation

• Medical: Chronic pain, chronic illness (cancer, HIV, MS, TBI), recent diagnosis of terminal illness

• Cognitive: Hopelessness, rigid thinking, perfectionism, poor problem-solving

• Behavioral: Impulsivity, aggression, recent discharge from psychiatric facility (72 hours–30 days = highest risk window), giving away possessions, finalizing affairs

Relationship, Community, Societal, Cultural Risk Factors for Suicide

• Relationship: IPV/abuse, childhood maltreatment (ACEs), bullying, family conflict, family history of suicide, recent relationship loss, social isolation

• Demographic: Male gender (4x completion rate); older adults (85+ highest rate); White males (~70% of deaths); AI/AN populations highest rate by race/ethnicity

• Marital: Divorced > widowed > single > married; married with children = lowest risk

• Professional: Healthcare workers (including nurses), military/veterans, first responders, construction workers

• Access to Means: Firearms, large quantities of medication, high-rise buildings - means restriction is one of the most effective prevention strategies

• Community: Barriers to mental health care, suicide clusters/contagion, media glorification

• Cultural: African American: male > female; religion + extended family = protective; Hispanic: Catholic faith + familismo = protective; Asian American: interdependence culture - suicide seen as dishonor; LGBTQ+ youth: 4x higher risk due to bullying, rejection, discrimination

• Social Media: Cyberbullying, social comparison, exposure to pro-suicide content; BUT also: crisis resources, AI detection, awareness campaigns

Social Media Factor : Social Media & Suicide: Double-Edged Sword

Protective Factors

• Crisis resource sharing (988 Lifeline)

• AI/algorithm-based flagging of at-risk users

• Peer support communities

• Awareness campaigns (#BeThe1To)

• Reducing stigma through lived- experience advocates

Harmful Factors

• Exposure to pro-suicide content

• Cyberbullying & social comparison

• Contagion effect from detailed reporting

• Misinformation about mental health

• Glorification or normalization of suicide

LGBTQ+ Youth & Suicide Risk

• Suicidal ideation 41% of LGBTQ+ youth seriously considered suicide (Trevor Project, 2023)

• Suicide attempts 14% of LGBTQ+ youth attempted suicide in the past year

• Transgender/nonbinary youth At HIGHEST risk within the LGBTQ+ community

• Risk factors
  — Family rejection, bullying/harassment, conversion therapy exposure, homelessness, lack of affirming care

• Protective factors
  — Family acceptance (reduces risk by ~50%), GSAs in schools, affirming healthcare, connection to LGBTQ+
  community

Biological Factors for Suicide

• HPA axis dysregulation - chronic stress → elevated cortisol → neuronal damage

• Neuroimaging findings - decreased prefrontal cortex activity (impaired decision-making,
  impulse control); hyperactive amygdala (emotional dysregulation)

• Cholesterol - some studies link low cholesterol to increased suicide risk (controversial but testable)

• Inflammatory markers - elevated CRP and IL-6 associated with suicidal behavior

• Epigenetics - adverse childhood experiences can alter gene expression affecting stress
  response systems

Comorbidity and Suicide

• ~90% of people who die by suicide have a diagnosable psychiatric disorder (based
  on psychological autopsy studies)

• ~46% had a documented/diagnosed mental illness at the time of death

• This gap represents missed opportunities for identification and intervention

Comorbidity

• Major Depressive Disorder: 20x increased risk

• Bipolar Disorder: 20-30x increased risk; mixed episodes most dangerous

• Schizophrenia: ~5% lifetime risk; command hallucinations increase urgency

• Anorexia Nervosa: Highest mortality of ANY psychiatric disorder

• Borderline Personality Disorder: ~10% lifetime risk; chronic suicidality common

• PTSD: Particularly combat-related and sexual trauma

• Substance Use Disorders: Present in 25-50% of suicides; alcohol is most common

• Anxiety Disorders: Comorbid anxiety + depression = synergistic risk

Suicide Assessment: Clinical Interview

• Ideation: "Are you having thoughts of killing yourself?" "Are you thinking about suicide?"

• Plan: "Do you have a plan for how you would do it?"

• Intent: "Do you intend to carry out this plan?"

• Means: "Do you have access to [method]?" (firearms, medications, etc.)

• Timeline: "Have you thought about when you would do this?"

• Prior Attempts: "Have you ever tried to hurt yourself or end your life before?"

