Self-Protective Responses and Suicidal Behavior

Self-Protective Responses and Suicidal Behavior

Gail W. Stuart

Life is full of risk. People must choose the amount of danger to which they are willing to expose themselves. Sometimes these choices are conscious and rational; other risk-taking behaviors are unconscious. Most people go through life accepting some risks as part of their daily routine while carefully avoiding others.

Even though life is risky, most societies have a norm that defines the degree of danger to which people may expose themselves. This norm varies by age, gender, socioeconomic status, and occupation. In general, the very young, the elderly, and women are seen as needing to be protected from harm. Some risk takers are admired, particularly athletes, military personnel, those with dangerous occupations, and those who place themselves in danger to help others. At the same time, feelings of admiration may be accompanied by fear and perplexity about the danger-seeking behavior.

Continuum of Self-Protective Responses

Protection and survival are fundamental needs of all living things. On a continuum of self-protecting responses, self-enhancement and growth-promoting risk taking are the most adaptive responses, whereas indirect self-destructive


This case can help you understand some of the issues you will be reading about. Read the case background and then, as you read the chapter, think about your answers to the Case Critical Reasoning Questions. Case outcomes are presented at the end of the chapter.

Case Background

A mother calls the pediatric primary care office and wants to bring her daughter, Kara, in to be seen. She says something isn’t right. Kara, age 15, refused to go to school. Lately she has been acting strangely, staying in her room on her computer and not letting anyone in her bedroom.

The mother says her daughter used to take good care of herself, had many friends and liked socializing. But lately she has gained weight, stopped going out, and doesn’t care about her appearance. Her mother has even had to tell her to take a shower and wash her hair. Kara was a good student; now her grades are poor. She just doesn’t seem to care. Recently her boyfriend’s family moved away to seek a job in another state, and Kara hasn’t heard from him. The mother says her beautiful child has turned into someone else, and she is worried.

After talking with the mother you ask her to wait in the waiting room. Kara is in the exam room, and you ask her to remove her clothing and put on a gown. At first she refuses, but at your insistence she agrees. She appears very hostile, and you begin to better understand her mother’s concern.

When you return to the exam room, Kara opens the gown and exposes cuts she has made with a razor blade on her body—her wrists, thighs, breasts, and hips all have long superficial cuts. She is very angry and says, “There, is that what you want to see?”

When you ask her what has happened, she says she hates herself and hates her life. She says her boyfriend told everyone she was a slut and they are making fun of her on Facebook. She doesn’t want to live anymore. When you ask her if she has thoughts of hurting herself further, she says she is going to hang herself as soon as she gets a chance; she just hopes she has the guts to do it.

You call and ask for another staff member to come into the exam room, telling your colleague not to let the girl out of the room and to sit within arm’s length of her. Then you go to the desk and call the Mobile Crisis Unit. You return to the exam room and stay with the patient until the emergency responders arrive. You ask your colleague to take the mother into another exam room and tell her what is happening.

behavior, self-injury, and suicide are maladaptive responses. Self-destructive behavior may be direct or indirect.

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.

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.

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.

• 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.




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.


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.


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:

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:

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

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:

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.


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.

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.

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.

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.

Nature of the Assessment

Most people who commit suicide have visited a primary care provider, emergency department (ED), or psychiatric outpatient service in the weeks before their death. Errors in recognition and inadequate assessment likely contribute to a number of these deaths. Adequate screening, protection of the patient, and acceptable treatment could prevent these occurrences (Reid, 2010).

Suicidal patients often present initially in the ED. About 666,000 people visited EDs for nonfatal, self-inflicted injuries in 2008 (Centers for Disease Control and Prevention, 2011). As many as 1 in 10 people who end their lives by suicide are seen in the ED within 2 months of dying, but many of them are never assessed for suicide risk (Pompili et al, 2011).

