Suicide: The Silent Epidemic A Clinical Focus on Students

1. Suicide: The Silent EpidemicA Clinical Focus on Students Lisa Firestone, PhD The Glendon Association

6. Suicide Rates by Age for Youths Aged 10-19 Years in the United States, 2000-2006 [8] Epidemiology of Youth Suicide and Suicidal Behavior ,Scottye J. Cash, Ph.D. and Jeffrey A. Bridge, Ph.D. Curr Opin Pediatr. 2009 October ; 21(5): 613–619

7. Number of Youth Suicides, by Gender: 2009 Definition: Number of suicides by youth ages 15 - 24, by gender. Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use Death Files.

8. Youth Suicide Rate: 1995-1997 - 2007-2009  Definition: Number of suicides per 100,000 youth age 15 - 24. Data Source: California Department of Public Health, Center for Health Statistics, Vital Statistics Section, CD-Rom Public Use Death Files. State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050, accessed online at http://www.dof.ca.gov (August 2011). Footnote: Figures are presented as rates over three-year periods. LNE (Low Number Event) refers to data that have been suppressed because there were fewer than 20 suicides.

9. Self-Inflicted Injury Hospitalization Rate: 2009 Definition: Number of non-fatal self-inflicted injury hospitalizations per 100,000 for children/youth ages 5 - 20. Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011). Footnote: Injury hospitalizations are measured by the number of discharges from acute care hospital facilities for injuries among children and youth. The most common types of self-inflicted injuries are related to poisoning, and cutting or piercing. LNE (Low Number Event) refers to data that have been suppressed because there were fewer than 20 cases in the numerator.

10. Number of Youth Suicides, by Race/Ethnicity: 2009 Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011).

11. Suicide Figures from the Centers for Disease Control for the year 2009.All rates are per 100,000 population.

12. Suicide Figures from the Centers for Disease Control for the year 2009.All rates are per 100,000 population.

13. Why is this topic important? • Suicide is the third leading cause of death for youth ages 10-24 nationwide.  • In 2009, 6.3% of U.S. 9th-12th-graders reported having attempted suicide one or more times in the past year. • Approximately 149,000 young people ages 10-24 are treated for self-inflicted injuries at U.S. emergency departments every year. • According to data collected by the National Center for Injury Prevention and Control, poisoning is the most common reason for intentional, self-inflicted, non-fatal injury hospitalizations for 10- to 24-year-olds. • Self-injurious behavior, in general, often is stigmatized and hidden from family and friends. Data Source: State of California Department of Public Health, Epidemiology and Prevention for Injury Control Branch, California Office of Statewide Health Planning and Development, Patient Discharge Data. Accessed online athttp://epicenter.cdph.ca.gov/; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 1990-1999, 2000-2050. Accessed online at http://www.dof.ca.gov (May 2011).

14. ED Treatment of Mental Disorders One in ten suicides are by people seen in the ED within two months of dying.

15. Suicide in Adolescents • A previous suicide attempt increases suicide risk by 38-40 times. • Forwood et al. (2007) reported that a suicide attempt is likely to be highest among youth presenting with a combination of depression and externalizing behavior and those with a romantic breakup, being assaulted, or being arrested. • More than 90% of adult suicide attempters and 80% of adolescent attempters and completers communicate suicidal ideation prior to the attempt. • Adolescents with prior attempts are 18x more likely to make future attempts. • Half of the youth who attempt suicide do not receive treatment beyond psychotropic medication.

16. Suicide in College Students • Self-reports of suicidal ideation in college students have ranged from 32% to 70%. • It is estimated that there are 1100 suicides on college campuses in the US each year • Suicide is the second leading cause of death in college-age students. • One in 12 college students have seriously contemplated suicide.

17. Implications of Epidemiological Data • There is a need to intervene early in the development trajectory of the depression and suicidal behavior. The Melissa Institute for Violence Prevention

18. Misconceptions About Suicide • Most suicides are caused by one particular trigger event. • Most suicides occur with little or no warning. • It is best to avoid the topic of suicide. • People who talk about suicide don't do it. • Nonfatal self-destructive acts (suicide attempts) are only attention-getting behaviors. • A suicidal person clearly wants to die. • If a person who has been depressed is suddenly feeling better, the danger of suicide is gone.

