Theories of self-destructive behavior overlap with those of self-concept (see Chapter 17) and disturbances in mood (see Chapter 18). To think about or attempt destruction of the self, the person must have low self-regard. Low self-esteem leads to depression, which is always present in self-destructive behavior. The range of self-protective responses is shown in Figure 19-1.

FIG 19-1 Continuum of self-protective responses.

The levels of behavior in the continuum may overlap. For instance, the girl who learns and excels at gymnastics is building her self-esteem and projecting a positive self-concept. However, if she tries movements she is not prepared for and does not take safety measures, her behavior becomes self-injurious or indirectly self-destructive. Similarly, a diabetic man who has never complied completely with his prescribed diet and medication regimen may become discouraged and intentionally take an overdose of insulin. The nurse must be alert to subtle shifts in mood and behavior of patients when assessing maladaptive self-protective responses.

Critical Reasoning

Where do you think patients’ requests for assisted suicide fall in the continuum of self-protective responses?

Epidemiology of Suicide

Worldwide, at least 1000 suicides occur each day. Suicide is the leading cause of death, outnumbering homicide or war-related deaths. Most people with suicide ideation, plans, and attempts receive no treatment (Bruffaerts et al, 2011).

In the United States more than 36,000 people complete the act of suicide each year, an average of one person every 15 minutes. In 2008, 8.3 million adults reported having suicidal thoughts (Centers for Disease Control and Prevention, 2011).

Suicide is the tenth leading cause of death, outnumbering homicide, which is the fifteenth leading cause of death in the United States (American Association of Suicidology, 2011). The actual number of suicides may be two to three times higher because of underreporting. In addition, many single-car accidents and homicides are, in fact, suicides.

Additional statistics regarding suicide in the United States include the following:

• The highest suicide rate for any group in the United States is among people older than age 80 years. Elderly adults have a rate of suicide almost 50% higher than that of the nation as a whole (all ages).

• Suicide is the third leading killer of young people. The rate of suicide among youth has tripled in the past 30 years. Teen suicide in the United States is almost five times as common among boys as among girls. Reports of suicide among young children are rare, but suicidal behavior is not. As many as 12,000 children ages 5 to 14 years are hospitalized in the United States every year for deliberate self-destructive acts.

• The incidence of suicide varies among cultural groups (Box 19-1). Suicide is more common among whites than African Americans at all ages.

BOX 19-1 SOCIOCULTURAL CONTEXT OF CARE

Suicide Among Minority Groups

Suicide rates can be viewed as a reflection of the many stressors faced by minority groups within contemporary U.S. culture. The following statistics call for an agenda of prevention and intervention:

• Among American Indians/Alaskan Natives ages 15 to 34 years, suicide is the second leading cause of death.

• Suicide rates among American Indian/Alaskan Native adolescents and young adults ages 15 to 34 years are 1.8 times higher than the national average for that age group.

• Hispanic, female high school students in grades 9 through 12 reported a higher percentage of suicide attempts than their white, non-Hispanic or black, non-Hispanic counterparts.

From Centers for Disease Control and Prevention (CDC): Suicide: facts at a glance, Summer 2009. Accessed October 2011 at www.cdc.gov.

• Males commit the overwhelming majority of completed suicides; women attempt suicide three times more often then men.

• Suicide is the fourth leading cause of death for women between the ages of 15 and 44 years, exceeding deaths due to homicide, cerebrovascular disease, or diabetes (LaVonne and Karch, 2010).

• Guns account for half of all completed suicides (Ilgen et al, 2008). Women tend to use potentially less lethal means, such as medications and wrist slashing. One third of all women and more than half of those 15 to 29 years of age who complete suicide use guns.

Critical Reasoning

What factors might contribute to the high rate of suicide among white elderly males?

Assessment

Behaviors

Noncompliance/Nonadherence

It has been estimated that one half of patients do not comply with their health care treatment plan. This level of noncompliance or nonadherence is the same for those with physical illnesses and those with psychiatric illnesses. Noncompliance accounts for 125,000 deaths annually and contributes to 10% to 25% of hospital and nursing home admissions.

