SUICIDE

By :
Dr. Cecep Sugeng, SpKJ

INTRODUCTION

Suicide 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 FACTORS
1.
2.
3.
4.
5.
6.

Psychiatric Disorders
Social Factors
Psychological Factors
Biological Factors
Genetik 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 5hydroxy-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 PATIENTS

Many 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.

Cont

The 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.

Cont

The 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.

Cont

Useful 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

AGGRESSION
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
Some 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

ETIOLOGY
Psychological Factors

ETIOLOGY
Social Factors
Frustation
The 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 Provocation
Television Violence

ETIOLOGY
Environmental Factors
Air Pollution
Noise
Crowding

ETIOLOGY
Situational Factors
Heightened Physiological Arousal
Sexual Arousal
Pain

ETIOLOGY
Biological Factors
Neuroanatomical Damage
Neurotransmitters

ETIOLOGY
Genetic Factors
Twin Studies
Pedigree Studies
Chromosomal Influences

EPIDEMIOLOGY
According 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 CONTROL

begins 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.

 Punishment
sometimes 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 aggressively
Punishment may only temporarily reduce the
strength or frequency of aggressive behavior
Certain punishments may backfire and actu ally
encourage, rather than inhibit, the dangerous
actions they are designed to prevent

 Catharsis
For 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 Skills

many 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 Responses

Empathy.
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.

Pharmacotherapy
Lithium (Eskalith) : especially delinquent
adolescent boys.
Anticonvulsants occasionally reduce seizureinduced 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 (betablockers) and stimulants : aggressive
children.
ECT .

VICTIMS
An 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.

 ACCIDENTS
An 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 USA
Accidents 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 Considerations
A 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.