Chapter25/Exam2

Core Definitions of Suicidal Behavior

• Suicidal Ideation: This refers to the cognitive process of thinking about killing oneself. It can range from fleeting thoughts to a preoccupation with self-destruction.

• Suicide Attempt: This involves engaging in behavior that is potentially self-injurious where the individual performs the act with the specific intention of causing their own death.

• Suicide: This is defined as the intentional act of killing oneself by any means available.

• Nonsuicidal Self-Injury (NSSI): This is characterized by the intentional damage to one’s own body tissue. Importantly, this occurs without conscious suicidal intent and is performed for purposes that are not socially or culturally sanctioned.

Comorbidity and Statistical Data

• Diagnosed Mental Illness: Approximately $46\%$ of individuals who die by suicide have a formally diagnosed mental illness at the time of their death.

• Associated Disorders and Risks: The risk for suicide is significantly elevated in patients experiencing the following conditions:

  • Depressive disorders.

  • Substance use disorders.

  • Psychosis.

  • Anxiety disorders.

  • Personality disorders.

  • Eating disorders.

  • Trauma-related disorders.

Biological, Cognitive, and Environmental Risk Factors

• Biological Factors:

  • Familial Tendency: Research indicates a higher prevalence of suicide among monozygotic (identical) twins compared to dizygotic twins.

  • Genetics and Epigenetics: Genetic factors play a role, as do epigenetic factors, which are external influences that alter gene expression.

  • Neurochemistry: Low levels of serotonin are consistently associated with increased suicide risk.

• Cognitive Factors:

  • Sigmund Freud: Conceptualized suicide as aggression turned inward. He categorized the psychological state into three specific wishes:

    • The wish to kill.

    • The wish to be killed.

    • The wish to die.

  • Karl Menninger: Highlighted three parts to suicide hostility.

  • Aaron Beck: Identified hopelessness as the central emotional factor driving suicidal behavior.

• Environmental Factors:

  • Family Dynamics: High levels of family conflict and low parental monitoring contribute to risk.

  • Clusters and Contagion: Suicides can occur in clusters, often referred to as contagion or copycat suicides.

  • Developmental Risk: Teens are at the highest risk for impulsive suicidal behavior due to an immature prefrontal cortex, which is responsible for executive function and impulse control.

Cultural and Social Factors

• Cultural Influences: Suicide risk is mediated by religious beliefs, family values, sexual orientation, and gender identity. Bullying behavior and general societal attitudes toward death also play significant roles.

• United States Trends ($1999–2017$): Suicide rates climbed during this period across almost all demographic groups. Rates increased for all races and ethnicities with the exception of non-Hispanic Asian or Pacific Islander groups.

• Social Factors (Ranked in Descending Order of Influence):

  1. Relationship problems.

  2. Recent or imminent crises.

  3. Substance use.

  4. Health problems.

  5. Financial problems.

  6. Legal problems.

  7. Loss of housing.

Application of the Nursing Process: Assessment

• Verbal and Nonverbal Clues:

  • Overt Statements: Clear, direct expressions of intent (e.g., "I am going to kill myself").

  • Covert Statements: Indirect hints or nonverbal cues (e.g., "Things will be better when I'm gone").

• Clinical Indicators:

  • Lethality of Plan: Evaluation of how deadly the proposed method is.

  • History: Previous history of attempts and family history of suicide are critical risk indicators.

  • Mood Changes: A sudden, unexplained switch from a sad or depressed mood to a happy/peaceful mood may indicate that the patient has made a firm decision to end their life.

  • Social Supports: Evaluation of the patient's existing support systems.

Application of the Nursing Process: Diagnosis and Planning

• Nursing Diagnoses:

  • Risk for suicide.

  • Self-care deficit.

  • Impaired sleep.

  • Impaired nutritional intake.

  • Anxiety.

• Outcomes Identification: The primary outcome is suicide self-restraint.

• Planning: Focuses on immediate safety and long-term stabilization.

Implementation, Evaluation, and Environmental Safety

• Implementation Strategies:

  • Psychosocial Interventions: Includes broad prevention efforts.

  • Health Teaching and Promotion: Educating patients and families.

  • Case Management: Coordinating care across multiple providers.

  • Milieu Therapy: Maintaining a safe, therapeutic environment.

  • Documentation: Precise recording of all care and observations.

  • Postvention: Intensive support for suicide survivors (those bereaved by a suicide loss).

• Evaluation: The evaluation process is continuous and ongoing.

• Environmental Safety Guidelines:

  • Use (and strictly count) plastic utensils.

  • Assign the patient to a non-private room; keep the door open at all times.

  • Ensure bathrooms are jump-proof and hang-proof.

  • Keep doors to non-patient areas locked.

  • Monitor and remove potentially harmful gifts from visitors.

  • Search the patient's belongings for harmful objects in their presence.

  • Regularly ensure patients do not bring in or leave behind harmful objects.

Treatment Modalities for Suicidal Behavior

• Biological Treatments:

  • Pharmacotherapy: Using medications to treat comorbid disorders (e.g., antidepressants or mood stabilizers).

  • Brain Stimulation Therapy: Targeted interventions used to decrease suicidal ideation.

• Psychological Therapies: Specialized talk therapies designed for suicidal patients.

• Advanced Practice Roles: The involvement of psychiatric nurse practitioners or specialists in diagnosing and prescribing.

Nonsuicidal Self-Injury (NSSI)

• Risk Factors:

  • Biological: Genetic or neurochemical predispositions.

  • Cognitive: Maladaptive thought patterns used to cope with emotional pain.

  • Environmental: History of abuse or neglect.

  • Societal: Peer influence or social modeling.

• Nursing Process for NSSI:

  • Assessment: Focus on empathy, identifying specific triggers for self-harm, and self-assessment for the healthcare provider to avoid negative transference.

  • Diagnosis: Risk for self-mutilation; Self-mutilation.

  • Outcomes: Improving coping skills, strengthening social support, and ensuring treatment adherence.

• Six-Step Planning Approach:

  1. Limit setting for safety.

  2. Developing self-esteem.

  3. Discovery of the motive and its role in the patient's life.

  4. Discovering self-control.

  5. Replacement of the behavior with healthy coping skills.

  6. Entering the maintenance phase.

• Implementation for NSSI:

  • Caring for physical injuries.

  • Establishing a therapeutic alliance.

  • Teaching new coping skills.

  • Promoting reflective dialogue to understand the behavior.

Questions & Discussion

• Discussion Scenario: You are worried about a close friend who recently broke up with a boyfriend. She is taking the breakup very hard and seems depressed.

  • Questions to Assess Ideation: What are some questions you could ask to assess for suicide ideation? (Note: Clinicians often ask directly: "Have you had thoughts of hurting yourself or ending your life?")

• Self-Assessment for Professionals: Healthcare professionals may experience fear, grief, anger, puzzlement, or condemnation of suicidal feelings. It is vital to acknowledge these feelings to team members to avoid countertransference.

• Audience Response Question: Which method of suicide has the highest lethality?

  • A. Ingesting pills

  • B. Cutting one’s wrists

  • C. Inhaling natural gas

  • D. Self-inflicted gunshot wound (Correct Answer)