Chapter 25: Suicide and Nonsuicidal Self-Injury

Suicidal Ideation

Thinking about killing oneself.

Suicide Attempt

Potentially self-injurious behavior with intent to die.

Suicide

Intentional act of killing oneself.

Nonsuicidal Self-Injury

• Intentional damage to one’s body tissue without conscious suicidal intent.

• Not culturally or socially sanctioned.

Comorbidity

• Many people who die by suicide have a diagnosed mental illness.

• Common disorders associated with suicide:

  • Depressive disorder.

  • Substance use disorder.

  • Psychosis.

  • Anxiety disorders.

  • Personality disorders.

  • Eating disorders.

  • Trauma-related disorders.

Risk Factors - Biological

• Family history of suicide.

• Higher risk among identical twins.

• Genetic and epigenetic influences.

• Low serotonin levels.

Risk Factors - Cognitive

• Freud

• Menninger

• Aaton Beck

Freud

Aggression turned inward

Menninger

• Wish to kill.

• Wish to be killed.

• Wish to die.

Aaron Beck

Hopelessness is central.

Risk Factors - Enviormental

• Family conflict.

• Low parental monitoring.

• Suicide clusters.

• Copycat suicide.

• Adolescents are high risk due to immature prefrontal cortex.

• Immature prefrontal cortex affects

Immature prefrontal cortex affects

• Judgment.

• Frustration tolerance.

• Impulse control.

Risk Factors - Cultural

• Religious beliefs.

• Family values.

• Sexual orientation.

• Gender identity.

• Bullying.

• Attitudes toward death.

Risk Factors: Social Factors

• Relationship problems.

• Recent or imminent crisis.

• Substance use.

• Health problems.

• Financial problems.

• Legal problems.

• Loss of housing.

• Family history of suicide.

• Family history of child maltreatment.

• Previous attempts.

• Mental disorders.

• Alcohol or substance use.

• Hopelessness.

• Impulsivity.

• Aggression.

Suicide Assessment: Verbal Clues

Overt statements:

• “I want to die.”

• “I’m going to kill myself.”

• “I can’t go on.”

Covert statements:

• “Everyone would be better off without me.”

• “I won’t be a problem much longer.”

• “There’s no point anymore.”

Suicide Assessment: Nonverbal Clues

• Giving away possessions.

• Sudden calm after depression.

• Withdrawal.

• Risk-taking.

• Saying goodbye.

• Acquiring means.

Suicide Assessment: Questions to ask

• “Have you ever felt that life was not worth living?”

• “Have you been thinking about death recently?”

• “Have you thought about suicide?”

• “Have you ever attempted suicide?”

• “Do you have a plan?”

• “What is your plan?”

• “Do you have access to the means?”

• “What has stopped you from acting on these thoughts?”

Lethality Assessment

• Specificity of plan.

• Lethality of method.

• Access to means.

• Timing.

• Intent.

• Past attempts.

• Substance use.

• Impulsivity.

• Supports.

• Protective factors.

Nurse Self-Assessment: Nurses may feel

• Fear.

• Grief.

• Anger.

• Puzzlement.

• Condemnation.

• Helplessness.

Nurse Self-Assessment: Important nursing actions

• Acknowledge feelings.

• Discuss with team.

• Avoid countertransference.

• Stay therapeutic and nonjudgmental.

Hospital Suicide Precautions

• Maintain observation according to risk level.

• Remove dangerous items.

• Search belongings according to policy.

• Ensure safe environment.

• Use safety trays if ordered.

• Monitor bathroom use as required.

• Document behavior and statements.

• Communicate risk during handoff.

• Do not leave high-risk patient alone.

Communication precautions

• Ask directly about suicide.

• Stay calm.

• Be nonjudgmental.

• Do not promise secrecy.

• Encourage expression of feelings.

• Focus on safety and hope.

• Avoid minimizing.

Community Interventions

• Create safety plan.

• Remove or secure lethal means.

• Identify crisis contacts.

• Encourage emergency care if risk is imminent.

• Involve support people when appropriate.

• Refer to therapy and psychiatric care.

Treatment - Biological

• Treat underlying disorder.

• Antidepressants, mood stabilizers, or antipsychotics may be used depending on diagnosis.

• Monitor closely when starting antidepressants, especially in youth.

Treatment - Psychological

• CBT.

• DBT.

• Crisis intervention.

• Safety planning.

• Family therapy when appropriate.