Self harm is commonly used by psychiatrists and mental health professionals to describe a wide variety of behaviors that may or may not be related to suicide. Both self harming behaviors and suicide permeate society around the world and across demographics. Suicide is defined as self inflicted death with evidence that the person intended to die according to APA practice guidelines. Self harm is more diﬃcult to define because its causes are poorly understood and the spectrum of behaviors can vary widely between individuals and between cultures. Behaviors commonly included in the self harm spectrum include overdoses, self battery, cutting, burning, poisoning, hanging and jumping from high places that do not result in death (Skegg, 2005). Suicide ultimately results in intentional self-inflicted death and self harm may lead to suicide. The APA practice guidelines define terms related to self harm and suicide as the following: Suicide self inflicted death with evidence that the person intended to die Suicide attempt self injurious behavior with a nonfatal outcome and evidence that the person intended to die Aborted suicide attempt-potentially self injurious behavior with evidence that the person intended to die but stopped before physical damage occurred Suicide ideation thoughts of serving as the agent of one’s own death Suicidal intent subjective expectation and desire for self-destructive act to end in death Lethality objective danger to life associated with suicide action or method Deliberate self harm willful self-infliction of painful, destructive or injurious acts without intent to die Both of these phenomenons are important to clinicians to understand and be aware of because of their prevalence in the mental health patient population. An estimated 4.3 to 17% of the psychiatric patient population will engage in deliberate self-harm, with higher rates in some subgroups (Fliege, 2006). Self-harm and suicidal behaviors pose a significant public health burden and utilize a tremendous amount of hospital resources (Sinclar, 2006). Up to 40% of people who deliberately harm themselves will go on to become repeat oﬀenders (Zahl, 2004). Treatment of chronic self-harmers can be frustrating to the treatment team due to the poorly understood nature of the behavior and high rates of repeat admissions. Many patients are managed in emergency departments or do not seek treatment after performing these behaviors. Management depends largely on the underlying pathology and controlled trials of therapies are limited (Skegg, 2005). 20.1 Phenomenology Naming and classifying self-harm has been a topic of debate since the early 1900’s (Skegg, 2005; Mcalister, 2003). Diﬀerent terms that have historically been used to delineate self-harm behaviors include attempted suicide, parasuicide, deliberate self injury and deliberate self poisoning. Terminology can vary in diﬀerent parts of the world and imply intent. Recent literature suggests that many who self-harm do so without suicidal intent (Skegg, 2005). Skegg describes self-harming behaviors in a 2005 review on a spectrum from self-harmful behaviors without visible injury to highly lethal traditional methods of suicide. Excessive exercise, denying oneself as punishment, stopping medication or deliberate recklessness fall on the end of this spectrum without visible injury. Self battery behaviors include head banging, self-hitting or hair-pulling. Self-injury with tissue damaging behaviors include self-biting, scratching, gouging, carving words or symbols into skin, sticking needles or pins into skin and interfering with wound healing. At the other extreme less lethal traditional methods of non-intentional suicide include overdose, recreational drug ingestion as self-harm, cutting and burning. Traditional highly lethal methods of suicide include hanging, shooting, jumping from a high place, poisoning, stabbing, electrocution and drowning. When considering these behaviors on a spectrum, it is important to consider intent. Tra-ditional risk assessments correlate lethality with suicidal intent, however in a sample of survivors of near-fatal self harm, only two-thirds of patients experienced suicidal thoughts prior to the event (Douglas, 2004). The current consensus view is that those who self harm, despite how seriously, believe that they will survive (Mcallister, 2003). It is important to consider, however, that patients who harm themselves are more likely to go on to commit suicide than those who do not. 20.2 Epidemiology Rates of self-harm and suicide vary widely around the world and have historically been diﬃcult to quantify because many people do not seek medical attention after attempts and discussion of such behaviors is sometimes considered socially taboo. Birth cohort studies show higher odds for self harm in people born in recent years. The WHO/EURO study of parasuicide showed lower rates in southern European areas compared to northern areas (Skegg, 2005). In the United States, African Americans are at lower risk for self harm than other ethnic groups. Self-harming behaviors are common in adolescents and an estimated 5-9% of Australian, US and English adolescents reported self-harm over a one year period (Skegg, 2005). Lifetime self-harm ranged from 