_____________________________________________________________ Suicide Assessment and Prevention
THE MISREPORTING OF DEATH BY SUICIDE There is broad agreement that not all suicide deaths are accu- rately recorded and reported. Reasons for under-reporting include [5; 18; 19; 20; 21]: • Families or family physicians may hide evidence due to the stigma of suicide. • The determination of death is judged by local stan- dards, which can vary widely. • Ambiguous cases involving suicide may end up classi- fied as “accidental” or “undetermined.” • Compared with the “accidental” or “undetermined” motive categories, a larger number of deaths are offi- cially classified as “ill-defined and unknown causes of mortality,” in which even the actual cause of death is uncertain and some of which are undoubtedly suicides. • The frequency of physician-assisted suicide for the ter- minally ill is unknown but is probably both substantial and increasing. In contrast, some ambiguous cases are classified as suicides, often in institutions such as prisons, hospitals, religious orders, and the military, where the verdict of suicide is likely to be less embarrassing than homicide. Other motivations for declaring a death a suicide, despite much doubt surrounding a case, are that homicides must be investigated and a murderer sought and accidental death may be the basis of negligence lawsuits [5]. SUICIDE REPORTING IN THE MEDIA Suicide rates may temporarily spike with intense media cover- age of a suicide, especially among youth, and both news reports and fictional accounts of suicide in movies and television can produce this effect [22; 23; 24]. Imitation is often the key fac- tor and is most powerful with the highly publicized suicides of entertainment celebrities [5; 25]. Media coverage of suicide can lead to misinformation, as when suicide is attributed to a single event, such as the loss of a job or a relationship, without mention of a broader context involv- ing ongoing problems with depression, substance abuse, or lack of access to treatment for these conditions. On the other hand, responsible coverage of suicide can educate audiences about the causes, warning signs, and treatment advances and prevention of suicide [5]. Thirty-six hours after admission, Patient A has been extubated and is awake, sitting up, and talking to a young man (the boyfriend) at her bedside. As you approach, she smiles sheepishly and asks, “Can I go home now?” Before answering, which of the following management options would you consider appropriate at this juncture? • Have physical therapy assess strength and ambulation. If normal, discharge her home to the care of her family. • Ask the young man to step out, then take a careful medical and social history, exploring in detail her mindset, actions, and intent in the period leading up to admission.
• Anticipate transfer out of the intensive care unit and the need for an around-the-clock “sitter” in her room as a suicide preven- tion precaution. • Request social service consult to assess her resources and support system and a psychiatry consult to assess the need for further inpatient care and recommend a plan for outpatient follow-up.
PATHOPHYSIOLOGY OF SUICIDAL BEHAVIOR
Although suicide is a potential complication of all psychiatric disorders, serious suicidal actions have a neurobiologic basis that is distinct from the psychiatric illnesses with which they are associated [26]. Alterations in several neurobiologic systems are associated with suicidal behavior, most prominently hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, serotonergic system dysfunction, and excessive activity of the noradren- ergic system. While the first and the last system appear to be involved in the response to stressful events, serotonergic dysfunction is thought to be trait-dependent and associated with disturbances in the regulation of anxiety, impulsivity, and aggression [27; 28]. Altered functioning of these systems may stem from both genetic and developmental causes. Exposure to extreme or chronic stress during childhood has developmental consequences on these systems that persist into adulthood. Genetic differences may also contribute to alterations in the functioning of these neurobiologic systems, and the interac- tive effect of adverse childhood experiences, such as physical abuse, sexual abuse, or caregiver abandonment, with genetic vulnerability is increasingly believed to play a role in suicidal behavior [27; 29]. Neurobiologic and psychologic perspectives have converged to identify the most prominent risk factors for suicidal behavior: dysregulated impulse control and a propensity to intense psy- chologic pain that includes hopelessness, often in the context of a mood disorder. These factors are believed to largely reflect serotonergic system dysregulation [30]. Investigation into the role played by serotonergic dysfunction in suicidal behavior has identified two prominent regions: the dorsal and median raphe nuclei in the midbrain, which host the main serotonergic cell bodies, and the prefrontal cortex, particularly the ventral prefrontal cortex, which is innervated by the serotonergic system. In vivo and postmortem examinations have revealed serotonergic hypofunction in these two brain systems in per- sons who have died by suicide or made serious suicide attempts. The deficient serotonergic input in the ventral prefrontal cortex stemming from this serotonin hypofunction can result in a breakdown in inhibitory function leading to a predisposition to impulsive and aggressive behavior. This vulnerability to deficient impulse control coupled with the development of psychiatric illness or other life stressors elevates the risk of acting on suicidal thoughts [31].
53
EliteLearning.com/Psychology
Powered by FlippingBook