• Protective Factors: "What keeps you going? Who would you call if you were in crisis?"

• Lethality: Specificity of plan + lethality of method + access to means = risk level

Columbia-Suicide Severity Rating Scale (C-SSRS)

• Population: All ages, all settings

• Description: Gold standard; screens ideation AND behavior on a severity scale

• Key Features: Escalating questions from wish to be dead → active ideation with plan and
  intent; differentiates ideation from behavior

PHQ-9 Item 9

• Population: Adults, primary care

• Description: "Thoughts that you would be better off dead or of hurting yourself"

• Key Features: Score >0 triggers full suicide risk assessment; embedded in depression screening

ASQ (Ask Suicide-Screening Questions)

• Population: Medical settings, ages 10+

• Description: 4 brief questions; <2 minutes

• Key Features: Validated in EDs and inpatient medical/surgical units; appropriate for non-psychiatric settings

SAD PERSONS Scale

• Population: Adults

• Description: Mnemonic scoring: Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social supports lacking, Organized plan, No spouse, Sickness

• Key Features: Quick risk stratification; useful for clinical reasoning

SBQ-R (Suicide Behaviors Questionnaire-Revised)

• Population: Adults

• Description: 4-item self-report

• Key Features: Total score ≥7 = significant risk

Acute Warning Signs Requiring IMMEDIATE Intervention

Verbal
• "I want to die" / "I want to kill myself"
• "Everyone would be better off without me" (perceived burdensomeness — Joiner)
• "I feel trapped" / "There's no way out"
• "I can't take the pain anymore" (psychache - Shneidman)

Behavioral
• Giving away meaningful possessions
• Sudden brightening after prolonged depression
• Researching methods, acquiring means
• Withdrawing from all social contact
• Writing suicide notes, updating will
• Increased substance use
• Extreme mood swings

Emotional
• Hopelessness (Beck - strongest predictor)
• Agitation, rage, or desire for revenge
• Feeling like a burden
• Humiliation or shame

Assessing Lethality of a Plan

• Specificity:

— How detailed is the plan?
— Vague ("I'd probably take pills") vs. Specific ("I'll use my husband's gun in the garage at
midnight")

• Lethality of Method

— How likely is the method to result in death?
— Hard methods (high lethality): Firearms (~90% fatality), hanging, jumping

• Access to Means

— Does the patient have the means readily available?
— Gun in the home, stockpiled medications, bridge nearby

• Proximity to Help

— Will anyone find them in time?

— Home alone vs. public location

• Preparation

— Has the patient made preparations?

— Writing notes, giving away possessions, choosing a time when alone

High-Risk Transitions-The Lethal Gap. The Most Dangerous Time Periods

First 72 hours of psychiatric admission

• Risk: Patient may still be acutely suicidal; medications not yet effective; unfamiliar environment

• Nurse Action: Continuous assessment; 1:1 if indicated; orient to environment; establish therapeutic relationship

Privilege changes (moving from1:1 to Q15)

• Risk: May perceive this as "clearance" to attempt

• Nurse Action: Reassess before every privilege change; document rationale

First 7 days after discharge

• Risk: Return to stressors without 24/7 support

• Nurse Action: Schedule follow-up within 72 hours of discharge; caring contacts (phone call within 24 hours)

First 30 days after discharge

• Risk: HIGHEST RISK PERIOD for post-discharge suicide

• Nurse Action: Ensure outpatient appointments are scheduled; confirm means restriction; provide 988 number; family education

Transitions between units/facilities

• Risk: Communication gaps; loss of therapeutic relationship

• Nurse Action: Warm handoff; communicate risk level clearly; transfer safety plan

Risk Level Determination

Low

• Vague ideation, no plan, no intent, identifiable protective factors

• Safety plan; outpatient referral; means restriction counseling; follow-up within 1 week

Moderate

• Ideation with some plan elements, ambivalent intent, limited protective factors

• Safety plan; urgent psychiatric referral; consider voluntary hospitalization; means restriction; follow-up within 48 hours

High

• Specific plan + lethal method + available means + stated intent

• 1:1 observation; DO NOT leave alone; involuntary hospitalization if patient refuses voluntary; means restriction IMMEDIATELY

Imminent

• Active attempt or interrupted attempt

• Medical stabilization → psychiatric emergency evaluation → inpatient admission

Suicide Survivors

• Those within the social circle of a person who has died by suicide constitute the
  largest group of individuals impacted by mental health consequences associated
  with suicide.