19. Our Approach to Suicide • Each person is divided: • One part wants to live and is goal directed and life affirming. • And one part is self-critical, self-hating and at its ultimate end, self-destructive. The nature and degree of this division varies for each individual. Anti-Self - Critical Real Self - Positive

20. Our Approach to Suicide Negative thoughts exist on a continuum, from mild self-critical thoughts to extreme self-hatred to thoughts about suicide You need to have a drink, so you can relax You don’t deserveanything You should be by yourself You should just kill yourself You’re a creep

21. Our Approach to Suicide Self-destructive behaviors exist on a continuum from self-denial to substance abuse to actual suicide. Substance Abuse Hating Yourself Self-Denial Risk Taking Isolation Suicide

22. Our Approach to Suicide There is a relationship between these two continuums. How a person is thinking is predictive of how he or she is likely to behave. Thoughts Feelings Behavior Event

23. Definition of the Voice The critical inner voice refers to a well-integrated pattern of destructive thoughts toward our selves and others. The “voices” that make up this internalized dialogue are at the root of much of our maladaptive behavior. This internal enemy fosters inwardness, distrust, self-criticism, self-denial, addictionsand a retreat from goal-directed activities.  The critical inner voice effects every aspect of our lives: our self-esteem and confidence, our personal and intimate relationships, and our performance and accomplishments at school and work.

24. Where Do Critical Inner Voices Come From?

25. How Voices Pass From Generation to Generation

26. Attachment Theory Sir John Bowlby, Ph.D. Harry Harlow, Ph.D. Rene Spitz, M.D Mary Ainsworth, Ph.D. Mary Main, Ph.D. Erik Hesse, Ph.D. Adult Attachment Interview: predicts the baby’s attachment to the parent with 80% accuracy before the baby is even born

27. Where do voices come from? Patterns of Attachment in Children Parental Interactive Pattern • Emotionally available, perceptive, responsive • Emotionally unavailable, imperceptive, unresponsive and rejecting • Inconsistently available, perceptive and responsive and intrusive • Frightening, frightened, disorienting, alarming • Category of Attachment • Secure • Insecure – avoidant • Insecure- anxious/ambivalent • Insecure - disorganized

28. Attachment Figures Low Risk Non-Clinical Populations Secure 55-65% Ambivalent 5-15% Avoidant 20-30% Disorganized 20-40% (Given a Best Fit Alternative) High Risk, Parentally maltreated Disorganized 80%

29. What causes insecure attachment? • Unresolved trauma/loss in the life of the parents statistically predict attachment style far more than: • Maternal Sensitivity • Child Temperament • Social Status • Culture

30. Implicit Versus Explicit Memory • Explicit Memory • Implicit Memory

31. How does disorganized attachment pass from generation to generation? • Implicit memory of terrifying experiences may create: • Impulsive behaviors • Distorted perceptions • Rigid thoughts and impaired decision making patterns • Difficulty tolerating a range of emotions

32. The Brain in the Palm of Your Hand Daniel Siegel, M.D. – Interpersonal Neurobiology

33. Body Regulation Attunement Emotional Balance Response Flexibility Empathy Self-Knowing Awareness (Insight) Fear Modulation Intuition Morality 9 Important Functions of the Pre-Frontal Cortex

34. “Type D” AttachmentDisorganized/Disoriented • Predicts later chronic disturbances of: • affect regulation • stress management • hostile-aggressive behavior

35. Infant’s Response to Trauma • Two sequential response patterns: • hyperarousal • dissociation

36. Poly-Vagal Theory -Stephen Porges, 2007 Neuroception (Vagus Nerve) Receptivity

37. Division of the Mind Parental AmbivalenceParents both love and hate themselves and extend both reactions to their productions, i.e., their children. Parental Nurturance Parental Rejection, Neglect Hostility

38. Prenatal Influences Disease Trauma Substance Abuse/ Domestic Violence

39. Birth Trauma Baby Genetic Structure Temperament Physicality Sex

40. Unique make-up of the individual (genetic predisposition and temperament); harmonious identification and incorporation of parent’s positive attitudes and traits and parents positive behaviors: attunement, affection, control, nurturance; and the effect of other nurturing experience and education on the maturing self-system resulting in a sense of self and a greater degree of differentiation from parents and early caretakers. Self-System Parental Nurturance

41. Personal Attitudes/Goals/Conscience Realistic, Positive Attitudes Toward Self Realistic evaluation of talents, abilities, etc…with generally positive/ compassionate attitude towards self and others. Behavior Ethical behavior towards self and others Goal Directed Behavior Goals Needs, wants, search for meaning in life Moral Principles Acting with Integrity

42. Anti-Self System Unique vulnerability: genetic predisposition and temperament Destructive parental behavior: misattunement, lack of affection, rejection, neglect, hostility, over permissiveness Other Factors: accidents, illnesses, traumatic separation, death anxiety The Fantasy Bond (core defense) is a self-parenting process made up of two elements: the helpless, needy child, and the self-punishing, self-nurturing parent. Either aspect may be extended to relationships. The degree of defense is proportional to the amount of damage sustained while growing up.