13-30% in these samples of adolescents (Skegg, 2005). Skegg (2005) correlated demographic variables with risk of self-harm behaviors. It is rare before pubery and becomes common through adolescence. Older people are at much lower risk for self harm. More women than men present to mental health facilities with complaints of self -harm. Separated and divorced people appear to have higher rates of self-harm than other populations. Low socioeconomic status, less education and living in poverty are also risk factors for self harm (Skegg, 2005). Further studies investigating suicidal behaviors are necessary to better understand the phenomenon and to create prevention strategies. Using three national medical databases, the annual rate of nonfatal emergency department treated intentional self-harm events in 2002-3 was between 127.2 and 164.7 per 100,000 US population (Classen, 2006). However, these rates do not include behavior of individuals not seeking treatment or seeking treatment in other medical facilities. 20.3 Clinical Symptoms and Classification Vignette #1 Sue was a 25 year old female who presented to the emergency room with a 3cm laceration on her left wrist. The laceration was superficial but deep enough that it required sutures. There were multiple other superficial lacerations that did not require sutures as well as multiple healed scars from previous lacerations all up and down her forearm. After Sue’s wrist was sutured, she was evaluated by a psychiatrist for a possible suicide attempt. Sue revealed that she had been having a fight on the phone with her boyfriend and they had broken up. She denied any thoughts of suicide but rather said she was trying to reduce the tension and anger she felt about the situation. When asked about whether the self harm helped, she said it did release tension and therefore makes her feel more normal. She described it as a coping skill and did not see it as a problem behavior. She was discussing plans for going out with friends and maybe getting together with a boy who might want to be her new boyfriend. Sue’s past history is significant for sexual abuse at age 5 years by a cousin who was living with the family for the summer. Sue said she had always been sad and depressed but she did not endorse enough symptoms to qualify for a major depressive disorder. She said that she has a history of getting more depressed whenever someone left her or told her she was not making them happy. That was when she would cut on herself. She was very clear that she did not intend to kill herself during those times although she endorsed the idea that she might be better oﬀ dead than alive. Sue was deemed to be safe to go home. She was referred to therapy to work on the issues that caused her to use self harming behaviors for comfort. 20.3.1 Assessment Assessment of suicide and self harming behaviors takes place in a variety of treatment situations. It is often evaluated during an initial meeting with a patient in the emergency setting or at an outpatient intake. On an inpatient ward, assessment of suicide and self harm should be completed prior to advancement in privilege level, passes and discharge. If changes in the patient’s presentation occur or if the patient begins to display evidence of suicidal or self harming thoughts, an assessment should be completed. The APA practice guidelines describe a thorough assessment of the suicidal patient. During the interview, the psychiatrist obtains information about the patient’s psychiatric history, medical history and current psychologic state through direct question and collateral information. This enables the psychiatrist to make a risk assessment, determine the patient’s current level of safety, choose an appropriate treatment setting and develop a treatment strategy. Suicide scales can be used to supplement the interview, but should not be used as a substitute because they lack the predictive validity to take the place of a thorough interview (APA practice guidelines). A suicide assessment should include evaluation of current suicidal state, consisting of thoughts and plans regarding suicide. Specific methods should be elicited, including perceived lethality and access to firearms. The presence of hopelessness, guilt and anhedonia should be determined as well as reasons that prevent the patient from carrying out suicide plans. It should also include current and previous psychiatric illnesses including mood disorders, psychotic disorders, substance use disorders and anxiety disorders. Personal and family history of suicide and self harm behaviors should be noted, as well as outcomes. An individual’s psychosocial state should be assessed to evaluate current stressors that could exacerbate suicidal behaviors, as well as cultural or religious beliefs that could be protective (APA practice guidelines). It is important for the psychiatrist to collect as much information as possible regarding current suicidal or self harming behaviors. These include frequency and duration of thoughts, specific plans and preparation made to complete plans. Attention should also be given to prior attempts, including timing, intent, relation to substance use and outcome. If a specific method is identified as a current suicidal ideation, perceived lethality should be determined. Highly lethal and irreversible means with advance planning place an individual at increased risk. If firearms are involved, the psychiatrist should contact a friend or relative and have them removed from the patient’s home before release (APA practice guidelines). 