Suicide Lecture 2023

SUICIDE AND
DELIBERATE SELF HARM
If you want to show me that you really love me,

don’t say that you would die for me, instead, stay
alive for me.” – Unknown
Objectives
1. Describe suicide or deliberate self-harm.
2. Identify the importance of risk assessment in a
Psychiatric setting.
3. Describe the prevalence, etiology, and D/D of
DSH.
4. Formulate a BIO-PSYCHO-SOCIAL management
plan for suicidal patient behavior.
Any ideas and experience
Case Scenario
You are Called by E/R to see a 25-year-
old female who has presented after
ingesting 25 paracetamol and 20
fluoxetine after the break-up of a
relationship. She has a history of self-
harm a year ago. She was feeling sad,
had no interest in life, disturbed sleep,
and negative view of the future. You are
requested to make an assessment.
What are you going to do?
DEFINITION
Suicide is broadly defined as
 Unnatural death
 Result of victim’s own action
 Victim intend to kill himself
THE EPIDEMIOLOGY OF
SUICIDE
Accurate figures are difficult to
obtain. There are several sources
of error.
Often it is uncertain whether
death is due to suicide, murder,
or accidental.
Statistics may only represent half
to two-thirds of all suicides.
In the United Kingdom suicides
account for nearly one percent of
all deaths.
WHO REPORT 2021
More than 700 000 people die due to suicide every
year.
For every suicide, there are many more people who
attempt suicide.
A prior suicide attempt is the single most
important risk factor for suicide in the general
population.
Suicide is the fourth leading cause of death among
15-19 year-olds.
77% of global suicides occur in low- and middle-
income countries.
Ingestion of pesticides, hanging, and firearms are
among the most common methods of suicide
globally.
DEMOGRAPHICS
Male preponderance especially elderly
Increase in young suicide in last 20 years

in industrialized nations
Single / divorced / widows
Unemployed
Unskilled workers & professionals

(farmers, pharmacists, and prisoners)
CAUSES
 Social variables
 Biological variables
 Clinical variables
 Physical variables
SOCIAL VARIABLES
First classification was proposed by Emil Durkheim

Anomic - Normal cohesive bond in social
groups are weakened
Egoistic - Individual separated from social
group
Altruistic - Ending one’s life for greater cause
SOCIAL VARIABLES
Unemployment
Poverty
Isolation
Empty nesters
Urbanites
Following the death of a
spouse
BIOLOGICAL VARIABLES
Neurotransmitters
Low concentration of CSF serotonin metabolite
5HIAA5 (hydroxyindoleacetic acid), which is a
waste product of serotonin metabolism that is
excreted in urine.
Aggression/Violence
Strong association of suicide with impulsivity &
aggression.
BIOLOGICAL VARIABLES
Genetic Studies
 Monozygotic twins have greater concordance as

compared to dizygotic twins
 Suicide is 8 times > relatives.

CLINICAL VARIABLE
 Affective Disorder (36 – 90%)
 Alcohol (43 – 54 %)
 Substance abuse ( 4- 45 %)
 Personality disorders (5- 44 %)
 Schizophrenia (10 – 15%)

CLINICAL VARIABLE
Barraclough et al (1974) 100 cases of suicide
 90% of people who commit suicide had mental

disorders
70% - Depressive episode
15% - Alcohol dependence
3% - Schizophrenia
 This result was replicated by cheng at all (2000)

SUICIDE IN SPECIAL GROUPS
b) Pregnancy & Perpeurium

First postnatal year –having high rate of psychiatric
morbidity.
c) Suicide in Young People

It is of particular concern nowadays
 Acute & Chronic Mental Disorder
 Social withdrawal
 Chronic & recent interpersonal problems
Howton investigated characteristic features of

people with suicide under 25 years old
 Low social class

 Unemployment
 Hanging & CO Poisoning - frequent methods
 80% self-harmed within previous years
d) Children & Adolescents

 Suicidal Behavior & Depressive disorders are common
among parents & siblings
 Two groups of children show more suicidal behavior.
Superior intelligence who seems to be isolated by less educated or

mentally ill parents
Impulsive, prone to violence, resentful to criticism.

D) Physical Health
 Chronic neurological disorders
 Gastrointestinal disorders
 CVS disorders
 Malignant disorder
100 cases reviewed, 65% had significant
physical illness out of which 23% were
medical in-patients last year.
E) Ethnic Group
 Immigrants in the UK - Asian
F) Suicide Pact
 2 people agree that at the same time each will take his
or her own life
 Completed pacts are uncommon
 Lovers, aged < 30 years or interdepended couples
aged more than 50 years
G) Rational Suicide
 Rational act of the mentally healthy person.
 Mostly occurs in patients with a chronic, painful
illness
FACTORS ASSOCIATED WITH HIGH RISK
Age > 45 years.

