CP Suicide Prevention (lecture 4)

Question 1

Why is it important that we discuss and learn about suicidality?

Answer 1

• Its common in patients with all kinds of mental disorder
• Its a taboo topic
• Awarness helps feeling more confident
• However, it’s not in the DSM-V

Question 2

Suicidal ideation

Answer 2

Thoughts of killing oneself
Much more common than attempted or completed suicide

Question 3

Suicide attempts

Answer 3

Involve behaviours that are intended to cause death
- Most suicide attempts don’t result in death

Question 4

Suicide

Answer 4

Involves behaviours that are intended to cause death and do so

Question 5

Nonsuicidal self-injury (NSSI)

Answer 5

Involves behaviours that are meant to cause immediate bodily harm but are not intended to cause death
- most common in early adolescence
- those who try NSSI do so less than 10x
- those who persist - risk factor for suicifal ideation and behaviour
- Influences: social factors (social modelling, reinforcement from friends and family but caring all of a sudden), experience of intense emotions, self-critical beliefs (deserve punishment)

Question 6

What are the four types of suicide according to Emile Durkheim?

Answer 6

1. Egoistic
2. Altruistic
3. Anomic
4. Fatalistic

Question 7

Egoistic suicide

Answer 7

• Stems from absence of social integration
  ↪ Low level of social integration
• Don’t fit in society, feel unloved and alone
• See suicide as a solution to free themselves from the loneliness and excessive individuation

Question 8

Altruistic suicide

Answer 8

• Social group involvement is too high
  ↪ High level of social integration
• Willing to sacrifice their own life in order to fulfill some obligation for the group (religion or political)
• E.g. Japanese Kamikaze pilots of WWII

Question 9

Anomic suicide

Answer 9

• Low level of social regulation
• Occurs during high levels of stress and frustration
• Stems from sudden and unexpected changes in situations (e.g. financial loss, uneployement…)

Question 10

Fatalistic suicide

Answer 10

• High level of social regulation
• Occurs when individuals are kept under tight regulation - extreme rules or high expectations are set upon them (e.g. slavery, persecution)
  ↪ removed sense of self or individuality

Question 11

Risk factors for suicide

Answer 11

1. Psychological disorders
2. Neurobiological
3. Social influences
4. Psychological influences

Question 12

Psychological disorders as a risk for suicide

Answer 12

2/3 who attempt suicide have history of psychological disorders but most people with psychological disorders don’t die from suicide

Question 13

Neurobiological factors

Answer 13

• Twin studes: heritability accounts for 50% of the likelihood of suicide attempts
• Disruptions of the serotonin system - PET
• Overly reactive HPA system (stress system)

Question 14

Social influences

Answer 14

• a cluster of suicides occurs after media reports of the suicide of a celebrity (but clusters of suicide are still rare)
• lack of social belonging, perceived sense of burden to others, interpersonal conflict (as well as divorce or widowed), peer victimization
• economic recessions

Question 15

Psychological influences

Answer 15

• feeling of being defeated and inescapability of the problems that lead to defeat
• increased when: problem-solving deficits
• loss of hopefulness
• life satisfaction

Question 16

Our lecturer contributed in writing a guildline about suicidality. Why did it take so long to have something like this available for clinicians to use in practice?

Answer 16

• Suicidal behaviour is seen as a by-product of mental disorders (e.g. depression)
• Hence, there’s a misconception that when you treat the mental disorder, the suicidal ideation will go away. That is not always the case

Question 17

What are some common myths about suicidality?

Answer 17

1. Talking about suicide will increase the chance someone will act on it
2. Most people die by suicide during the Christmas Holidays
3. Someone thinking of suicide wants to die
4. The media influences the number of suicide
5. Artists have an increased risk of suicide
6. Women mostly talk about suicide, men die more often

Question 18

What were the results of a study on the myth Talking about suicide increases the chance someone will act on it?

Answer 18

• One of four GPs and one in five patients supported the notion that screening for suicidal ideation could increase the likelihood of someone thinking about or actually harming themselves
  ↪ The research found that it’s not true - actually the opposite is true; talking about it helps relieve the sense of isolation
• The whole suicidal process is a long process - doesn’t happen just because someone asked about it
• But it depends on how the clinicians ask about it

Question 19

What is the situation currently like with training professionals about suicidality in their patients?

Answer 19

Most GPs had not received any formal training in how to assess suicide risk
Many professionals ask in a wrong way, are hesitant
↪ results in patients not disclosing and not being honest

Question 20

What is an estimate of how many people day every year due to suicide?

