MENTAL HEALTH NURSING
Deliberate self-Harm & Suicidal
Behaviors
By:
Mr. TAUQEER AHMED
Lecturer-FUCN
Dated: 26/10/2023
1
Objective
s
⚫ Define the terms related to suicide
⚫ Discuss national and international prevalence of self harm
and suicidal behavior
⚫ Review the continuum of adaptive and maladaptive self-
protective responses
⚫ Explore causative theories from different school of thoughts
⚫ Differentiate between facts and myths regarding suicide
⚫ Utilize nursing process in the care of client with suicidal
risk
2
DSH
⚫ Self-harm (SH) or deliberate self-harm (DSH)
includes self-injury (SI) and self-poisoning and is
defined as the intentional, direct injuring of
body tissue without suicidal intent.The most
common form of self-harm is skin cutting, bu
rning, scratching, banging or hitting body
parts, hair pulling and the ingestion of toxic
substances or objects
http://en.wikipedia.org/wiki/Self-harm
3
⚫ The term Suicide stems from Latin
words
sui, of oneself, and cidus means to kill
⚫ Suicideis the intentional acts of
killing oneself
4
Terms related to
suicideSuicidal ideation
Is the thought of self inflicted death - it can be passive or
active
Suicidal Threats
Verbal or nonverbal warning that a person is considering
suicide
Suicidal attempts
Any self-directed action taken by the individual that will lead
to death if not interrupted
Completed suicide
May take place after warning signs
Ref: Stuart,W. have been missed or
G. (2009)
ignored.
5
Suicidal gesture
A more serious warning than suicidal ideation or
threat, It involve an action that suggests the act of
suicide may be about to happen
6
Prevalence of
suicide
According to Center for Disease Control and Prevention
⚫ Suicide is the 2nd leading cause of death in all age group for the over
all population of USA
⚫ The prevalence of suicide in the United States is approximately 12
100,000
per persons
annually
⚫ More than 30 % of suicide worldwide happen in China (Keth &
Heeingen
,
⚫ people
Suicide 15-24 years ofleading cause of death (after accident) among
is the second
age.
7
⚫ Every year, almost one million people
die from suicide; a "global" mortality
rate of 16 per 100,000.
http://www.who.int/mental_health/preve
ntion/suicide/suicideprevent/en/
4/15/2016 8
Prevalence of
suicide
⚫ Depression is one of the most common causes of suicide
and as many as 2.86/100,000 Pakistani commit suicide.
⚫ This may still be under-reported because there is no official data
or reporting system in Pakistan and many suicides are recorded
as accidental deaths to avoid legal and religious complications.
REF:
www.dawn.com/weekly/cowas/20
080203.htm
9
⚫ Mental disorders (particularly
depression and alcohol use disorders)
are a major risk factor for suicide in
Europe and North America; however,
in Asian countries impulsiveness plays
an important role. Suicide is complex
phenomenon with psychological,
social, biological, cultural and
environmental factors involved.
(WHO, 2013)
http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/
10
Continuum of self
protective
responses
Maladaptiv
Adaptive
e
response
respons
e
Adaptive Maladaptive
responses responses
Sel Growth Indirect self
enhancemen
f promoting destructiv Self-Injury suicide
t risk taking e
behavior 11
C AUSATIVE THEORIES
Genetic and familial
variables:
• A family history of suicide is a significant risk factor
for self-destructive behavior (Stuart & Laraia, 2005)
• Identification with and imitation of a family member who
has committed suicide (Stuart, 2009)
• Genetic factor may be an inability to control impulsive
behavior, and that either environmental stress or a mental
illness may drive the impulsive behavior toward suicide
• Monozygotic twins have a higher rate for suicide than
dizygotic twins
REF:Stuart, G.W. & Laraia, M.T. (2005). Principles and practice of psychiatric nursing (8th ed.).
St. Louis: Mosbyp.393
12
Neurobiological
Theory:
⚫ There is growing evidence of an association
between suicide or suicidal tendencies and a low
level of the brain neurotransmitter serotonin.