20.3.2 Pathogenesis The pathogenesis of self harm and suicidal behavior is complicated and multifactorial. Sourander et al. (2006) attempted to identify early factors correlating with self-harm behaviors in childhood and adolescents. In this longitudinal study, parents rated children on Childhood Behavior Checklist and adolescents and their parents rated psychopathology at ages 12 and 15. Psychopathology in the child, poor parental well- being and living in a broken home at age 12 correlated with deliberate self harm at age 15. School and problems with peer groups at age 12 correlated with ideations of self harm at age 15. Acts of deliberate self harm in pre-adolescences led to higher rates of future behaviors. Biological Factors Studies have found that up to 90% of individuals who present with self harm meet diagnostic criteria for psychiatric disorders. The most common is depression, followed by substance use disorders and anxiety disorders (Skegg, 2005). General population studies have indicated that individuals with psychopathology are at increased risk of self harm and suicide. Individuals with antisocial and borderline personality disorders exhibit high rates of self harming behaviors. Eating disorders, schizophrenia and post traumatic stress disorder have also been found in study samples of self harmers (Skegg, 2005). Treating underlying psychopathology may reduce risk in aﬀected individuals. Table 1: Selected Risk Factors for Self Harm 1. Between puberty and old age 2. Female 3. Separated or divorced 4. Low socioeconomic status 5. Less education 6. Poverty Skaggs, 2005 Deliberate Self-Harm (DSH) and Depression While DSH is almost always associated with dysphoria, it is not always associated with the syndrome of depression. DSH can occur in the setting of depression associated with both bipolar disorder and unipolar major depressive disorder. Haw et al. (2001) when he looked at a cohort of 106 patients who presented to a hospital following an episode of DSH found that 92% of these patients had a psychiatric diagnosis and that the most common diagnosis was aﬀective disorder (72% using ICD-10 criteria). Early adverse life events have a major impact on subsequent mood states. Similarly, early adversity is a major correlate of subsequent DSH behaviors (Gladstone et al. 2004; Parker et al. 2005). Gladstone et al. (2004) examined DSH behaviors, personality characteristics, and childhood variables, including parental styles and childhood sexual/physical abuse, among 125 women with depressive disorders. Findings indicated that participants who were victims of childhood sexual assaults were more likely to engage in DSH as adults (Gladstone et al. 2004). In addition, respondents who were victims of childhood sexual abuse became depressed earlier in life than non-abused controls (Gladstone et al. 2004). Adolescents with DSH generally have less severe depressive symptoms than individuals with suicidal ideation, but more severe symptoms than those without any history of self-injurious ideation. In a community sample, adolescents who have a history of self-harm reported more depressive symptoms than those without a self-harm history (Muehlenkamp et al. 2004). In a study of 218 adolescents, ages 13-19, who were receiving outpatient treatment for a depressive mood disorder, adolescents who had DSH behavior had less severe depressive symptoms than those with suicidal ideation or suicide attempts (Tuisku et al. 2006). Similarly, among adults the degree of seriousness of a self injurious act was associated with depression and with intent. In a study of 49 prisoners in Germany, measures of depression and hopelessness were both highly correlated with suicidal intent and lethality; less lethal methods were not correlated with depression (Lohner et al. 2006). Impulsive acts of self-harm were rarely associated with depression (Lohner et al. 2006). DSH behaviors are not fixed over the life time. For example, 70% of 132 adolescents who had deliberately poisoned themselves and who were followed for 6 years stopped the self-harm behaviors within 3 years of the index event (Harrington et al. 2006). DSH continued into adulthood mainly among those with psychiatric disorders. Only 56% of these study participants had a psychiatric disorder, and the most common psychiatric diagnosis was depression (Harrington et al. 2006). DSH behaviors may appear de novo in the elderly. Lamprecht et al. (2005) looked at older people presenting to an acute hospital with an episode of DSH. Sexual distribution among males and females was equal. Only 37% had a major depressive illness at the time of the DSH assessment, but 21% of the males had no psychiatric diagnoses at the time of the DSH (Lamprecht et al. 2005). In young adults, the lack of depression in subjects with DSH has also been noted. Among 1,986 high-functioning military recruits (62% male), only 10% of those with a history of DSH reported depressive symptoms on the Beck’s Depression