People who do not comply with recommended health care activities are generally aware that they have chosen not to care for themselves. They usually have a reason for noncompliance, such as not having symptoms, not being able to afford the treatment they need, not understanding the treatment, or not having time. Patients also may minimize the seriousness of their problems. Many chronic illnesses are characterized by long periods of stability, during which the person may not be aware of discomfort. This reinforces the noncompliant behavior.

The most prominent behavior associated with noncompliance is refusal to admit the seriousness of the health problem. This denial interferes with acceptance of treatment. Another aspect of noncompliance is that guilt about not following health care recommendations also may interfere with obtaining regular care.

Noncompliant people are also struggling for control. Serious illness is often seen as an attack on the person and a betrayal by the body. Patients need to reassert their control and prove that they are still master of their fate. Most chronically ill people need to test the limits of their control and the validity of the prescribed self-care regimen. The following clinical example illustrates the problem of noncompliance with a prescribed health care regimen.

CLINICAL EXAMPLE

Ms. C was a 61-year-old, white, married woman who had been in good health most of her life. She had three grown children who had left home and established their own families. She and her husband were both looking forward to his retirement in 6 months. They planned to buy a recreational vehicle and travel around the United States.

The nurse practitioner did a complete physical examination each time Ms. C was seen. On her most recent visit, laboratory studies revealed an elevated blood glucose level. Her diagnosis was diabetes mellitus, adult onset. Ms. C was told that her condition was not serious and could be controlled by diet. She was 20 pounds (9 kg) overweight and was advised that she needed to lose the excess weight. She was instructed about her diet, how to test her urine, and the possible complications of diabetes.

Ms. C was frightened about her condition but did not mention this because no one else seemed very concerned. At first she was conscientious about following her diet and testing her urine. She felt very well and was proud when she lost 5 pounds. As time went on, Ms. C began to wonder whether she was really so sick. She had never felt ill.

On her husband’s birthday, she fixed a special dinner and baked a cake. She decided she deserved a reward for “being good” and did not follow her diet. She anxiously tested her urine at bedtime, and it was negative. Then her son and his family visited for a week. She fixed all their favorite foods and ate with them. She still felt fine and decided she did not need to test her urine. When it was time for her next checkup, she postponed calling the nurse practitioner. She was very busy preparing for retirement travel.

Selected Nursing Diagnosis

• Noncompliance related to fear of the diagnosis of diabetes, as evidenced by lack of adherence to medical treatment plan

Critical Reasoning

Do you think that noncompliance can ever be an adaptive response? Why or why not?

Self-Injury

Society accepts some forms of self-harm as normal. Examples of culturally sanctioned forms include body piercing, cosmetic eyebrow plucking, circumcision, nail biting, and tattoos. Self-injury is the act of deliberate harm to one’s own body. The injury is done to oneself, without the aid of another person, and the injury is severe enough to cause tissue damage. Common forms of self-injurious behavior include cutting and burning the skin, banging the head and limbs, picking at wounds, and chewing fingers.

Many nurses mistake self-injury for potential suicide. In fact, they are two separate phenomena. Usually the lethality of self-injury is low, and patients who self-injure typically want relief from the tension they feel rather than to kill themselves. Self-injury also differs from other self-destructive behaviors such as bingeing, drug abuse, smoking, and high-risk activities. Self-injury is a contained event that occurs in a short time span and with an awareness of the consequences of the act.

Self-injurious behavior may be categorized by the type of patient and the clinical context in which the behavior occurs:

• People with mental retardation. The mentally retarded may have outward-directed aggression along with self-injurious behavior.

• Psychotic patients. Self-injuring acts among psychotic patients tend to be sporadic and often occur in response to command hallucinations or delusions.

• Prison populations. Self-injury in prisons is difficult to assess because of poor documentation, drug use, and undiagnosed psychiatric disorders. Many self-injurious events among prisoners may be intentionally manipulative, designed to force transfer to a less restrictive facility.