Male.
Single.
Alcohol abuse.
Prior suicidal act.
Recent loss.
Depressive episode.
Longer episodes of depression.
Chronic ill health.
Unwilling to accept help
PROTECTIVE FACTORS
1. Survival & coping skills

2. Responsibility of family
3. Fear of social disapproval
4. Moral and religious objections
MANAGEMENT
General Issues
 All unnatural deaths, whether definite suicides

or not must be reported to authorities.
 Postmortem examination.
 Helping family to cope
ASSESSMENT
Specific Inquiries
 What were the patient’s intentions when he
harmed himself?
 Does he now intend to die?
 What are the patient’s current problems?
 Is there any psychiatric disorder?
 Helpful recourses available for the patient?
High intent (contributing factors)
An act carried out in isolation.

Act timed so that intervention is
unlikely.
Precautions are taken to avoid
discovery.
Preparations were made( making a Will,
organizing insurance).
Preparations made for the act (e.g.
purchasing means, saving up tablets)
Communicating intent to others before
Assessment
 Collateral information
 Physical Assessment
 DSH/ Suicide Risk
 Mental Illness
Deliberate Self Harm
Self-injurious behavior
 Associated with no intent to die.
 To relieve distress (superficial cuts or scratches
hitting/banging, or burns)
 Tochange others or the environment.
DIFFERENCE BETWEEN SUICIDE AND
 More common in young females
 Motives are different---
To manipulate the situation

Escape from situation
Cry for help
To make others feel guilty
To get relief from pain
To die
 Methods----
90% of drug overdosages

Self-injury
DIFFERENCE BETWEEN SUICIDE AND
Causes are different---
 Childhood loss, abuse or neglect
 Poor problem-solving skills
 psychiatric disorders are low 5%-15%
 Personality disorders
 drug abusers
 criminal record.
Treatment
 Out patients treatment
 Emergency contact cards
 Problem-solving skills
 Interpersonal skills
 Medications
SUICIDE PREVENTION
?
Primary prevention
1. Better and more available psychiatric services
2. Restricting the means of suicide
3. Educational program
4. Restricting opportunities for imitation by responsible
media reporting
Secondary prevention
5. Better and more available psychiatric services
6. Crises center and hot lines
SUICIDE PREVENTION
 Medical attention for high-risk groups
 Collaborative care with E/R and primary care physicians and

psychiatrists (75% of depression is treated in primary care)
 Early referrals to psychiatric services
 Reduce availability of methods

Bible Old and New
Testaments
have many references to
suicides:
"Suicide is the interference with the
plan of God for one's life. As such, it is
sin - an act of defiance and rebellion."
Certainly the mentally ill are not as

responsible for their acts as those who
are fully aware of what they do.
- Psalms 31:15-1 Corinthians 6:20"

\Sahi Bukhari says:
Narrated by Thabit bin Ad-Dahhak
Narrated by Abu Huraira: The Prophet said,
"He who commits suicide by throttling shall keep

on throttling himself in the Hell-Fire (forever)
and he who commits suicide by stabbing himself
shall keep on stabbing himself in the Hell-Fire
(forever).”
Sahih Al-Bukhar Vol-II Chapter 82 - Page 251-252

Para 445-446
ANY QUESTIONS?

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SUICIDE AND

DELIBERATE SELF HARM

If you want to show me that you really love me,

Suicide is broadly defined as

Increase in young suicide in last 20 years

Unskilled workers & professionals

First classification was proposed by Emil Durkheim

 Monozygotic twins have greater concordance as

 Suicide is 8 times > relatives.

 Affective Disorder (36 – 90%)

 Personality disorders (5- 44 %)

 Schizophrenia (10 – 15%)

Barraclough et al (1974) 100 cases of suicide

 90% of people who commit suicide had mental

 This result was replicated by cheng at all (2000)

b) Pregnancy & Perpeurium

c) Suicide in Young People

Howton investigated characteristic features of

 Low social class

d) Children & Adolescents

 Two groups of children show more suicidal behavior.

Superior intelligence who seems to be isolated by less educated or

Impulsive, prone to violence, resentful to criticism.

Age > 45 years.

1. Survival & coping skills

 All unnatural deaths, whether definite suicides

An act carried out in isolation.

 DSH/ Suicide Risk

 To relieve distress (superficial cuts or scratches

To manipulate the situation

90% of drug overdosages

 Medical attention for high-risk groups

 Collaborative care with E/R and primary care physicians and

 Early referrals to psychiatric services

 Reduce availability of methods

Certainly the mentally ill are not as

- Psalms 31:15-1 Corinthians 6:20"

Narrated by Abu Huraira: The Prophet said,

"He who commits suicide by throttling shall keep

Sahih Al-Bukhar Vol-II Chapter 82 - Page 251-252

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