SUICIDE & Other Psychiatric Emergencies: SUICIDE & Other Psychiatric Emergencies KIRAN RANDHAWA Psychiatric emergencies : Psychiatric emergencies A psychiatric emergency is an acute disturbance of behavior ,thought or mood of patient which if untreated may lead to harm ,either to individual or to others in the environment. A sudden onset of an unusual disordered inappropriate behavior caused by an emotional & psychological situation. Bimla kapoor 2002 Objective of psychiatric emergencies: Objective of psychiatric emergencies To safeguard the life of patient To reduce anxiety To promote emotional security of client & family members To educate client & his family members the ways of dealing emergency situation by adaptive coping strategies, problem solving methods. Characteristics of psychiatric emergencies: Characteristics of psychiatric emergencies Certain conditions or stressors predisposes the client & family members to seek immediate intervention as they feel more discomfort. Disharmony between client & his environment. Sudden unexpected disorganization in person Unable to cope up with stressful situation Classification : Classification 1.Suicidal patient 2.Agitated and violent behavior 3.Panic attack 4.Stupor & catatonic syndrome 5.Withdrawal syndrome 6.Overdosage of alcohol or drug 7.Severe depression 8. Hysterical attack 9.delerium 10.Disasters Suicide : Suicide Suicide is not diagnosis or disorder ,it is a behavior. the judeo Christian belief that life is from god & taking it is strictly forbidden. In ancient Greece suicide was an offence against the state and individual who committed suicide were denied burial in community sites. In middle age is was considered as criminal act. Most of religious belief suicide is sin against god. All of religion condemned suicide. Definition : Definition “ Aggression towards self following the internalization of frustration or disappointment related to loved one” Freud1957 “Ultimate act of self destruction” Clayton1985 In USA suicide ranks 8 leading cause of death . It is act of killing self. Epidemiological factors: Epidemiological factors Approximately 30,000 person in US end their lives each year by suicide It is 18 th leading cause of death among adults & 3 rd leading cause of death behind accidents and homicide In India it is very common especially in urban setting than rural. 90 -94 % of patient are mentally ill when committing suicide Most common in 15 -30 yr Risk factors: Risk factors Marital status - rate for a single person is twice than a married person Divorced ,widowed or separated have 4 -5 times more than those married. Gender – women attempt suicide more & men succeed more often. Successful suicide rate is about 70% in male & 30% in female. Age – suicide risk and age having positively correlated among adolescent it has tripled Elderly it risen to 25% female suicide decline after 65 yr Cont….: Cont…. Religion – protestants have significantly higher rate of suicide than catholic and jews . Socioeconomic status – individual in very highest & lowest social class have hogher suicidal rate than those in middle class. Other risk factors – Mood disorders Mental disorders Depressive disorders Schizophrenia, substance abuse, organic brain disorders,panic disorders Cont….: Cont…. Loss of loved ones Lack of employment Increased financial burden Loss of health Constant failure to use normal coping mechanism Multiple risk factors Significant changes in relation ship. Psychological causes: Psychological causes Isolated feeling Loneliness To solve problems Intolerable psychological pain Severe frustration Hopelessness & helplessness Conflict Life long pattern of failure, stress, threat Excessive anger Aggressive act towards self Cont….: Cont…. Violent behavior Stressor of conflict Guilty ,shame Unfulfilled need Grief reaction Fear Impaired thought process Repressed desire to kill someone Cont…..: Cont….. Menninger's view it is self directed death instinct , components of suicide Wish to kill Wish to be killed Wish to die Social causes: Social causes Family problems – lack of parental & maternal care Physically abused Economic failure Lack of social support Disturbed interpersonal relationship Lack of satisfaction Social isolation Low social status Predisposing factor theories of suicide : Predisposing factor theories of suicide Psychological theories – 1 .Anger turned inward – freud believe that it was response to intense self hatered that individual possessed . It occur as result of an earlier reppressed desire to kill someone else .they inetrpreted suicide to be an aggressive act towards the self that often was directed towards others . Cont….: Cont…. 2 .Hopelessness – ghosh & victor identify hopelessness as central factor in suicide 3. Despration and guilt – Hendin 1991 identified desperation as imp. Factor with it individual feel helpless to change . 4. History of aggression & violence – violent behavior goes hand in hand with suicidal behavior . 5. Shame and humilation – some have viewed as face saving mechanism a way to prevent public humiliation following social defeat Cont….: Cont…. 