• Character disorders, particularly borderline personality disorder. These patients are often young and female and have a poor tolerance of anxiety and anger; also included are patients with eating disorders.

Suicidal Behavior

Suicidal behavior is usually divided into the categories of suicide ideation, suicide threats, suicide attempts, and completed suicide.

Suicide ideation is the thought of self-inflicted death, either self-reported or reported to others. Suicide ideation can be passive, when there are only thoughts of suicide with no intent to act, or active, when there are thoughts and plans of causing one’s own death.

Suicide threat is a warning, direct or indirect, verbal or nonverbal, that a person is planning to take his or her own life. It may be subtle but usually occurs before overt suicidal activity takes place. The suicidal person may make statements such as the following:

• “Will you remember me when I’m gone?”

• “Take care of my family for me.”

• “I won’t be in your way much longer.”

• “There’s nothing more that I can do.”

• “I just can’t deal with things anymore.”

Nonverbal communication often reveals the suicide threat. The person may give away prized possessions, make a will or funeral arrangements, or withdraw from friendships and social activities. Less often, a person may make a direct verbal suicide threat. The threat is an indication of the ambivalence that is usually present in suicidal behavior. It represents the hope that someone will recognize the danger and rescue the person from self-destructive impulses. It also may be an effort to discover whether anyone cares enough to prevent the person from self-harm.

Suicide attempt is any self-directed action taken by a person that will lead to death if not stopped.

In the assessment of suicidal behavior, much emphasis is placed on the lethality of the method threatened or used. Although all suicide threats and attempts must be taken seriously, vigilant attention is needed when the person is planning or tries a highly lethal method, such as gunshot, hanging, or jumping. Less lethal methods include carbon monoxide and drug overdose, which allow time for discovery once the suicidal action has begun. Assessment of the suicidal person

QUALITY AND SAFETY ALERT

• All suicidal behavior is serious, whatever the intent.

• Suicide ideation, threats, and attempts all require the nurse’s highest priority.

also includes whether the person has made a specific plan and whether the means to carry out the plan are available.

The most suicidal person is one who has all of the following:

• A highly lethal method (e.g., a gunshot to the head)

• A specific plan (e.g., as soon as one’s spouse goes shopping)

• The means readily available (e.g., a loaded gun in a desk drawer)

Such a person is exhibiting little ambivalence about a suicide plan. On the other hand, the person who contemplates taking a bottle of aspirin if the situation at work does not improve soon is communicating an element of hope. This person is really asking for help in coping with a poor work situation. The following clinical example illustrates the behavior of a suicidal person.

CLINICAL EXAMPLE

Mr. Y was a 52-year-old African-American man employed in the foundry of a large steel mill. He had worked for the company for 20 years. He lived in a rented room in a blue-collar neighborhood near the mill. Most of his neighbors were Appalachian white and southern African-American families who had moved to the community to work at the mill. The neighborhood had an undercurrent of racial tension, but Mr. Y was not involved in conflicts with his neighbors. He had separated from his wife before moving to the community and had no close friends or family. The separation resulted from his violent behavior related to drinking binges.

The occupational health nurse, Ms. G, saw Mr. Y when he came to the employee health clinic following a 6-week absence from work. He had been hospitalized for broken ribs and a concussion after he was beaten and robbed by a gang of adolescents in an alley behind his home. Ms. G was familiar with this patient because he had participated in the company’s employee assistance program for persons with alcoholism.

When she saw him in the clinic, she immediately noted that he appeared depressed. His face was expressionless, his posture was slumped, and he had lost weight. He appeared disheveled, which was a change from his usual neat appearance. His speech was slow and halting and so soft that he could barely be heard.

He told Ms. G that he had a request to make of her. He knew from past conversations that she was an animal lover. He wanted her to take his pet dog, Rover, because he did not feel able to care for the dog adequately and the neighbors who kept Rover while he was in the hospital had neglected the dog. Ms. G was very concerned about Mr. Y and asked him how he was spending his time. He said he kept the television on and he thought a lot. When asked, he said he felt “too shaky” to go outside unless he absolutely had to. He thought the boys who attacked him were still in the neighborhood.