• Children who have lost a parent to suicide are four times more likely to die by
  suicide themselves

• Adults who have experienced bereavement due to suicide exhibit a higher
  likelihood of attempting suicide compared to those who have experienced
  bereavement due to sudden natural causes.

• Healthcare professionals who provided care to a patient who died by suicide within
  a treatment facility often experience significant trauma.

• Each suicide is estimated to intimately affect 135 people (Cerel et al., 2019) —
  previously estimated at 6; updated research shows much broader impact

• Complicated grief/Prolonged Grief Disorder risk is elevated in suicide bereavement

• Postvention IS prevention — supporting survivors reduces their own suicide risk

• The American Foundation for Suicide Prevention (AFSP) provides survivor support groups

• Healthcare professionals: Approximately 1 in 2 psychiatrists and 1 in 5 psychologists
  will lose a patient to suicide during their career*

Nurse Self Assessment for Suicide

Fear

• May avoid asking about suicide; may prematurely discharge

• Seek supervision; use standardized tools to guide assessment

Anger

• "Why would they do this to their family?" - judgmental care

• Recognize as normal; process with team; reframe through illness model

Grief

• Difficulty maintaining professional boundaries; over-identification

• Debrief with team; access EAP; consider personal therapy

Helplessness

• “Nothing I do will make a difference" - may give up on patient

• Recognize as countertransference; seek peer support; focus on what IS within your control

Condemnation

• Moral judgment → punitive or dismissive care

• Examine personal beliefs; suicide is a symptom of illness, not a moral failing

Relief (after pt discharge)

• May rush discharge planning to reduce own anxiety

• Recognize this; ensure discharge is clinically appropriate, not anxiety-driven

Protective Factors Against Suicide

• Individual: Effective coping skills, problem-solving ability, reasons for living, future orientation, resilience, sense of purpose

• Clinical: Active engagement in treatment, medication adherence, therapeutic relationship with provider

• Relationship: Strong family connections, supportive friendships, marriage (especially with children), feeling of belonging

• Community: Access to mental health care, school connectedness, employment, housing stability

• Cultural/Spiritual: Religious beliefs opposing suicide, cultural values emphasizing family/community, spiritual practices

• Environmental: Restricted access to lethal means, safe media reportin

Stanley & Brown Safety Planning Intervention 6-Step Safety Plan

1. Warning Signs

• Personal triggers and signs that a crisis is developing

• "When I start thinking no one cares

2. Internal Coping Strategies

• Things the patient can do ALONE to distract from suicidal thoughts

• Deep breathing, physical activity, journaling, ice cube technique

3. People who provide distraction

• Social contacts and social settings that provide distraction (NOT to disclose crisis)

• "Call my friend Marcus," "Go to the gym

4. People to Ask for Help

• Family or friends the patient can tell they are in crisis

• "Call my sister Angela

5. Professionals and Agencies

• Crisis resources

• 988 Suicide & Crisis Lifeline, therapist's number, local E

6. Making the Environment Safe

• Means restriction

• Removing firearms, giving medications to trusted person, removing sharps

Environmental Safety Guidelines

• Ligature risks: Identify and remove or mitigate ALL potential ligature points: door hinges, shower rods, towel hooks, IV poles, call light cords, bed frames, window hardware

• Contraband: Search belongings in patient's presence; remove sharps, belts, cords, shoelaces, drawstrings, razors, glass items, plastic bags

• Room design: Breakaway shower rods, tamper-proof hardware, recessed sprinklers, shatterproof glass/mirrors, anti-ligature door handles

• Bathroom safety: Doors must open outward or be removable; no locks; collapsible shower rods

• Common area: Lock access to non-patient areas (utility rooms, kitchens, stairwells)

• Visitor management: Search visitor belongings; do not allow visitors to leave items without inspection

• Utensils: Plastic utensils ONLY; count before and after meals; account for ALL items

• Medication safety: Directly observe medication ingestion; check oral cavity; monitor for hoarding

• Observation: Per facility policy: continuous 1:1, every 15 minutes, or every 30 minutes

• Transition safety: Highest risk: within 72 hours of admission and within 30 days of discharge

Suicide Precaution: Level of Observation

Continous 1:1

• Criteria: Imminent risk; active suicidal ideation with plan and intent; recent attempt