Inventory (Klonsky et al. 2003). Peers viewed self-harmers as having strange and intense emotions and a heightened sensitivity to interpersonal rejection (Klonsky et al. 2003). Given that DSH may not necessarily be associated with depression, why does it occur? Tzemoz and Birchwood (2006) examined dysfunctional thinking patterns and intrusive memories in patients diagnosed with both unipolar depressive and bipolar mood disorders. They recruited 49 participants diagnosed with major depression, manic, or hypomanic episodes. Twenty healthy controls were also recruited from the same areas in Central England. Compared to the healthy controls, dysfunctional attitudes were abnormal in the mood disordered groups when ill (Tzemoz and Birchwood, 2006). Interestingly, whereas dysfunctional attitudes resolved in bipolar subjects as they became euthymic, they persisted into euthymia for those diagnosed with unipolar major depression (Tzemoz and Birchwood, 2006). Deliberate Self Harm and Bipolar Illness Intentional self harm in mania is rare and is probably related to the depressed mood that can occur during manic episodes (Ostacher and Eidelman, 2006). However, DSH during bipolar depressions is more common than DSH in unipolar depressive illness (Parker et al. 2005). Parker et al. (2005) reported that across samples of depressed individuals, more individuals with bipolar disorder tended to report DSH behaviors compared to those with unipolar depression. Smith et al. (2005) examined the prevalence rates of bipolar disorders and major depression among 87 young adults with recurrent depression; 83.9% of study respondents met criteria for major depressive disorder, 16.1% met criteria for a DSM-IV-defined bipolar disorder. The authors reported that among the respondents diagnosed with major depression, 45.7% had a history of DSH, and 13.0% had a history of a previous suicide attempt. Of the 14 respondents diagnosed with BP disorder, 71.4% had DSH and 28.6% had a history of deliberate self-harm. One of the best known occurrences of DSH was performed by Vincent van Gogh (1853-1890), a Dutch Impressionist artist who had bipolar disorder (Jamison, 1993). On Christmas Eve in 1888, Van Gogh cut oﬀ his own earlobe with a razor blade as he was apparently attempting to attack an acquaintance. Following this episode of self-harm, van Gogh exhibited alternating states of "madness and lucidity," and received treatment in an asylum in Saint-Remy. Two months after his discharge from the asylum, he committed suicide by shooting himself "for the good of all" (Anonymous, 2007). Mood Disorders and Suicide Suicide, the act of ending one’s life, is the most dramatic form of self-harm. Epidemiologic research indicates that in 2004, 31,484 individuals in the US died from suicide or self-inflicted injury (10.8 per 100,000 population) (Center for Disease Control, 2006). Extensive research has examined risk factors for suicide, and several studies have identified a history of prior suicide attempts as a very strong predictor of suicide risk (American Psychiatric Association, 2003; Borges et al. 2006; Gaynes et al. 2004). Certain sociodemographic characteristics have also been associated with high suicide risk. These include male gender, European-American ethnicity, and advanced age. However, the National Comorbidity Survey Replication Study, found that low income, "non-Hispanic Black" (p. 1750) ethnicity, and age less than 45 were significant correlates of suicide ideation (Borges et al. 2006). Additional risk factors include the presence of a psychiatric disorder, particularly depression, alcohol abuse, physical and sexual abuse, and a family history of suicide (Gaynes et al. 2004). Psychiatric disorders may be present in up to 90% of those who commit suicide (American Psychiatric Association, 2003). Divorced, separated, or widowed individuals have a higher risk of suicide (American Psychiatric Association, 2003). Conversley, high-conflict or violent marriages may increase the risk for suicide among married individuals (American Psychiatric Association, 2003). Unipolar Depression and Suicide Numerous studies have identified depression as a significant risk factor for suicide. This contributes to mortality rates associated with depression that are approximately 20 times higher than the general population (American Psychiatric Association, 2003). The fraction of people who have committed suicide that were depressed at the time of their death has been estimated to range from 15% (Rich et al. 1986) to 97.5% (Sinclair et al. 2005). However, most studies, including those that are based on psychological autopsies, estimate a rate of 30-34% (Arato et al. 1988; Henriksson et al. 1993; Foster et al. 1999). The fraction of adolescent suicides that involve depression may be slightly higher at 43% (Brent et al. 1999). Co-morbid psychiatric conditions may additionally increase the risk for suicide. Paramount among these is co-occurring substance use which accounts for some 45% of completed suicides (Rich et al. 1986). Additionally, aggression (Dervic et al. 2006; Keilp et al. 2006) and cluster B personality disorders (Dervic et al. 2006) are associated with suicide attempts in depressed individuals with a history of childhood sexual