Transcript PowerPoint

Suicide Risk and Violence
Threat Assessment
Developed by DATA of Rhode Island
through a grant from the RI Department of Human Services
Part 1:Suicide Assessment
GOALS
• Participants to increase knowledge of
suicide risk factors
• To understand which risk factors
should most of concern
• To understand when and how the
worker should intervene?
SUICIDE PREDICTION vs.
SUICIDE ASSESSMENT
• Suicide Prediction refers to the foretelling of whether
suicide will or will not occur at some future time, based on
the presence or absence of a specific number of defined
factors.
• Suicide (risk) Assessment refers to the establishment of a
judgment of risk in the very near future, based on the
weighing of information that is available.
• In general it is always better to err on the side of caution
COMPONENTS OF SUICIDE
ASSESSMENT
Survey and identify client risk
factors and protective factors
Elicit direct client communication
about suicide
Review previous History
SUICIDE: Contributing Factors
Psychiatric Illness
Co-morbidity
Personality
Disorder/Traits
Neurobiology
Impulsiveness
Substance
Use/Abuse
Hopelessness
Suicide
Severe Medical
Illness
Family History
Access To Weapons
Life Stressors
Psychodynamics/
Psychological Vulnerability
Suicidal
Behavior
Areas to Evaluate in Suicide Assessment
Psychiatric
Illnesses
Comorbidity, Affective Disorders, Alcohol / Substance Abuse,
Schizophrenia, Cluster B Personality disorders.
History
Prior suicide attempts, aborted attempts or self harm; Medical
diagnoses, Family history of suicide / attempts / mental illness
Individual
strengths /
vulnerabilities
Coping skills; personality traits; past responses to stress;
capacity for reality testing; tolerance of psychological pain
Psychosocial
situation
Acute and chronic stressors; changes in status; quality of
support; religious beliefs
Suicidality and
Symptoms
Past and present suicidal ideation, plans, behaviors, intent;
methods; hopelessness, anhedonia, anxiety symptoms;
reasons for living; associated substance use; homicidal ideation
Adapted from APA guidelines for suicide assessment
RISK FACTORS
Demographic
male; widowed, divorced, single; increases with age;
white
Psychosocial
lack of social support; unemployment; drop in socioeconomic status; firearm access
Psychiatric
psychiatric diagnosis; comorbidity
Physical Illness
Cancer; HIV/AIDS; systemic lupus; pain syndromes;
functional impairment; diseases of CNS
Psychological
Dimensions
hopelessness; pain/anxiety; psychological turmoil; low
self-esteem; fragile narcissism & perfectionism
Behavioral
Dimensions
impulsivity; aggression; severe anxiety; panic attacks;
agitation; intoxication; prior suicide attempt
Cognitive
Dimensions
thought constriction; polarized thinking
Childhood
Trauma
sexual/physical abuse; neglect; parental loss
Genetic &
Familial
family history of suicide, mental illness, or abuse
PROTECTIVE FACTORS
 Children or family in the home
 Pregnancy
 Deterrent religious beliefs
 Life satisfaction
 Reality testing ability
 Positive coping skills
 Positive social support
 Positive therapeutic relationship
SUICIDE RISKS by SPECIFIC DISORDERS
Higher Risk Groups
•Prior suicide attemptor (highest risk)
•Bipolar disorder
•Major depression
•Mixed drug abuse
•Personality disorders
•Alcohol abuse
•Cancer
•Chronic Pain Syndrome
COMORBIDITY
In general, the more diagnoses
present, the higher the risk of
suicide.
50% had multiple Axis I and at least
one Axis III diagnosis (medical
problems)
44% had 2 or more Axis I diagnoses
31% had Axis I and Axis II diagnoses
Only 12 % had a single Axis I
diagnosis with no comorbidity
AFFECTIVE DISORDERS AND SUICIDE
Highest Risk Profile:
• Elevated anxiety or panic symptoms
• alcohol abuse or dependence
• Prior suicidality
• Previous Hospitalization for affective
disorder and/or suicidality
• Risk for men is four times as high as for
women except in bipolar disorder where
women are equally at risk
• Persisting Medical Condition
SCHIZOPHRENIA AND SUICIDE
High-Risk Profile:
 Previous suicide attempt(s)
 Significant depressive symptoms - hopelessness
 Male gender
 First decade of illness – (however, rate remains elevated
throughout lifetime)
 Poor premorbid functioning
 Current substance abuse
 Poor current work and social functioning
 Recent hospital discharge
ALCOHOL / SUBSTANCE ABUSE AND SUICIDE
 Suicide occurs later in the course of the illness with
communications of suicidal intent lasting several years
 In completed suicides, men have higher rates of alcohol
abuse, women have higher rates of drug abuse
 Increased number of substances used, rather than the
type of substance appears to be important
 Comorbid psychiatric disorders, females have
Borderline Personality Disorder
High Risk Profile:

Recent or impending interpersonal loss
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Comorbid depression
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%
 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.
GENETICS FACTORS
 Suicide appears to be an independent, inheritable
risk factor.
 Relatives of suicidal subjects have a four-fold
increased risk compared to relatives of nonsuicidal subjects.
 Higher concordance of suicidal behavior between
identical rather than fraternal twins.
 Adoption studies: a greater risk of suicide among
biologic rather than adoptive relatives.