Psychiatric evaluation of suicide attempters in the ED should include the use of a standardized tool to evaluate suicide ideation and suicide risk (Pompili et al, 2009). After completing the assessment, the nurse should document the following (Scott and Resnick, 2009):

Directly questioning the patient about suicidal thoughts and plans will not cause the patient to take suicidal action. Rather, most people want to be prevented from carrying out their self-destruction. Most patients are relieved to be asked about these feelings (Crawford et al, 2011).

In asking about suicide, nurses can begin with general questions, such as the following:

These can be followed by more specific questions, such as

If the patient has had thoughts of death, self-harm, or suicide, the nurse must then ask more focused and direct questions about the method, plan, and means. A tool used in one inpatient setting is presented in Figure 19-2. Other suicide assessment tools also are available (Young and Erwin, 2008; Hermes et al, 2009).

Predisposing Factors

No one theory explains self-destructive behavior or guides therapeutic intervention. Behavior theory suggests that self-injury is learned and reinforced in childhood or adolescence. Psychological theory focuses on problems in early stages of ego development, suggesting that early interpersonal trauma and unmanaged anxiety may provoke episodes of self-injury. Interpersonal theory proposes that self-injury may result from interactions that leave the child feeling guilty and worthless.

Childhood trauma and a history of abuse or incest also may precipitate self-destructiveness if negative perceptions have been internalized (Bruffaerts et al, 2010). Other predisposing factors related to self-destructive behavior include the inability to communicate needs and feelings verbally; feelings of guilt, depression, and depersonalization; and fluctuating emotions.

Five predisposing factors—psychiatric diagnosis, personality traits and disorders, psychosocial factors and physical illness, genetic and familial variables, and biochemical factors—contribute to a biopsychosocial model for understanding self-destructive behavior throughout the life cycle.

Psychiatric Diagnosis

More than 90% of adults who end their lives by suicide have an associated psychiatric illness. The four broad psychiatric disorders that put people at particular risk for suicide are mood disorders, substance abuse, schizophrenia, and anxiety disorders.

Suicide is the most serious complication of mood disorders; 15% of individuals with these illnesses end their lives by suicide. The time spent depressed is a major risk factor determining overall long-term risk (Holma et al, 2010). Suicide is particularly common among depressed elderly men. Patients with bipolar disorder and psychotic depression are at greatest risk. Many who die from suicide have a prior history of attempts, have explicitly communicated their intent, and have been in psychiatric treatment during the months before their death.

Alcohol use is associated with 25% to 50% of suicides. Among patients who are alcohol dependent, suicide often occurs late in the disease and is often related to some interpersonal loss or the onset of medical complications.

Among patients with schizophrenia, 40% report suicidal thoughts, 20% to 40% make unsuccessful suicide attempts, and 10% to 15% end their lives by suicide. The risk is greatest for patients with chronic recurring illness who are male, white, young, unmarried, unemployed, living alone, and depressed.

Anxiety disorders, particularly panic disorder and posttraumatic stress disorder, are associated with increased rates of suicidal ideation, suicide attempts, and completed suicide. Other disorders that are associated with high risk include eating disorders, body dysmorphic disorder, attention deficit/hyperactivity disorder, some personality disorders (borderline personality disorder and antisocial personality disorder), and conduct disorders in adolescents (Berk et al, 2009).

Personality Traits and Disorders

The four aspects of personality that are most closely associated with increased risk of suicide are hostility, impulsivity, depression, and hopelessness. These traits are important because they cross personality disorder diagnostic groups. The co-existence of antisocial and depressive symptoms appears to be a particularly lethal combination in both adults and young people.

The association between hostility and suicide stems from the idea that the suicidal person turns rage inward against the self. Other studies have found that suicidal people are more socially withdrawn, have lower self-esteem, are less trusting of others, expect bad things to happen to them, feel powerless over their lives, and have a rigid and inflexible way of thinking.

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Feb 25, 2017 | Posted by in NURSING | Comments Off on Self-Protective Responses and Suicidal Behavior

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