abuse. A decline in depression and hopelessness was associated with a decline in suicidal ideation in 198 people diagnosed with major depression (Sokero et al. 2006). There is a close correlation between the increased use of antidepressants and an observed decline in overall suicide rate (Korkeila et al. 2007; Gibbons et al. 2006), but this trend may have begun prior to the introduction of antidepressants (Safer and Zito, 2007). Antidepressants may have no eﬀect on suicide ideation (Hammad et al. 2006) or may actually increase the risk of suicide attempt among depressed adults (Tiihonen et al. 2006) and suicide ideation among adolescents (Bridge et al. 2007; Dubicka et al. 2006), but may reduce completed suicides (Tiihonen et al. 2006). The United States Food and Drug Administration (FDA) has placed a warning on all antidepressants, that they may increase suicidal ideation in adolescents (Kuehn, 2007). While lithium is rarely used in major depressive disorder, it appears to have an anti-suicide eﬀect, similar to that seen in bipolar illness (Guzzetta et al. 2007). Vignette #2 John was a 61 year old male who presented to the emergency room with a 7cm laceration on his left inner forearm. The laceration was moderately deep and required multiple sutures. There were no other signs of current or former abuse on his arms or the rest of his body. After John’s arm was sutured, he was evaluated by a psychiatrist for a possible suicide attempt. John revealed that he was in a marriage that had not been healthy for quite some time and that his wife had called to say she was not coming home and that she wanted a divorce. John decided he could not face life without his wife and saw no way to call for help so cut himself. He denied suicidal intention at the time of the injury and denied it again at the time of the interview. John could not identify any social support persons and did not have any plans for the future. He kept insisting that he needed to go home but would not say what he needed to do there. John’s past history was significant for physical abuse by his father when he was a child. His father then left when he was 11 years old. His mother was not emotionally available and was overwhelmed at being left with 4 children to care for when she only had a minimum wage job. John was on his own for most of his teen age life. As the oldest child, he was responsible for helping with the other 3 children when his mother was not around. John related that he had always thought the marriage to his husband was going to be diﬀerent from his mother’s and was not going to end in divorce. He said he felt like it was all his fault and he would never find another person to love him. John’s psychiatrist felt that he was a risk for attempting suicide when he returned home and placed him in a psychiatric hospital for safety and stabilization. Bipolar Disorder and Suicide Lifetime prevalence of all bipolar disorders is approximately 2%; bipolar I disorder has a incidence rate of 0.8%, compared to 1.2% for bipolar II disorder. Suicide risk is high in bipolar disorder. Angst et al. (1995) followed 406 patients for 36 years; findings indicated that 11% committed suicide, regardless of whether patients were diagnosed with type I or II disorder. Other estimates approach 19% (Ostacher and Eidelman, 2006). The risk appears higher than in unipolar major depression. Chen et al. (1996) examined data from the Epidemiologic Catchment Area Study (ECA) to estimate lifetime rates of suicide attempts in mood disorders; findings indicated that 29.2% of respondents with bipolar disorder attempted suicide, compared to 15.9% among those with unipolar depressive disorder. Additionally, when subjects with bipolar disorder attempt suicide, the lethality of that attempt may be greater. Among 2,395 hospital admissions of patients with unipolar depression and bipolar disorder subjects with bipolar disorder had a higher incidence of more lethal suicide attempts (Raja et al. 2004). The odds of completed suicide in those with bipolar disorder is 2.0 times higher compared to those with unipolar depression (Raja et al. 2004). However, prevalence rates of suicide may be inflated, since researchers typically focus on hospitalized patients and those who have received treatment from a mental health provider. This self-selected population may be more ill compared to those who receive treatment from primary care providers, or those who do not receive any psychiatric treatment. Risk for suicide is highest during a depressive episode of bipolar disorder. Isometsa et al. (1994) found that among patients diagnosed with bipolar disorder, 80% of completed suicides occur during a depressive episode. Mortality from suicide in bipolar depression may be 30 times that of normal controls (Ostacher and Eidelman. 