⚫ Lower 5-HIAA (serotonin) level had been found in
people who used guns and other means to commit
suicide than those who used nonviolent methods,
such as drug over dose
REF: Stuart, G.W. & Laraia, M.T. (2005). Principles and practice of psychiatric nursing (8th
ed.). St. Louis: Mosbyp.393
13
Socio cultural
theory
⚫ Social Isolation
⚫ Rapid social change
⚫ Difficulty in adopting the demand of
new roles
⚫ Painful or lost relationship
⚫ Loss of job/ financial problems
Ref: Fontaine, L. K. (2003). Mental health nursing.(5th ed.). New jersey: Prentice Hall. p. 601
14
Socio cultural theory-learning
from media sources
⚫ Media reporting and portrayal of
suicidal behaviour can influence
suicide and self harm in general
population
⚫ Suicide in TV drama can influence risk
⚫ Some website might encourage
suicide and provide detailed
information
Biddle, about
L.,Donovan, J., Hawton K, et al (2008)methods that
Suicide and the internet.
may be used inBMJ,suicide 336, 800-802
15
Behavioral
Theory:
• Learned problem solving behavior
Interpersonal theories:
⚫ Interpersonal conflict conflicts and
doubt suicides becomes way to
end the conflict or helplessness /
hopelessness
⚫ Progressive failure in life processes
16
Development
Theory
Children
Escape from physical or sexual abuse,
feeling unloved or constantly criticized,
anticipation of disciplinary action,
humiliation in school, and loss of
significant others
17
Adolescent
Absence of meaningful relationship, difficulties
in maintaining relationships, sexual
problems, and
problems with
parents.
Older adults
Change in status from autonomy to dependency,
accompanied by decreased participation in social
activities, loneliness , social isolation, loss of partner
and friends, loss of work
Ref: Fontaine, L. K. (2003). Mental health nursing.(5th ed.). New jersey: Prentice
Hall. P. 601
18
Personality
disorder
⚫ Borderline personality
disorder
⚫ Antisocial personality disorder
4/15/2016 19
Psychiatric
Disorder
⚫ More than 90% of adults who end
their lives by suicide have an
associated psychiatric illness
Anxiety disorder
Mood disorder Substance
abuse
Schizophrenia
20
Personality traits and
disorder
⚫ The three aspects of personality that
are most closely associated with
increased risk of suicide are
Hostility
Impulsivity
Depression
Hopelessness
21
Risk factors
Psychiatric Illness
Co-morbidity
Personality Biochemical
Disorder/Trait imbalance
s
Impulsiveness
Substance
Use/Abuse Hopelessness
Severe Medical
Illness
Suicide Family History
Access To Weapons
Age, gender, marital status
Life Stressors Suicidal
Behavior
22
Protective
factors
⚫ Effective treatment and therapy
⚫ Easy access to clinical intervention
and support for help
⚫ Restricted access to items that may be
used for suicide
⚫ Social support- family/ friends &
community
⚫ Problem solving and coping history
⚫ Sense of responsibility- mother
⚫ Hopefulness
⚫ Fear of suicide-outcomes
Cultural and religious beliefs to
suicide
23
⚫ Mental Health O rdinance Pakistan
“A person who attempts suicide shall be
assessed by an approved psychiatrist
and if found to be suffering from a
mental disorder shall be treated
appropriately under the provision of
this act.”
24
Are these statements
correct?
⚫People who talk about suicide never commit
suicide
Eight out of ten people who kill themselves have given definite clues
and warning about their suicidal intentions
⚫ Once a person is suicidal, he or she is suicidal
forever
People who want to kill themselves are only suicidal for a limited time. If
they are saved can lead to normal lives
⚫ The chances of suicide lessens as depression
lessns
When the depression is lessen, there is more energy to carry out a
previous considered suicidal plan
⚫ All suicidal individuals are mentally ill, and suicide is the act
of a psychotic person.
Although suicidal persons are extremely unhappy, they are
not necessarily psychotic.
25
Are these statements
⚫
correct?
There
or
is no way to help someone who wants to kill himself
Most suicidal people are very ambivalent about their feelings regarding living or
herself.
dying.This ambivalence often prompts the cries for help evident in overt
or covert cues.
⚫ Talking about suicide may give the person ideas of
suicide
Asking about suicide does not cause a non-suicidal person to become suicidal
When asked about suicide, it is often a relief for the client to know that his or her
cries for help have been heard and that help is on the way
⚫ Suicidal threats and gestures should be considered manipulative
or
attention- seeking behavior, and should not be taken seriously.
All suicidal behavior should be taken seriously , these gestures are cry for help
⚫ If an individual has attempted suicide, he or she will not do it
again of all people who ultimately kill themselves have a history of a
50%-80%
previous attempt.