Ms. G asked if he had thought about harming himself. Mr. Y looked startled and then admitted that he saw no other solution to his problem. “It makes sense. I don’t have anybody. If you take Rover, I can go.” With further questioning he admitted that he had a loaded revolver at home and planned to use it after he left the clinic. Ms. G realized that Mr. Y needed help immediately and initiated plans for hospitalization.

Selected Nursing Diagnoses

• Risk for suicide related to impoverished social environment, as evidenced by intent to kill self with a gun

• Powerlessness related to recent neighborhood attack, as evidenced by expressed feelings of despair and hopelessness

Completed suicide, or simply suicide, is death from self-inflicted injury, poisoning, or suffocation where there is evidence that the decedent intended to kill himself or herself. Completed suicide may take place after warning signs have been missed or ignored. Some people do not give any easily recognizable warning signs.

Research done on completed suicide has of necessity been retrospective. However, it can be informative to interview survivors. This procedure is known as the psychological autopsy (Innamorati et al, 2008). It is a retrospective review of the person’s behavior before the suicide. Table 19-1 compares the characteristics of suicide completers and suicide attempters based on this process.

TABLE 19-1

CHARACTERISTICS OF SUICIDE COMPLETERS AND ATTEMPTERS

SUICIDE COMPLETERS	SUICIDE ATTEMPTERS
Three times as likely to be men	Mainly women younger than 40 years of age
Usually have depression and/or alcohol or substance abuse	Less likely to have depression and other psychiatric conditions; more likely to have personality disorders
Plan the suicide act	Act impulsively
Use highly lethal method	Use method with low lethality
Select a setting where they are unlikely to be interrupted	Act in the presence of or notify others

Significant others of suicidal people, including people who have survived a suicidal attempt, have many feelings about this behavior. An element of hostility exists in suicidal behavior. Often the message to significant others, stated or implied, is “You should have cared more.” At times, when the person survives the attempt, this message may be transmitted in a manipulative way.

An example is the adolescent girl who discovers that her boyfriend is dating someone else and takes an overdose of over-the-counter sleeping pills. If she sets the scene so that she will almost inevitably be discovered and makes sure that her boyfriend hears of her behavior, she is behaving in a hostile, manipulative way. A remorseful response by the boyfriend would be reinforcing and would increase the likelihood that she will repeat the behavior.

It is important to treat all suicide attempts seriously and to help the patient develop healthier communication patterns. People who do not really intend to die may do so if they are not discovered in time.

When suicide is successful, the survivors are left with many feelings that they cannot communicate to the involved object, the dead person (Box 19-2). This may lead to an unresolved grief reaction, depression, social stigma, and suicidal ideation. Some suicide prevention centers have become involved in postvention, in which survivors are helped, either individually or in groups, to express their feelings and work through their grief.

BOX 19-2 A FAMILY SPEAKS

My husband died last year. He didn’t commit suicide, but he took his own life just as surely as if he had pulled the trigger of a gun. Only his weapon was a cigarette. You see, 2 years ago his doctor discovered a cancer lesion on his lung. At that time my husband was told he needed to lose weight, cut down on his drinking, and most of all, stop smoking. But my husband wasn’t a very good patient.

Sometimes I blame myself for not doing more. I nagged for a while, but that only seemed to make our marriage worse. My husband said that what he did with his life was his own choice and that his father had smoked all of his life and had lived until he was 84. My husband died at age 62.

One good thing has come out of this tragedy, however. My son has stopped smoking and has vowed he will never touch another cigarette for as long as he lives. That small goodness gives me comfort and some sense of hope.

In summary, the suicidal patient may have many different clinical behaviors. Mood disturbances are often present, as are somatic complaints. Feelings of hopelessness and helplessness are important in explaining suicidal ideation. Nurses should take a careful medical and psychiatric history, paying specific attention to the mental status examination (described in Chapter 6) and the psychosocial history, and should evaluate the patient for recent losses, life stresses, and substance use and abuse.