with higher risk of suicide. It has been described that perfectionism and good levels of insight among individuals who have recently developed psychotic symptoms are significantly associated with higher numbers of suicidal attempts. Moreover, recent evidence shows that prefrontal cortex-based circuit dysfunction may be related to suicide in the early stage of schizophrenia. Rates of completed and attempted suicides among schizophrenia patients are lower than those reported for patients affected by other psychiatric conditions (0.24 and 0.74 per 100 person years, respectively). In particular, the suicide-related mortality is higher among subjects recently diagnosed with schizophrenia (5 years or less from diagnosis). In fact, suicide risk is two-fold higher at the onset of psychotic illness than in the later course. The first episode of psychosis (FEP) can be divided in four phases: 1. Prodromic, early phase or emerging psychosis. 2. Untreated psychosis (UP; the duration of untreated psychosis is labeled as DUP). 3. Acute psychosis and its treatment. 4. Post-psychotic recovery. Each phase is characterized by different risk of suicide. In the first phase, which may be called “at-risk mental state” or “prodromic,” suicidal behaviors may be due to the distress caused by unfamiliar emerging pre-psychotic experiences. The delay in accessing the mental healthcare system and starting treatment, called “duration of untreated psychosis” (DUP), may greatly contribute to increase suicide risk among schizophrenia patients at FEP. During the acute phase of schizophrenia, psychotic experiences (distressing delusions, command hallucinations or passivity phenomena) and feelings such as fear, stigma, and loss (in patients with some degree of insight), are relevant factors for suicide. Risk of suicide during the following phase of post-psychotic recovery may be related to the loss of role and function mostly due to neurocognitive sequelae, which is defined as a pathological condition or complication resulting from a disease, injury, therapy, or other trauma and is typically a chronic condition that follows a more acute condition. Eating disorders Eating disorders are a known risk factor for suicidal behavior, especially among young women (Miranda-Mendizzbal, Castellvi, Pares-Badell, Alayo, Almenara, et al., 2019). Suicide is the leading cause of death among those with anorexia nervosa, bulimia nervosa, or binge-eating disorder (Yao, Kuja-Halkola, Thornton, Runfola, D’Onofrio, et al., 2016). Anorexia nervosa is an eating disorder characterized by extreme low weight, refusal to maintain a normal body weight, and excessive overvaluation of weight and shape. Those with anorexia nervosa may or may not exhibit bingeing and purging behavior, in which an excessive amount of food is consumed, and then compensatory purging behaviors are enacted to mitigate caloric intake via vomiting, excessive exercise, laxative use, and other behaviors meant to reduce weight. Because bingeing and purging behavior can occur in anorexia nervosa, and the presence of these behaviors is also required for a diagnosis of bulimia nervosa, there is common confusion between these diagnoses. While bulimia is defined by required bingeing and purging behavior that occurs at least once per week for an extended period of time, and is paired with body weight and shape concerns, anorexia is instead defined by excessively low body weight. An individual at low body weight who is bingeing and purging would be diagnosed with anorexia nervosa – binge/purge subtype, rather than bulimia nervosa. Finally, a more recently established diagnosis of binge-eating disorder pertains to individuals who are at normal weight and engage in binge-eating behavior on a weekly basis without any accompanying purging behaviors. Lifetime suicidal ideation is associated with all types of eating disorders (Goldstein & Gvion, 2019). Bulimia and subthreshold
Studies show that only 20% of patients who attempted suicide report a comfortable living situation; in most of the cases, there may be a concern regarding loneliness, which may suggest that living with others is a protecting factor. In addition, studies found an increased risk for suicide in patients who experienced the fear of losing their partner or social position. In fact, it is clinically relevant to focus psychotherapeutic interventions on the feeling of loss. It is of interest that the risk of unnatural-cause mortality is reduced by 90% when there is a family involvement at intake or first contact with mental healthcare services. Further research is needed; family involvement and family cohesion are relevant factors that impact the outcome of illness as well as socioeconomic status and level of education. It can be very helpful for providers to integrate and include families and caregivers in the early intervention programs in order to improve the outcome of FEP. Several evidences report that higher education or higher cognitive functioning is associated with an increased risk of suicide in FEP. Specifically, higher levels of executive functions may influence the ability to plan suicidal behaviors. This agrees with previous research showing that higher cognitive functions, in particular attention and psychomotor speed, verbal fluency, verbal memory, working memory, and executive function, are associated with greater suicidality. Depressive symptoms in the prodromal phase of schizophrenia were frequently associated with suicidality during the following 12 months of outcome. Specifically, depressive symptoms are associated with lifetime as well as current risk for suicidal behaviors with higher rates of depression after the first episode and any relapse of psychosis. Many authors point out that, in FEP patients, depression and suicidal behavior may be a reaction to the perceived persecutors and entrapment. Other authors found that hopelessness was associated with suicidal ideation in FEP individuals and that this symptom in fact predicted suicidal ideation. It has also been hypothesized that suicidality in FEP may be linked to the patient’s altered basic self-awareness or sense of self, called self- disorders . There is a clear association between current suicidality and self-disorders, which appears to be connected by depressive states. anorexia have often been associated with increased risk of suicide plans and behavior; bulimia and binge-eating disorder have also been associated with suicide attempts (Conti et al., 2017; Smith, Forrest, & Velkoff, 2018). More than half of all adolescents with bulimia reported suicidal ideation and nearly one- third reported a suicide attempt (Smith et al., 2018). When treating patients with these disorders it is imperative to assess them for risk of suicide. Key demographic features of eating disorders are as follows: ● 90% of those with eating disorders have depression or other co-occurring mental disorders. ● The mortality rate for people with anorexia nervosa is roughly 20%. At least one-fifth of these deaths are from suicide. ● Research on young girls with anorexia found that 60% of the participants exhibited suicidal behaviors and 49% exhibited self-harm behaviors (Bodell et al., 2019). ● Roughly 17% of people with anorexia attempt suicide at least once in their lives, with people who develop purging symptoms having higher rates of attempts than those with restrictive symptoms (Bodell et al., 2019). (Smith, 2018) Researchers estimate that 30 to 40% of people with an eating disorder will also engage in self-harm, putting them at increased risk of accidental death due to the extent of the injury or developing suicidal thoughts. Possible motivating factors for self-harm include:
● Feeling unworthy and hopeless. ● Having a distorted sense of reality.
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