Answer 20

• estimated 800 000 people: 1 every 40 seconds
• In the Netherlands, around 1850 people: 5 people every day

Question 21

What are key facts about suicidality that all clinicians should be aware of?

Answer 21

• For every suicide there are many more people who attempt suicide
  ↪ Females have more attempts but men actually die more often because they use more lethal methods
• Population based studies found that each year, 3% (350 000) of the Dutch adult population have serious suicidal thoughts
• 77% of global suicide low- and middle- income countries (BUT! see next flashcard)
• Ingestion of pesticide, hanging and firearms are among the most common methods of suicide globally

Question 22

Vulnerability paradox

Answer 22

Most suicides come from low- and middle- classes because they are the majority in the world. But there is a higher suicide rate among high-income countries compared to low- or middle- classes.

Question 23

How does people’s thinking about suicide changed over the years?

Answer 23

Ancient Greek - suicidal behaviour saves your soul, you have control over your life
Middle ages, western countries - suicide became illegal
After the Enlightenment - became more liberal, people should be able to decide what they want to do with their lives

Question 24

Why is suicidality a taboo topic?

Answer 24

Because it reminds us of our vulnerability which we are often afraid of and don’t want to face it.
Also, it’s very much against the social norms
↪ if people are reminded of their vulnerability they conform to norms more

Question 25

What is the most common thing that clinicians do when they are confronted with suicidal thoughts in their patients?

Answer 25

They try to provide solutions because it’s difficult to endure the suicidal ideation (face their vulnerability)

Question 26

What should we/clinicians do when we are confronted with suicidality?

Answer 26

The basic model has 4 steps:
1. Ask questions if you have at least some rapport with the person, not straight after someone discloses their sadness
2. Tune in to the distress (don’t just say that they should have happy thoughts)
3. Tap into the hope
4. Safety and referral
Most importantly, be empathetic, do not try to solve

Question 27

Interpersonal theory of suicidal behaviour

Answer 27

Very infuential theory - closed the gap between thoughts and actions
Three conditions need to be met for a person to decide that they are gonna commit a suicide
First suicidal thoughts must be there! Desire for suicide:
1. Thwarted belongingness (I am alone)
2. Perceived burdensomness (I am a burdem)
↪ Suicidal thoughts are much more common than the attempts
3. Capability for suicide (no fear of death - self-harming, less pain sensitivity)
↪ After this third one is met > lethal (or near-lethal) suicide attempts

Question 28

What is the important model to understand suicidal behaviour?

Answer 28

Three phases
1. Pre-Motivational Phase
2. Motivational Phase
3. Volitional Phase

Question 29

Model of suicidal behaviour

Pre-Motivational Phase

Answer 29

Background Factors & Triggering Events
- Diathesis + environment + life events

Question 30

Model of suicidal behaviour

Motivational Phase

Answer 30

Ideation/Intention Formation
Steps: Defeat & humiliation > Entrapement > Suicidal ideation & intent

Question 31

Motivational phase

Moderators between each step

Answer 31

Defeat & humiliation
↪ Threat to Self moderators, e.g. social problem-solving, coping, memory biases, ruminative processes
Entrapement
↪ Motivational moderators, e.g. Thwarted belongingness, burdensomeness, future thoughts, goals, norms, social support, attitudes
Suicidal ideation & intent
↪ Volitional moderators, e.g. capability, impulsivity, implementation intentions (planning), access to means, imitation
↪ These are already in the volitional phase - if they have these, they’re attempting at suicide

Question 32

model of suicidal behaviour

Volitional phase

Answer 32

Behavioural enaction = suicidal behaviour
Depending on the volitional moderators

Question 33

What are the two psychological ways to prevent suicides?

Answer 33

1. Treating the associated psychological disorder (meds and ECT for mood disorders, antipsychotics for schizophrenia)
2. Treating suicidality directly
3. Programs to study suicidality and prevent it at the same time (within military - higher rates of suicide than general public)
4. Means restriction (making highly lethal methods less available)

Question 34

Treating suicidality directly - three strategies

Answer 34

1. CBT - challenge negative thoughts, tolerate emotions of distress, develop safety plan of coping startegies in case of suicidal crisis
2. DBT - CBT specifically for self-harming patients
   ↪ safety plan, mindfulness, acceptance, emotion regulation through individual and group therapies
3. CAMS - identify possible drivers of suicidal thoughts and then develop techniques to target those concerns

Question 35

Important things to remember

Answer 35

1. You can ask people about suicidal thoughts
2. Most people with suicidal thoughts do not want to die
3. Even experienced professionals find it difficult to dicuss suicidal behaviour