• Documentations: Arm's length; document location, behavior, mood, statements every 15 minutes minimum

Close Observation (Q15 minutes)

• Criteria: High risk; suicidal ideation without imminent plan

• Documentations: Document exact location and activity at each check; use irregular timing (not predictable)

General observation (Q30 minutes)

• Criteria: Moderate risk; risk factors present but no active ideation

• Documentations: Document as above; ensure patient attends all meals and groups

Application of Nursing Process Diagnosis

• Risk for Suicide (PRIORITY)

• Risk for Self-Directed Violence

• Hopelessness

• Ineffective Coping

• Social Isolation

• Disturbed Sleep Pattern

• Self-Neglect

• Chronic Low Self-Esteem

  
  
  

Implementation for Suicide Prevention

• Safety: 1:1 observation; environmental safety; means restriction; medication safety

• Therapeutic Communication: Active listening; validate pain WITHOUT reinforcing suicidal intent; convey hope; use open-ended questions; sit with the patient - presence matters

• Pharmacological: Administer prescribed medications; monitor for therapeutic and adverse effects; educate about onset of action (2–4 weeks for antidepressants); monitor
  closely during first 2 weeks of antidepressant initiation (Black Box Warning period)

• Psychoeducation: Teach coping skills; crisis resources (988 Lifeline); safety plan review; means restriction education for family

• Milieu Therapy: Structured, safe environment; group participation; therapeutic activities; peer interaction

• Documentation: Document: risk assessment findings, precaution level, interventions, patient response, patient's own words (direct quotes), transitions of care communication

• Interprofessional: Communicate risk level at every shift change and transition of care; involve psychiatry, social work, chaplaincy, pharmacy

Documentation Requirements for Suicide

• Risk assessment findings: C-SSRS results, PHQ-9 score, identified risk and protective factors

• Patient's own words: Direct quotes: "Patient states, 'I don't want to be here anymore.'"

• Observation level: "Continuous 1:1 observation initiated per MD order”

• Environmental safety: "Room safety check completed; all contraband removed; belongings searched in patient's presence"

• Interventions: Safety plan developed, medications administered, therapeutic communication provided

• Patient response: "Patient able to identify 2 coping strategies. Denies current suicidal ideation.

• Transitions of care: Handoff communication to oncoming nurse, transfer communication to receiving unit

• Discharge planning: Follow-up appointment date/time, safety plan reviewed, crisis resources provided, means restriction confirmed, family education completed

Therapeutic Communication (DO’s)

• “Are you thinking about killing yourself?" — direct, non-euphemistic

• “I'm glad you told me. That took courage."

• "I want to help keep you safe."

• “It sounds like you're in a lot of pain right now." (Validate)

• “Tell me more about what you're experiencing."

• "What has kept you going until now?" (Identify protective factors)

• "Let's work on a plan together to keep you safe."

• Sit with the patient. Silence is therapeutic.

• Use their words: "You said you feel like a burden — tell me more about that."

• Document direct quotes in the medical record

Therapeutic Communication (DO NOT’s)

• “You're not thinking about doing something stupid, are you?"

• "You have so much to live for."

• "Think about how this would hurt your family."

• "You don't really want to die." (Dismissive)

• "Just think positive”

• "Promise me you won't hurt yourself." (No-suicide contract)

• "If you were really suicidal, you would have done it already."

• Rush to fill silence with advice or platitudes

• Change the subject or redirect away from suicidal content

• Document only "patient denies SI" without exploration

Evaluation

• Evaluation is ONGOING-not a one-time event

• Every shift: Current ideation (reassess using C-SSRS); mood; behavior; medication effects; participation in treatment

• Before privilege changes: Is patient safe for less restrictive observation? Assess ideation, engagement, protective factors

• Before discharge: Complete safety plan; confirm follow-up appointment
  (within 72 hours); means restriction confirmed; family educated; crisis resources provided

• Post-discharge: First 30 days after discharge = highest risk period.
  Caring contacts (phone calls, texts) reduce suicide risk. Schedule follow-up within 72 hours

Outcomes SMART Goal for Suicide Prevention

Immediate (24 hrs)

• Patient will remain safe from self-harm with 1:1 observation and verbalize intent to remain safe

Short-term (48–72 hrs)

• Patient will identify 2 personal warning signs and 2 coping strategies to use during crisis