2006). However suicidal ideation and suicide completions may occur during the mixed (Dilsaver et al. 1994) or even manic phase (Cassidy et al. 2001). Rapid cycling also carries a higher likelihood for more serious suicide attempts but not an increase in completed suicides compared to other types of episodes (42 vs 27%) (MacKinnon et al. 2003). Suicide risk is highest in newly diagnosed bipolar patient. Fagiolini et al. (2004) found that among 104 patients with bipolar disorder, 50% attempted suicide within 7.5 years of the initial onset of the illness (either mania or depression). In these young bipolar patients, suicide rarely occurs during episodes of mania. Lithium appears to have a clear eﬀect on reducing completed suicide in bipolar patients with a five fold reduction in relative risk (Baldessarini et al. 2006; Tondo et al. 2001). More impressively, lithium reduces non-suicidal DSH and non-psychiatric mortality in bipolar patients (Cipriani et al. 2005). Vignette #3 Dick was a 24 year old young man in law school when he had his first manic episode. He had a history of a depressive episode that had been diﬃcult to treat when he was 18 but had not had any problems since that time and was not on any medications at the time of this manic episode. During the episode, he lost his job, his relationship with his girlfriend and he spent thousands more dollars than he could aﬀord to spend in cars, jewelry, vacations and gifts to his girlfriend. He was hospitalized and stabilized on appropriate anti-manic medications. Approximately 4 months later, Dick began another depressive episode. This time he was thinking of all the things he had lost. He felt like his life as a lawyer was over and that he was destined to be a disabled person with no job, no family and no friends for the rest of his life. He did continue to take his medicines and see his psychiatrist but did not discuss any of these thoughts with any of his support persons. 2 months after the depressive episode began, Dick was found in his home, having hung himself from a rafter in the garage. Serotonin System and Suicide On a molecular level, the serotonin system has been implicated in self harm population studies. Low levels of 5 HIAA have been found in cerebrospinal fluid in self-harmers (Skegg, 2005). There are many biological associations between mood symptoms and aggression or violence. These include increased aggression with increased cytokine activity (Zalcman and Siegel, 2006), catecholamine metabolism (Volavka et al. 2004), testosterone (Pope et al. 2000), and hypothalamic-pituitary-adrenal axis dysfunction (Shea et al. 2005; Malkesman et al. 2005). However, the most consistent findings are with the serotonergic system. Among the many findings associated with serotonergic dysfunction in aggression, platelet serotonin 2A receptor (5-HT2A) binding was increased in subjects with trait aggression (Lauterbach et al. 2006). Prefrontal cortical 5-HT2A binding was also increased in aggressive suicidal patients (Oquendo et al. 2006). Similarly, relative increases in plasma tryptophan levels (a precursor to serotonin) are associated with increased aggression and hostility (Lauterbach et al. 2006; Suarez and Krishnan. 2006) Lower CSF 5-HIAA concentration was independently associated with severity of lifetime aggressivity and a history of a higher lethality suicide attempt and may be part of the diathesis for these behaviors. The dopamine and norepinephrine systems do not appear to be as significantly involved in suicidal acts, aggression, or depression (Placidi et al. 2002). However, the most compelling findings regarding the involvement of serotonin in both mood disturbance and violence is found in the serotonin transporter polymorphisms. Several recent studies have investigated the role of polymorphisms in the serotonin reuptake pump or the serotonin transporter gene (5HTTLPR). A common polymorphism of this gene is a deletion in the area of the gene that regulates its transcription into messenger RNA, and ultimately translation into expressed protein, the promoter region. Individuals with this deletion, called the short or "s" allele, express fewer serotonin transporters. Individuals who are homozygous for the "s" allele (ss), are more likely to develop depression (OR 1.5-179) (Cervilla et al. 2006) and depression after a traumatic event (Kaufman et al. 2004; Caspi et al. 2003). Thus, the observed link between early life adversity, or later life trauma, and subsequent depression, is related, at least in part, to having the ss genotype (Kaufman et al. 2004; Caspi et al. 2000). While stressful life events or extreme adversity are clearly associated with subsequent depression, adversity is quite potent in inducing depression in subjects with the ss genotype; so that the dosage of adversity required to produce depression is much lower in individuals homozygous for the short form of the 5HTTLPR (Cervilla et al. 2007). Several studies have also found that the ss genotype is also associated with subclinical depressive symptoms in individuals without depression (Gonda et al. 2005, 2006; Gonda and Bagdy, 2006). The ss genotype of the 5HTTLPR is also associated with aggression. In a case control study of conduct disorder with or without aggression, it was found that the ss genotype was strongly associated with aggression but not conduct disorder without aggression (Sakai et al. 2006). A positron emission tomography (PET) study of 5HRRLPR density found that reduced transporter density is associated with impulsive aggression (Frankle et al. 2005). While this study did not examine the genotype of the study subjects, it found that the phenotype that is expected with the ss genotype is associated