SUICIDEBy :Dr. Cecep Sugeng, SpKJ

INTRODUCTIONSuicide is a major public health problem Approximately 0.9 percent of all deaths are the result of suicide Edwind Shneidman defined suicide as the conscious act of induced annihilation, best understood as a multidimentional malaise in a needful individual who defines an issue for which the act is perceived as the best solution. Thus suicide is not random or pointless, but a release from a problem or crisis inevitably producing intense suffering.

RISK FACTORSPsychiatric DisordersSocial FactorsPsychological Factors Biological FactorsGenetik Factors Physical Factors

Psychiatric Disorders

Almost 95% all of people who commitor attemp suicide have a diagnosed psychiatric disorder. Depressive disorder account for 80% of this figure, Schizofrenia account for 10% and Dementia or Delirium for 5%. Among people with mental disorder, 25 % also alcohol-dependent and have dual diagnoses. People with Delutional Depresion are at th highest risk of suicide.

Depressive Disorders Schizophrenia Alcohol Use Disorders Other Substance Use Disorder Personality Disorder Panic Disorder Comorbidity

Social Factors National Suicide Rates Age. Sex Race Marital Status Employment Work

Psychological Factors Freud stated that suicide represented aggression turned inward against an introjected, ambivalently cathected love object Menninger: Suicide as a retroflexed murder, an inverted homicide, as a result of the patient's anger toward another person Recent Theories: It is thought that the suicidal patients who are most likely to act out suicidal fantasies are those who have suffered the loss of a love object

Biological Factors Diminished central serotonin plays a role in suicidal behavior. A group at the Karolinska Institute were the first to note that low concentrations of the serotonin metabolite 5-hydroxy-indoleacetic acid (5-HIAA) in the lumbar cerebrospinal fluid (CSF) were associated with suicidal behavior.

Genetik Factors tends to run in families. Monozygotic twin pairs have significantly greater concordance for both suicide and attempted suicide, which suggests that genetic factors may play a role in suicidal behavior.

Physical Factors a physical illness is present in 25 to 75 percent of all suicide victims Cancer ; diseases of the central nervous system (epilepsy, multiple sclerosis, head injury, cardiovascular disease, Huntington's disease, dementia, and acquired immune deficiency syndrome (AIDS) ; endocrine conditions (Cushing's disease, anorexia nervosa, Klinefelter's syndrome, and porphyria ) ; gastrointestinal disorders (peptic ulcer and cirrhosis ) ; urogenital problems (prostatic hypertrophy and hemodialysis ) ; cerebrovascular disorders

MANAGEMENT OF SUICIDAL PATIENTSMany suicides among psychiatric patients are preventable Risk factors are useful in assessing the short-term risk of suicide of a patient in an acute crisis The psychiatric and social risk factors for suicide include a past attempt, a chronic psychiatric disorder, recent hospital discharge, living alone, being unemployed, being unmarried, and being liable to develop depressive symptoms.

ContThe evaluation for suicide potential involves a complete psychiatric history, a thorough examination of the mental state, and inquiry about depressive symptoms, suicidal thoughts, intents, plans, and attempts Lack of future plans, giving away personal property, making a will, or having recently experienced a loss imply increased risk for suicide.

ContThe decision to admit the patient to a psychiatric facility depends on the diagnosis, the severity of depression and suicidal ideation, the patient's and family's ability to cope, the living situation, the availability of social support, and the absence or presence of risk factors for suicide. Precautions against suicide include removing potentially lethal drugs and firearms from the home and prescribing medication only in weekly supplies.

ContUseful measures for managing a depressed suicidal inpatient include searching the patient's belongings and person on arrival on the unit for objects that might be used for suicide, and repeating the search at times of exacerbation of suicidal ideation. the suicidal depressed inpatient should be managed on a locked unit with shatterproof windows, and the patient's room should be located near the nursing station to maximize observation by the nursing staff. Vigorous treatment with antidepressant medication should be initiated , ECT should be considered

AGGRESSION

Dr . H. Cecep Sugeng, SpKJ

The term aggression is not specifically defined in the text revision of the fourth edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).Aggression implies the intent to harm or otherwise injure another person, an implication inferred from events preceding or following the act of aggression. AGGRESSION

AGGRESSIONSome conditons that produce increased aggressive impulses in the context of diminished control may produce violent acts. Situations with combinations of factors include toxic and organic states, developmental disabilities, florid psychosis, conduct disorder, and overwhelming psychological and environmental stress.