Intermediate (1–2 weeks)

• Patient will complete a written safety plan and identify 3 persons to contact in crisis

Discharge

• Patient will verbalize understanding of medications, follow-up plan, and crisis resources (988)

Post-discharge (30 days)

• Patient will attend scheduled outpatient appointment and demonstrate use of safety plan

Psychopharmacology for Suicidal Patients

SSRIs (fluoxetine, sertraline,escitalopram)

• First-line for comorbid depression; onset 2–4 weeks

• FDA Black Box Warning: Increased suicidality in ages ≤24 during first 1–2 months and dose changes; monitor weekly × 4 weeks → biweekly × 4 weeks → monthly

Lithium

• Specific anti-suicidal properties independent of mood stabilization; reduces suicide risk by ~60% in bipolar patients

• Therapeutic: 0.6–1.2 mEq/L; hydration; sodium; avoid NSAIDs; renal/thyroid monitoring

Clozapine

• ONLY antipsychotic FDA- approved for reducing suicidal behavior in schizophrenia/schizoaffective disorder

• Requires REMS program; weekly→biweekly→monthly ANC monitoring; risk of agranulocytosis; myocarditis; metabolic syndrom

Esketamine (Spravato)

• Intranasal; FDA-approved for treatment-resistant depression; rapid onset (hours, not weeks)

• REMS program; administer in certified healthcare setting ONLY; monitor for 2 hours post-dose; dissociation, sedation, increased BP

Benzodiazepines

• Short-term for acute agitation/anxiety

• Use with extreme caution in suicidal patients - disinhibition may INCREASE risk; monitor for respiratory depression

ECT

• Most rapid reduction in acute suicidal ideation;

• 6–12 sessions Pre-procedure: NPO, informed consent, remove dentures; Post: reorient, side-lying, monitor VS

Evidence-Based Treatment Modalities

Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP)

• Targets suicidal cognitions; develops safety plans; builds coping skills. Strong evidence

Dialectical Behavior Therapy (DBT)

• Originally developed for BPD with chronic suicidality; distress tolerance, emotion regulation, mindfulness, interpersonal effectiveness

• Strong evidence, especially for chronic suicidality

Collaborative Assessment and Management of Suicidality (CAMS)

• Therapeutic framework where patient and clinician collaboratively assess and treat suicidal drivers; Growing evidence

Safety Planning Intervention

• Stanley & Brown 6-step model; Strong evidence

Caring Contacts

• Post-discharge phone calls, texts, or letters expressing caring and concern

• Reduces suicide deaths and attempts

Means Restriction Counseling

• Educating families about securing firearms and medications

• One of the most effective prevention strategies

Patient-Centered Care Prevention Levels

Primary Level

• Prevention BEFORE crisis

• Gatekeeper training (QPR), school-based programs, means restriction legislation,
  stigma reduction campaigns, screening in primary care

Secondary Level

• Intervention DURING crisis

• Crisis intervention, 988 Lifeline, safety planning, hospitalization, 1:1 observation, pharmacotherapy

Tertiary Level

• Support AFTER suicide attempt or death

• Postvention programs, survivor support groups (AFSP), staff debriefing, rehabilitation, long-term case management

Lifespan Considerations

Children (5–12)

• Risk Factors: Bullying, family discord, ACEs, NSSI exposure

• May not verbalize suicidal intent clearly; use age- appropriate screening (ASQ); assess family environment

Adolescents (13–18)

• LGBTQ+ identity, social media, cyberbullying, impulsivity (immature prefrontal cortex), contagion/clusters, substance experimentation

• ASQ or C-SSRS; ask about online activity; means restriction (especially firearms); involve family cautiously (consider confidentiality)

Young Adult (19-34)

• Relationship loss, academic/career stress, substance use, 2nd leading cause of death in this age group

• PHQ-9 + C-SSRS; screen in primary care, college health settings

Middle Adults (35–64)

• Financial stress, divorce, chronic illness, job loss, midlife crisis, substance use

• Screen at routine medical visits; assess for comorbid depression and substance use

Older Adults (65+)

• HIGHEST completion rates; social isolation, bereavement, chronic illness, chronic pain, retirement, cognitive decline, access to firearms

• Older adults are more likely to use lethal methods AND less likely to give warning signs; PHQ-9 in every primary care visit; assess for self-neglect as passive suicidality; Adults 85+ have the highest rate

Veterans

• Combat trauma, TBI, PTSD, moral injury, access to firearms, transition to civilian life

• 988 → Press 1 for Veterans Crisis Line; assess military history in EVERY patient

NSSI Epidemiology for Self Harm

• Most common in adolescents and young adults; peak onset between 12–24 years.