6. Developmental stressor – the stressor of conflict , separation and rejection are associated with suicidal behavior in adolescence & early adulthood. Economic problems & medical illness. Sociological theory – Durkheim described 3 social categories of suicide 1 . Egoistic suicide – the response of individual who feels separate &a apart from the main stream of society . Integration lacking does not feel part of society. Cont….: Cont…. 2. A ltruistic suicide – opposite of egoistic individual who is prone for this is excessively integrated in group. Group is governed by culture , religion or political ties ,individual sacrifice life for group. 3. Anomic suicide – occur in response to change in an individual life that disrupts feeling of relatedness to group .e.g. Divorce , loss of job Feeling of separation or without support . Cont….: Cont…. Biological theorie s – Genetic – possible existence of genetic predisposition towards suicidal behavior . Neurochemical factor – decrease in level of serotonin in depressed client attempted suicide Method of committing suicide : Method of committing suicide Low lethal methods- self poisoning –pill ingestion inhalation of gaseous substances High lethal methods- Gun shooting Hanging Drowning Consuming high doses of barbiturates Car crash Piercing vital organs Co -Poisoning Assesment : Assesment Observable behavior of client – Depressed ,isolated from self Tense ,worried, anxiety ,hopelessness Insomnia, restlessness, fatigue, listen to voices telling them to die Acts aggressively ,motor agitation, frustrated feelings The frequency & extent of suicidal ideas Contemplated means of committing suicide The feeling associated with suicide Mental status examination Nursing management : Nursing management Risk for suicide related to feeling of hopelessness and desperation Intervention – ask directly have thought of harming yourself ? if so what do you plan to do? Do you have means to carry out ? Create a safe environment for patient , remove all potentially harmful objects from client access e.g.. Sharps, straps, belts, ties, glass item, alcohol. Formulate short term verbal or written contract that client will not himself. Cont…..: Cont….. Maintain close observation of client provide one to one contact, constant visual observation. Accompany to off ward activities such as to washroom Maintain special care in administration of medications Make round at frequent intervals Encourage client to express honest feelings ,anger . Cont…: Cont… Hopelessness related to absence of support system and perception of worthlessness evidenced by verbal clues ,suicide ideas Intervention – Identify stressor in client life that precipitated crisis Determine coping behavior previously used and its effectiveness. Encourage client to explore & verbalize feeling & perceptions Provide expression of hope to client in positive , low key manner you are very imp. To people who care about you. Cont…..: Cont….. Help client to identify areas of life situation that under own control. Identify resources that client may use after discharge when crises occur or feeling of hopelessness & possible suicidal ideas prevail . Information for family & friends of suicidal client : Information for family & friends of suicidal client Take any hint of suicide seriously anyone expressing feeling need immediate attention. Do not keep secrets do not make promise with client asking you not to tell anyone. Centers of disease control offers following suggestions – Be a good listeners and support them let them know that you are there with them. Express concern for individual who express thoughts of committing suicide Cont….: Cont…. Restrict access to self harm The mental health sanctuary offer following tips – Acknowledge & accept their feeling Try to give them hope Stay with them Show love & encouragement Help them seek professional help Remove harmful objects from home Do not : Do not Judge suicidal patient Show anger towards them Provoke guilt in them Discount their feelings Prevention of suicide: Prevention of suicide Primary prevention – Improve skills of team members in identifying high risk client & planning treatment care. Never allow high risk to be alone Refer high risk for psychotherapeutic interventions Early recognition & prompt treatment of psychiatric disorders Identify stressors Educate community & focus group. Cont…….: Cont……. Guidance and counseling services Conduct crisis intervention programme Restrict means of suicide Modify environment Assess criteria of suicide Secondary prevention: Secondary prevention Establishment of crisis prevention & counseling centers Improve availability and quality of help for those who may be contemplating suicide Guidance & counseling services Arrange for screening high risk group Organize awareness campaign for resource person e.g.. Teacher , community leader Provide treatment for actual suicidal crisis in clinics , in hospitals. Tertiary prevention : Tertiary prevention Interventions with family & friends of person who has committed suicide e.g.. Guidance ,psychotherapy, family therapy Minimizing residual effects of suicidal attempts Follow up & continuity of care has to be planned Supportive system has to be strengthened .