PREDICTORS OF AGGRESSION

ETIOLOGYPsychological Factors

ETIOLOGYSocial FactorsFrustationThe single most potent means of inciting human beings to aggression is frustration. Frustration appears to increase aggression only when the frustration is intense. frustration is likely to facilitate aggression when it is perceived as arbitrary or illegitimate, rather than when it is viewed as deserved or legitimate. Direct ProvocationTelevision Violence

ETIOLOGYEnvironmental FactorsAir PollutionNoiseCrowding

ETIOLOGYSituational FactorsHeightened Physiological ArousalSexual ArousalPain

ETIOLOGY Biological FactorsNeuroanatomical DamageNeurotransmitters

ETIOLOGYGenetic FactorsTwin StudiesPedigree StudiesChromosomal Influences

EPIDEMIOLOGYAccording to FBI : +/- 11/2 million violent crimes committed in the USA each year.Violent crime rates are highest in large metropolitan areas and lowest in rural areas.Violent acts are most often committed by persons who know or knew each other

PREVENTION AND CONTROLbegins at the individual level. include psychiatric referral, notification of the proper legal or other authorities, and skilled counseling by appropriately trained thera pists. Many experts advocate limiting exposure to violence on television and in movies and computer games as way to decrease violence.

Punishmentsometimes an effective deterrent to overt aggres sion. The recipients often interpret it as an attack against them. To the extent that it is, aggressors may respond even more aggressivelyPunishment may only temporarily reduce the strength or frequency of aggressive behaviorCertain punishments may backfire and actu ally encourage, rather than inhibit, the dangerous actions they are designed to prevent

CatharsisFor many years workers have widely believed that providing angry persons with an opportunity to engage in expressive but noninjurious behaviors reduces their tension or arousal and weakens their tendency to engage in overt and potentially dan gerous acts of aggressionthe so-called catharsis hypothesis. At present, catharsis is thought to help some persons discharge aggression; other persons may become more aggressive as a result of the expressive behaviors.

Training in Social Skillsmany persons become involved in repeated aggressive encounters is their lack of basic social skills. communicate effectively, and thus they adopt an abrasive style of self-expression. providing such persons with the social skills that they sorely lack.

Induction of Incompatible ResponsesEmpathy. When aggressors attack other persons in face-to- face confrontations, the aggressors may block out, ignore, or deny signs of pain and suffering on the part of their victims. If aggressors are exposed to such feedback, they may feel empathy and subsequently reduce further aggression. In several experiments, exposure to signs of pain or discomfort on the victims part has inhibited further aggression.

Humor. Informal observation indicates that anger can often be reduced through exposure to humorous material, and some laboratory studies support this hypothesis. Several types of humor, presented in various formats, may induce reactions or emotions incompatible with aggression among the persons who observe the humor.

Other Factors. Many other reactions may also be incom patible with anger or overt aggression. Feelings of guilt about the performance of aggressive actions often reduce such behavior. Participation in absorbing cognitive tasks, such as solving mathematics problems, may induce reac tions incompatible with anger and aggressive actions. A sum mary of mechanisms of violence is given in Figure 4.42.

PharmacotherapyLithium (Eskalith) : especially delinquent adolescent boys. Anticonvulsants occasionally reduce seizure-induced forms of aggression.Antipsychotic : both psychotic and nonpsychotic violent patients.

Antidepressants : for depressed patients. Antianxiety : have a limited role in reducing aggression. Anticonvulsant : reducing aggressive outbursts. Antiandrogenic : aggressive sex offenders. Adrenergic receptor antagonists (beta-blockers) and stimulants : aggressive children. ECT .

VICTIMSAn estimated 18 million persons in the USA.Many victims of violent crimes are at increased risk for major psychiatric problems. Long-term depressive disorders and phobias are two mental disorders reported to occur more frequently in victims of crime than in the general population. Characteristic emotional effects are associated with being the victim of a crime and that these effects are related to the fact that victims are the targets of another persons intentional aggression.

ACCIDENTSAn accident is an event that occurs by chance or unexpectedly, without conscious planning. Causes can sometimes be determined and possibly corrected, but they are often multiple and require a multifaceted approach to the problem.These characteristics include anxiety, boredom, fatigue, and the ingestion of substances that alter concentration and motor coordination.For persons 15 to 24 years of age, accidents are the most common cause of death in the USAAccidents are the fifth most common cause of death overall in the USA. Vehicular accidents, industrial accidents, and home accidents were the most frequent types of injuries.

Psychophysiological ConsiderationsA physical condition such as fatigue may lead to either distraction or an inability to respond quickly enough to avoid an accident. Such toxic substances as barbiturates, antihistamines, marijuana, and particularly alcohol are important.Persons with diabetes, epilepsy, cardiovascular disease, and mental disorders are involved in more than twice as many accidents per 1,000 miles of driving as those who do not have these illnesses. Age-related impairments, both motor and cerebral function deficits, may lead to potentially impaired judgment, which contributes to fatal accidents among persons 65 and older.

dr. Cecep Sugeng, Sp.KJPsychiatric EmergencyBlock XXI, December 6, 2005 Week 5 (International Programme)*