Areas to Evaluate in Suicide
Assessment
Demographic male; widowed, divorced, single; increases with age; except
china more women than men die by suicide
Psychosocial lack of social support; unemployment; drop in socio-
economic status; living alone, school problem,
Psychiatric illness Previous suicide attempt, mood disorder, excessive drinking
or substance abuse, conduct disorder and depression in
adolescent
Physical Illness Cancer, HIV/AIDS; hemodialysis;
Presenting hopelessness;; decreased self-esteem; feeling of failure,
symptoms depressed mood, agitation and restless, persistent insomnia,
weight loss, slowed speech, fatigue, social withdrawal,
suicidal thoughts and plan
Personality factors impulsivity; aggression; agitation; hostility, cognitive rigidity
and negativity
Childhood Trauma sexual/physical abuse; neglect; parental loss
27
Cues to
Suicide
Verbal clues
⚫ I am going to kill myself
⚫ I am going to commit suicide
⚫ I’ve lived long enough. No more.
⚫ I’m tired of life
⚫ The pain will be over soon
⚫ The voices are telling me to hurt myself
⚫ I won’t be here when you come back on
Monday
⚫ My family would be better off without me
⚫ Nobody care about me
⚫ I won’t be around much longer
28
Behavioral
clues
⚫ Previous suicide attempts
⚫ Buying a gun
⚫ Stocking pills
⚫ Giving away money or
possessions
⚫ Loss of interest in favorite
activities
⚫ Making or changing will
⚫ Suspicious behavior
Frisch, N. C., & Frisch, L. E. (2006). Psychiatric mental health nursing (3rd ed). Albany: Delmar
Publishers p. 312
29
Clinical algorithm for planning treatment for the suicidal patient
patient expresses suicidal intention
Has suicidal plan
Yes No
Has access to lethal means?
Has poor social support?
Has impaired judgment?
Yes No
Hospitalize Evaluate for psychiatric disorders or stressors
Treat with antidepressants, psychotherapy
Nursing diagnoses
⚫ Riskfor self-mutilation related to
feeling of tension as evidence by
cutting of arms
⚫ Potential
for self-directed violence
related to loss of spouse as evidence by
purchase of gun and discussion of death
⚫ Noncompliance with drug manegment
related to denial of illness as evidence
by relapse of symptoms 31
Suicidal
Placingprecautions
the client under close supervision., including one-to-one
supervision
Remove sharp objects, such as knives, razors, scissors, and mirrors, from
the
client possession and access
Remove toxic substances such as drugs, and alcohol, and ensuring that
units medications are locked.
Remove clothing that could be used for self destruction, such as neck
ties,
dupatta, stocking, belts
Use plastic utensil
Do not allow client to spent too much time alone in their room. Do not
assign to a private room.
Take all potentially harmful gifts (Flowers in glass vases) from visitors
before allowing them to see client
Ensure Frisch,
visitors
N. C.,do not L.leave
& Frisch, potential
E. (2006). Psychiatricharmful objects
mental health nursing (3ined).
rd client’s
Albany: room
Delmar
(e.g., Publishers p. 312
32
•During observation when client is sleeping,
hand should always be in view, not under
the bedcovers.
•Carefully observe client swallow each dose
of medication
•Share suicide precaution plan- The nurse and
doctor should explain to the client what they
will be doing and why: both document this in
this chart
33
Reference
s
⚫ Antai-Otong, D., (2003). Psychiatric nursing biological & behavioral concepts. Thomson: Texas
⚫ Fontaine, L. K. (2003). Mental health nursing.(5th ed.). New jersey: Prentice HallP. 601
⚫ Frisch, N. C., & Frisch, L. E. (2006). Psychiatric mental health nursing (3rd ed). Albany: Delmar Publishers
p. 312
⚫ Lynch, A, M., Howard, B, P., El- Mallakh. P., & Matthews, M. J., (2008). Assessment and management of
hospitalized suicidal patients. Journal of Psychiatric Nursing,46(7), p 46
⚫ Stuart, G. W., & Laraia, M. T. (2005). Psychiatric nursing: Principles and practice of psychiatric nursing
(8th ed.). St. Louis: Mosby.
⚫ Stuart, W. G. (2002). Mosby’s pocket guide series psychiatric nursing. (5th ed.). Mosby:London p.250
⚫ Townsend, M. C. (2006). Psychiatric mental health nursing: Concepts of care in evidence - based
practice (5th ed.). Philadelphia: Lippincott.p. 251
⚫ Videbeck, S. L. (2004). Psychiatric mental health nursing. (2nd ed.). Philadelphia: Lippincott p. 361
4/15/2016 38