FAMILY PSYCHOPATHOLOGY
 Family history of abuse, violence, or other selfdestructive behaviors place individuals at
increased risk for suicidal behaviors
 Histories of childhood physical abuse and sexual
abuse, as well as parental neglect and
separations, are correlated with a variety of selfdestructive behaviors in adulthood
PSYCHOSOCIAL SITUATION:
LIFE STRESSORS
 Recent severe, stressful life events can be associated with
suicide in vulnerable individuals
 Stressors include interpersonal loss or conflict, economic
problems, legal problems
 High risk stressor: humiliating events, e.g., financial ruin
associated with scandal, being arrested or being fired can
lead to impulsive suicide.
 Identify stressor in context of personality strength,
vulnerabilities, illness, and support system.
PSYCHOSOCIAL SITUATION:
FIREARMS AND SUICIDE
 Firearms account for 55-60% of suicides (Baker 1984,
Sloan 1990).
 Firearms at home increase risk
•
•
Guns are twice as likely to be found in the homes of
suicide victims as in the homes of attempters
Type of gun (handgun, rifle, etc.) was not statistically
correlated with increased risk for suicide
Risk management point: Inquire about firearms
Document question and response.
PSYCHOLOGICAL VULNERABILITIES
 Capacity to manage powerful feelings
 Ability to tolerate aloneness.
 Ability to experience and tolerate psychological
pain
 Features of ambivalence.
 Tunnel vision/reversibility
 Capacity for intimate relationships.
 Ability to use external resources of support
COMPONENTS OF SUICIDAL IDEATION
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Intent:
Expectation and desire for a selfdestructive act to end in death.
Lethality:
Objective danger to life associated with a
suicide method or action.
Degree of ambivalence - wish to live, wish to
die
Intensity, frequency
Rehearsal/availability of method
Presence/absence of suicide note
Deterrents (e.g. family, religion, positive
therapeutic relationship, positive support
system - including work)
CHARACTERISTICS OF A SUICIDE PLAN
Risk / Rescue Issues:
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Method
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Time
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Place
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Available means
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Arranging sequence of events
PSYCHIATRIC SYMPTOMS
MOST ASSOCIATED WITH
SUICIDE
Hopelessness/Depression
Impulsivity / Aggression
Anxiety
Command hallucinations
PSYCHIATRIC SYMPTOMATOLOGY:
HOPELESSNESS/Depression
• There is relationship between hopelessness and
suicidal intent
• Subjective hopelessness is associated with fewer
reasons for living and increased risk for suicide
• Hopelessness is changeable through various
interventions
IMPULSIVITY / AGGRESSION
contributes to suicidal behavior
It is important to assess level of
impulsiveness when assessing for suicidality
and threat to others
Suicide attempters may be more likely to
present traits of impulsiveness / aggression
regardless of psychiatric diagnosis
Equally Important in assessing risk of
murder-suicide
ANXIETY
Anxiety symptoms (independent of an anxiety disorder)
associated with suicide risk:
 Panic Attacks
 Severe Psychic Anxiety (subjective anxiety)
 Anxious Ruminations
 Agitation
In a review of inpatient suicides 79% met criteria for severe
or extreme anxiety or agitation
COMMAND HALLUCINATIONS
 Patients with command hallucinations may not be at
greater risk, per se, than other severely psychotic
patients.
 However, the majority of patients with suicidal
command hallucinations should be considered
seriously suicidal
DIRECT QUESTIONING ABOUT
SUICIDE:
Don’t be afraid to ask direct questions.
Normalizing techniques help initiate the
conversation
Example: Worker: “People who have
experienced losses and who are
depressed, sometimes think that maybe
life is no longer worth living. Have you
ever felt that way?
If the client answers positively to suicidal
thoughts, ask more specific questions
COMPONENTS OF SUICIDE
ASSESSMENT Revisited
Survey and identify client risk
factors and protective factors
Elicit direct client communication
about suicide
Review previous history for suicide
and other risk factors
DETERMINING OF THE LEVEL OF
RISK
Evidence of suicidal ideation always deserves a
response. In determining risk level:
 Previous suicidal history
 The more immediate the plan, the higher the risk
 The more impaired (MH or alcohol), the higher the
risk
 Access to means
 Remember, suicide risk will need to be reassessed
at various points over time, as a patient’s risk level
will wax and wane.
DETERMINE A RESPONSE
SET A PLAN
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Always attend to issue of patient’s
safety first.
Consult others
Consult PCH or Mental Health Provider
In situations of potential imminent
danger, confidentiality is waived
Don’t rely on clients to follow through
If all else fails, call 911
Document, document, document
What to Document
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Observable Symptoms
Any suicidal behavior or ideation.
Actual statements made by client
Known Risk Factors
The issue of firearms:
If present - document
If absent - document as pertinent negative (no guns in
house)
 Actions Taken by You
With whom, when and outcome
Any follow up
WHAT TO DOCUMENT
IN A SUICIDE ASSESSMENT
 Document:
• The risk level
• The basis for the determining risk level
• The plan for intervention…calling CMHC or Police;
contacting supervisor
Example:
This 62 y.o., recently widowed man is experiencing his
2nd episode of major depressive disorder. In spite of his
denial of current suicidal ideation, he is at moderate to
high risk for suicide, because of a serious suicide attempt
in the past, his continued depression, anxiety and
hopelessness; recent loss and social isolation. The
immediate plan is to contact the area CMHC and the
clients primary care physician to advise of concerns.
WHEN A SUICIDE OCCURS
Despite best our efforts suicides can and do occur
Approximately, 12,000-14,000 suicides per year.
To facilitate the aftercare process:
 Ensure that the client records are complete
 Be available to assist grieving family members
 Remember document all activities and
interventions
 Seek support from colleagues / supervisors
 Consult risk managers if available
Questions