with aggression (Frankle et al. 2005). Among schizophrenic patients who attempted suicide, the ss genotype of the 5HTTLPR was associated with violent suicide attempts but not with non-violent attempts nor with non-attempters (Bayle et al. 2003). Psychological Factors Many psychological factors may also contribute to self harm and suicidal behaviors. It has been suggested that rage towards others, feelings of abandonment, guilt or desperation may play a role in these behaviors at a subconscious level (Skegg, 2005). Poor problem solving skills, impaired decision making skills and factors that contribute to the former have been studied and indicated as risk factors in those who harm themselves (Skegg, 2005). Neuroticism, dissociation and novelty-seeking personality traits are associated with suicide and self harm (Skegg, 2005). Direct Abuse or Neglect Childhood abuse and neglect are clearly associated with a substantial increase in the risk for subsequent depression and maladaptive behaviors (Cukor and McGinn, 2006; Reigstad et al. 2006; Widom et al. 2007). This is true in all cultures in which it has been studied (Afifi, 2006). Verbal and Emotional Abuse The experience of verbal abuse during childhood (e.g., "you are stupid") increases depression, anger and hostility in young adults (Teicher et al. 2006; Sachs-Ericsson et al. 2006). Verbal and emotional abuse influence the development of self-concept, and lead to a self-critical style of cognitive processing that contributes to low self esteem (Cukor and McGinn, 2006; Sachs-Ericsson et al. 2006). This impaired self-image may be one of the underlying phenomena that increase the risk of subsequent sexual victimization as a young adult (Rich et al. 2005). Physical Abuse Physical abuse may be a major contributing factor in the development of violence in later life (Huizinga et al. 2006). Physical abuse is also pivotal in the development of depression in youths and on into adulthood (Widon et al. 2007; Cukor and McGinn, 2006; Reigstad et al. 2006; Wright et al. 2004). Physical abuse may occur in either the home environment or in school. Bullying is a form of verbal and physical violence that can have major impact on development. The odds of experiencing social problems, depression with suicidal ideation and attempts are 3.9 times higher among victims of bullying compared to non-victims (Brunstein Klomek et al. 2007; Kim et al. 2006). Furthermore, bullying behaviors have been linked to mood disturbances. The odds of bullies developing social problems, depression, and suicidality are 1.8 times higher compared to people who are not bullies, and bullies who are also targets of other bullies are 4.9 times as likely to develop social problems (Brustein Klomek et al. 2007; Kim et al. 2006). High profile school shooters, such as Columbine High School or Virginia Tech University, have been bullied by class mates. Sexual Abuse Sexual abuse of children is associated with a wide variety of physical and psychological sequelae, many of which are life-long. Early sexual abuse is associated with a significant increase in depression in both males and females (Peleikis et al. 2005; Conway et al. 2004; Gladstone et al. 2004; Martin et al. 2004). The risk of subsequent suicide attempts is 15 times higher in boys who experience early sexual abuse compared to non-abused boys (Martin et al. 2004); among women suicide ideation is 4.5 times higher (Masho et al. 2005). The consequences of childhood sexual abuse includes greater severity of depressive illness in adult patients over age 50 (Gamble et al. 2006; McGuigan and Middlemiss, 2005). Adult women who have experienced childhood sexual abuse are more likely to be victims of violence (Gladstone et al. 2004) and other forms of trauma, including sexual assault (Rich et al. 2005; Banyard et al. 2002). Sexual abuse perpetrated by adult women can be just as harmful as sexual abuse perpetrated by men (Denov, 2004). Social/Cultural Factors Experiences early in life may be an important risk factor for later self harm. Children of divorced parents, women of low education or socioeconomic status and children of parents with psychopathology are at higher risk of deliberate self harm (Skegg, 2005). Trauma early in life such as physical, sexual or emotional abuse and exposure to household violence has been identified as risk factors (Skegg, 2005). It has been diﬃcult to determine if these experiences are independent risk factors, or if they lead to impairment in relationships that may also be a risk factor for self harm (Skegg, 2005). Social support appears to play a key protective role in self harming behaviors as evidenced by groups of people who have been found to be a higher risk. Divorced and separated individuals are at a higher risk, as are unemployed individuals. It has been found that social support reduces self harming behaviors and moderate stress (Skegg, 2005). Multiple studies have also found moral obligations and religious beliefs to be protective against suicide (Skegg, 2005). 