• Lifetime prevalence estimates in adolescents: ~15–20%

• Higher rates in females, though both genders engage in NSSI

• Increasingly recognized in diverse cultural groups'

• Dialectical Behavior Therapy (DBT) as the GOLD STANDARD treatment for NSSI,
  particularly in the context of BPD.

NSSI Assessment

1. Intent (Priority)

• Differentiate NSSI from SSI; always assess for suicidal ideation

• "When you hurt yourself, are you trying to end your life, or are you trying to manage how you feel?" / "Have you ever thought about wanting to die?"

2. Behavior History

• Methods, frequency, onset age, duration, escalation pattern

• "How long have you been hurting yourself?" / "How often?" / "Has it gotten worse or changed recently?"

3. Function

• Emotional triggers; antecedent feelings; feelings during/after

• "What are you usually feeling right before you hurt yourself?" / "How do you feel during?" / "How do you feel right after?"

4. Physical Assessment

• Skin exam: scars in multiple stages of healing; common locations; severity

• Forearms, thighs, abdomen, chest; parallel linear scars; concealment behaviors (long sleeves in warm weather)

5. Medical Needs

• Wound depth, infection, tissue damage, need for sutures/medical treatment

• Document wound characteristics objectively; treat medically as indicated

6. Comorbidity

• Co-occurring psychiatric diagnoses

• Screen for BPD, MDD, PTSD, eating disorders, substance use

7. Social Context

• Solo vs. peer group; online involvement; disclosure history

• "Have you told anyone else about this?" / "Are you part of any online groups related to self-harm?"

Application of the Nursing Process - NSSI Assessment

Self-Mutilation

• R/T: Ineffective coping, emotion dysregulation, childhood trauma

• AEB: Active self-harm wounds; patient report

Risk of Self-Mutilation

• R/T: History of NSSI, psychiatric comorbidity, current stressors

• AEB: History of self-harm; presence of risk factors

Ineffective Coping

• R/T: Underdeveloped emotion regulation skills; invalidating environment

• AEB: Use of self-harm as primary coping mechanism

Chronic Low Self-Esteem

• R/T: Negative self-evaluation, self- criticism, shame

• AEB: Self-deprecating statements; self-punishment function of NSSI

Impaired Skin Integrity

• R/T: Self-inflicted tissue damage

• AEB: Wounds, scars in multiple stages of healing

Social Isolation

• R/T: Shame, concealment, withdrawal from relationships

• AEB: Patient reports hiding behavior; loss of social connections

Outcome Timeframe for Self Harm

• Short-term (24–72 hrs): Patient will remain free from self-harm during hospitalization

• Short-term (24–72 hrs): Patient will identify 3 personal triggers for NSSI

• Short-term (48–72 hrs): Patient will demonstrate use of ≥2 alternative coping strategies (e.g., TIPP skills, journaling)

• Short-term (by discharge): Patient will verbalize the connection between emotional distress and NSSI

• Long-term (30 days): Patient will report decreased frequency of NSSI episodes

• Long-term (30 days): Patient will identify 2 trusted support persons and attend scheduled outpatient therapy

• Long-term (90 days): Patient will consistently use alternative coping strategies before engaging in self-harm

Interventions Framework

1. Collaborative Safety

• Intervention: Establish safety; environmental precautions; collaborative safety agreement (NOT punitive contract)

• Action: Remove sharps; assess for concealed items; patient participates in developing the agreement

2. Build Self Esteem

• Intervention: Strengths-based approach; positive reinforcement for healthy behaviors

• Action: Identify patient's strengths; reinforce coping attempts; therapeutic relationship as foundation

3. Explore Function

• Intervention: Discover the PURPOSE of NSSI (affect regulation? Self- punishment? Anti-dissociation?)