43. Anti-Self SystemSelf-Punishing Voice Process Voice Process 1. Critical thoughts toward self 2. Micro-suicidal injunctions 3. Suicidal injunctions – suicidal ideation Behaviors Verbal self-attacks – a generally negative attitude toward self and others predisposing alienation. Addictive patterns. Self-punitive thoughts after indulging. Actions that jeopardize, such as carelessness with one’s body, physical attacks on the self, and actual suicide Source Critical parental attitudes, projections, and unreasonable expectations. Identification with parents defenses Parents’ covert and overt aggression (identification with the aggressor).

44. Anti–Self System Self- Soothing Voice Process Voice Process 1. Self-soothing attitudes 2. Aggrandizing thoughts toward self 3. Suspicious paranoid thoughts toward others. 4. Micro-suicidal injunctions 5. Overtly violent thoughts Behaviors Self-limiting or self-protective lifestyles, Inwardness Verbal build up toward self Alienation from others, destructive behavior towards others. Addictive patterns. Thoughts luring the person into indulging. Aggressive actions, actual violence. Source Parental over protection, imitation of parents’ defenses Parental build up Parental attitudes, child abuse, experienced victimization. Imitation of parents’ defenses. Parental neglect, parents’ overt aggression (identification with the aggressor).

45. How does a Suicide Occur? Underlying Vulnerability e.g. Mood disorder/Substance abuse/ Aggression/ Anxiety/Family history/Sexual orientation/Abnormal serotonin metabolism Stress Event (often caused by underlying condition) e.g. In trouble with law or school/Loss Acute Mood Change Anxiety/Dread/Hopelessness/Anger Inhibition Facilitation e.g. Strong taboo/Available support/Slowed down mental state/Presence of others/Religiosity e.g. Weak taboo/ Method weapon available/ Recent example/State of excitation agitation/ Being alone Survival Suicide

46. Continuum of Negative Thought Patterns Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts): • Levels of Increasing Suicidal Intention • Self-depreciating thoughts of everyday life • 2. Thoughts rationalizing self-denial; thoughts discouraging the person from engaging in pleasurable activities • 3 Cynical attitudes towards others, leading to alienation and distancing Content of Voice Statements You’re incompetent, stupid. You’re not very attractive. You’re going to make a fool of yourself. You’re too young (old) and inexperienced to apply for this job. You’re too shy to make any new friends. Why go on this trip? It’ll be such hassle. You’ll save money by staying home. Why go out with her/him? She’s cold, unreliable; she’ll reject you. She wouldn’t go out with you anyway. You can’t trust men/women.

47. Levels of Increasing Suicidal Intention 4. Thoughts influencing isolation; rationalizations for time alone, but using time to become more negative toward oneself 5. Self-contempt; vicious self-abusive thoughts and accusations (accompanied by intense angry affect) Content of Voice Statements Just be by yourself. You’re miserable company anyway; who’d want to be with you? Just stay in the background, out of view. You idiot! You bitch! You creep! You stupid shit! You don’t deserve anything; you’re worthless. Continuum of Negative Thought Patterns Thoughts that lead to low-self-esteem or inwardness (self-defeating thoughts):

48. Continuum of Negative Thought Patterns Thoughts that support the cycle of addiction (addictions): Levels of Increasing Suicidal Intention 6. Thoughts urging use of substances or food followed by self-criticisms (weakens inhibitions against self-destructive actions, while increasing guilt and self-recrimination following acting out). Content of Voice Statements It’s okay to do drugs, you’ll be more relaxed. Go ahead and have a drink, you deserve it. (Later) You weak-willed jerk! You’re nothing but a drugged-out drunken freak.

49. Continuum of Negative Thought Patterns Thoughts that lead to suicide (self-annihilating thoughts): Content of Voice Statements See how bad you make your family (friends) feel. They’d be better off without you. It’s the only decent thing to do; just stay away and stop bothering them. What’s the use? Your work doesn’t matter any more. Why bother even trying? Nothing matters anyway. Why don’t you just drive across the center divider? Just shove your hand under that power saw! • Levels of Increasing Suicidal Intention • Thoughts contributing to a sense of hopelessness urging withdrawal or removal of oneself completely from the lives of people closest. • 8. Thoughts influencing a person to give up priorities and favored activities (points of identity). • 9. Injunctions to inflict self-harm at an action level; intense rage against self.

50. Continuum of Negative Thought Patterns Thoughts that lead to suicide (self-annihilating thoughts): Levels of Increasing Suicidal Intention 10. Thoughts planning details of suicide (calm, rational, often obsessive, indicating complete loss of feeling for the self). 11. Injunctions to carry out suicide plans; thoughts baiting the person to commit suicide (extreme thought constriction). Content of Voice Statements You have to get hold of some pills, then go to a hotel, etc. You’ve thought about this long enough. Just get it over with. It’s the only way out.