20.4 Treatment Risk assessment and the patient’s ability to follow through with treatment are key factors in determining treatment modality in the suicidal patient. Depending on the circumstances, treatment can range from involuntary hospitalization on secure psychiatric wards to out-patient clinic follow-up. Treatment should be carried out in the environment that is least restrictive, but includes adequate measures for safety. Goals of management include es-tablishing a therapeutic alliance, establishing safety and determining the patient’s needs. Incorporating the patient’s individual needs into the treatment plan is important to promote adherence (APA practice guidelines). When establishing the therapeutic alliance, it is important for the psychiatrist to be aware of countertransferance and transference reactions between themselves and the suicidal patient. Dealing with suicidal individuals can uncover the psychiatrist’s own feelings about death and suicide and may provoke anger in some. On the other hand, some patients with a strong desire to die may become angry at the treating physician, and others may have a desire to be saved instead of taking responsibility for their own actions (APA practice guidelines). Attending to the patient’s immediate safety is a priority in the treatment setting, especially in the acute phase. In the emergency setting, it is imperative to remove personal objects that the patient could use to harm themselves. Removing personal items such as purses and shoestrings that the patient could use to harm themselves may be necessary on inpatient units. Close surveillance via frequent safety checks or surveillance cameras may be necessary in acutely suicidal individuals (APA practice guidelines). A balance between suicide risk and risk associated with hospitalization must be accomplished to determine the most appropriate setting. While establishing safety is a priority, there are also eﬀects of hospitalization that may have negative eﬀects on a patient’s life situation. These include financial risks including hospital bills and lost time from work, social stigmatization and psychosocial stressors. Generally, hospitalization is indicated when patients are at high risk of self harm, have new onset of suicidal behaviors, require treatments that can only be performed in the hospital setting, or are unable to comply with less restrictive treatment options (APA practice guidelines). Pharmacotherapy Evidence clearly indicates that underlying mood disorders must be treated to optimize treatment in the suicidal or self-harming patient as discussed above in the pathogenesis discussion. A brief summary of findings regarding specific classes of drugs as related to self-harming behaviors is included below. Antidepressants According to the American Psychiatric Association practice guidelines, pharmacotherapy is commonly used in suicidal patients suﬀering from depression and anxiety disorders. They have also been used to treat suicidal patients with comorbid substance disorders. However, limited evidence based studies exist to support that this treatment modality reduces rates of suicide. Studies using FDA databases do not show diﬀerences in rates of suicide with the use of antidepressants (APA practice guidelines). Conflicting evidence exists regarding the increased incidence of suicide following SSRI treatment. Several case reports were published, however, and patients should be educated regarding these findings. However, clinicians must be careful to not neglect treatment of real mood pathology due to fear. Lithium The APA practice guidelines identify treatment with lithium salts as an evidenced based treatment to reduce suicide risk in patients with bipolar disorder and major depressive disorder. They report that this treatment has been shown to decrease suicidal acts by 14-fold. Practitioners should be aware of the high lethality of overdose on lithium when prescribing quantities to potentially suicidal patients. Other Mood Stablilzers Anti-convulsant agents are frequently used as mood stabilizer therapy. They may reduce suicidal behaviors, however, are not as evidenced supportive as Lithium (APA practice guidelines). Atypical Antipsychotics Atypical antipsychotics are commonly used to reduce hallucinations, delusions, agitation, aggression and contusion, which may reduce self-harm and suicidal behaviors. These agents are indicated for use in patients with schizophrenia, schizoaﬀective disorder, and mood disorders with psychotic features. These include aripiprazone, clozapine, olanzapine, quitiapine, risperidone and ziprasidone. Clozapine is typically reserved for patients who do not respond to other agents due to side eﬀects. For the same reason, typical antipsychotics are usually reserved for people not responding to newer agents (APA practice guidelines). Antianxiety Agents Theroetically, antianxiety agents would have the potential to reduce suicide and self-harm risk since anxiety is a risk factor. However, studies are limited. Agents commonly used are benzodiazepines and buspirone. Psychotherapy Since suicide is relatively rare in the general population, it is diﬃcult to conduct studies with enough events to reach statistical significance. A meta-analysis of psychosocial interventions by Crawford et al. (2007) suggests that specific psychosocial interventions following acts of self-harm do little more than standard care to prevent subsequent suicide. 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