• Action: "What does this do for you?" Function drives the intervention plan

4. Develop Self-Control

• Intervention: Teach impulse delay strategies; mindfulness

• Action: "Ride the wave" — urges peak and pass; delay 15 minutes → reassess

5. Replace with Adaptive Coping

• Intervention: Substitute NSSI with evidence-based alternatives

• Action: DBT TIPP: Temperature, Intense exercise, Paced breathing, Progressive relaxation. Sensory: ice cube, red marker, rubber band, sour candy

6. Maintenance & Relapse Prevention

• Intervention: Written plan; follow-up; family education; crisis resources

• Action: Identify early warning signs; plan for urges; outpatient appointment before discharge

Dialectical Behavioral Therapy (DBT) Modules

Mindfulness

• Present-moment awareness

• Replaces dissociation; grounds patient

Distress Tolerance

• Surviving crisis WITHOUT self-harm

• TIPP skills; ice cube; radical acceptance

Emotion Regulation

• Identifying, naming, modulating emotions

• Addresses alexithymia and emotional flooding

Interpersonal Effectiveness

• Communicating needs effectively

• Replaces NSSI as communication of distress

Implementations/Action for Diagnosis

• Wound Care: Matter-of-fact clinical neutrality. NOT punitive, NOT overly nurturing.
  Document objectively: location, size, depth, treatment.

• Therapeutic Alliance: Nonjudgmental stance; consistent boundaries; genuine empathy

• Coping Skills Teaching: DBT TIPP; sensory substitution; journaling; physical exercise; crisis plan development

• Reflective Dialogue: Help patient connect emotions → triggers → NSSI → consequences; build emotional vocabulary

• Medication Administration: Administer prescribed medications (SSRIs, mood stabilizers as indicated); monitor for side effects; educate

• Interprofessional Collaboration: Communicate assessment findings to psychiatrist, therapist, social worker; coordinate care plan

Implementation: RN Versus UAP Delegation

RN

• Suicide/NSSI assessment

• Safety plan development

• Patient/family education

• Medication administration

• Evaluation of outcomes

UAP

• 1:1 observation (assigned by RN)

• Report behavioral observations to RN

• Environmental safety checks

• Accompany patient to activities

• CANNOT assess, evaluate, diagnose, or teach

Interdisciplinary Implementation

Implementation across the interdisciplinary team. Nursing implementation doesn't happen in isolation:

• RN role: Assessment, medication administration, safety monitoring, therapeutic communication, wound care, patient education, documentation

• UAP/Technician role: 1:1 observation (if assigned), reporting behavioral observations to RN, environmental safety checks- UAPs do NOT assess, evaluate, or develop safety plans

• Psychiatrist/APRN: Medication management, diagnostic clarification, treatment planning

• Psychologist/Therapist: DBT, CBT, individual and group therapy

• Social Worker: Discharge planning, family involvement, community resources, school/workplace communication

Evaluation Indicators

Positive Inidcators

• Decreased frequency/severity of NSSI

• Uses alternative coping before urges peak

• Verbalizes emotions and triggers

• Engages in treatment

• No suicidal ideation

• Identifies support persons and resources

Concerning Indicators

• Increased frequency, new methods, deeper wounds

• Unable/unwilling to use alternatives

• Continued dissociation, alexithymia

• Refuses therapy, isolates, medication non-adherence

• New or increasing SI → ESCALATE IMMEDIATELY

• No supports; no follow-up plan
  
  

Evaluation and Evaluation Criteria

Frequency of NSSI

• Progress: Decreasing episodes; longer intervals between episodes

• Concern: Increasing frequency; new methods

Severity of NSSI

• Superficial; requiring less medical attention

• Deeper, requiring sutures; involving new body areas

Coping skill use

• Patient uses alternatives before, instead of, or after urges

• Patient unable or unwilling to try alternatives

Emotional Awarness

• Can name emotions; connects feelings to triggers

• Continued alexithymia; dissociation

Suicidal Ideation

• Absent or decreasing

• New or increasing — ESCALATE IMMEDIATELY

Treatment Engagement

• Attends therapy, takes medications, participates in groups

• Refusing treatment, isolating, not attending

Discharge Readiness

• Safety plan completed; outpatient appointment confirmed; support persons identified; means restriction verified

• No plan; no follow-up; ongoing acute risk

Suicide Mind

• What makes th e decis ion

• To flick the switch

• To end one’s life

• For t he sake of it

• Troubled , debts

• Bullied at s chool

• Fork in the road

• To let death rule

• Mums, dads

• Dau ghters and sons

• What ever affect s them

• They jus t can 't out run

• Sadnes s and t ears

• By all left behind

• Will they ever understan d