Deliberate self harm by Dr. R. Monisha

psychiatry

1. DELIBERATE SELF HARM

2. Overview Definition History Epidemiology Methods Warning signs Self harm cycle Assessment and treatment Facts Suicide – an overview References

3. Definition An act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences. (Platt et al., 1992; WHO).

4. ‘Self-poisoning or injury, irrespective of the apparent purpose of the act’. (NICE, 2004) ‘Self-injury is a compulsion or impulse to inflict physical wounds on one's own body, motivated by a need to cope with unbearable psychological distress or regain a sense of emotional balance. The act is usually carried out without suicidal, sexual, or decorative intent.’ (Sutton 2005)

5. Terminologies Diversity of terms: parasuicide self poisoning self injury self harm self-inflicted violence (SIV), N on suicidal self injury (NSSI)  Self mutilation

6. The term  self-mutilation  is sometimes used, although this phrase evokes connotations that some find worrisome, inaccurate, or offensive. Self- inflicted wounds   is a specific term associated with soldiers to describe non-lethal injuries inflicted in order to obtain early dismissal from combat.

7. History The  Maya priesthood performed auto- sacrifice  by cutting and piercing their bodies in order to draw blood. A reference to the priests of  Baal  "cutting themselves with blades until blood flowed" can be found in the Hebrew Bible. Auto-sacrifice of Maya priesthood

8. Self-harm is practiced in  Hinduism  by the ascetics known as  sadhu s . In  Catholicism  it is known as  mortification of the flesh . Some branches of Islam mark the  Day of Ashura , the commemoration of the martyrdom of Imam Hussein, with  a ritual of self-flagellation , using chains and swords

9. In former days these behaviors were often regarded as failed suicides. However, this view did not appear to be correct, and the great majority of patients in fact do not try to kill themselves. Therefore, the term deliberate self-harm was introduced to describe the behavior without implying any specific motive. Intentions may vary from attention seeking or communication of despair, appeal for help, to a means for stress reduction

10. Epidemiology In the 1960s and 1970s, there was a sharp increase in the number of people treated in hospitals in Europe, the United States and Australia because of intentional overdoses or self-injury. In the 1980s several studies showed a stabilization. In the early 1990s these numbers increased further in some regions Between 1985 and 1995 the rates of DSH increased by 62 per cent in males and 42 per cent in females

11. Sex and age : WHO Multicenter Study on Suicidal Behavior - the female DSH rates were 1.5 times higher than the male rates. DSH rates were consistently higher among those in the young age groups, with the highest person-based male DSH rates in the age group 25–34 years, whereas for females in most centers the highest rates were found in the age group 15–24 years

12. Sexuality and DSH Growing evidence supports an association between sexual orientation and self-harm in men and women ( O'Connor et al., 2009b ;  Skegg  et al., 2003 ). In a recent systematic review and meta-analysis (including data from 214,344 heterosexual and 11,971 non-heterosexual people), homosexuals and bisexual people were at a heightened risk of self-harm compared with heterosexual people ( King  et al. , 2008 ). The evidence for this association thus far is strongest for young people.

13. Sociodemographic characteristics : Single and divorced people were over-represented among people who engaged in DSH in the WHO/EURO study. Nearly half of the males and 38 per cent of the females were never married. DSH rates over the period 1995–1999, 26 per cent of the males and 14 per cent of the females were unemployed. DSH patients disproportionately have had low education and poverty.

14. Methods : In the WHO Multicenter Study, 65 per cent of males and 82 per cent of females took an overdose. Cutting, mostly wrist cutting, was employed in 16 per cent of male cases and 9 per cent of female cases There was an increase in the use of paracetamol from 31 per cent of poisoning cases in 1985 to 50 per cent in 1995.

15. Cutting 80% Bruising 24% Burning 20% Head banging 15% Biting 7% Self Injury Poll (2004) What is your primary method of self-injury http:vote.pollit.com/webpoll2?ID=25897

16. Hawton et al. found that 22 to 26 per cent of DSH patients had consumed alcohol at the time of the act (males more frequent than females), And 44 to 50 per cent had consumed alcohol during the 6 hours before the DSH acts This is more common in males than in females

17. Incidence and onset 4% in the general population Equal numbers of males and females (though more females present for treatment) Typical onset: puberty Can be seen also in young children and adults Often lasts 5-10 years But can last longer without treatment.

18. Prevalence The aggregate lifetime and 12-month prevalence of suicide attempts was 6% and 4.5% respectively. The aggregate lifetime and 12-month prevalence of non-suicidal self-injury was 22.1% and 19.5% respectively.  The aggregate lifetime and 12-month prevalence of deliberate self-harm was 13.7% and 14.2% respectively. (Global Lifetime and 12-Month Prevalence of Suicidal Behavior, Deliberate Self-Harm and Non-Suicidal Self-Injury between 1989 and 2018: A Meta-Analysis)

19. Adolescents : 13-16% (Ross & Heath, 2002) College students : 17-36% (Whitlock et al.,2006) Adults :4% (Klonsky et al., 2003)

20. Prevalence and Characteristics of Self-Harm in Adolescents: Meta-Analyses of Community-Based Studies 1990-2015. One hundred seventy-two datasets reporting self-harm in 597,548 participants from 41 countries were included Overall lifetime prevalence was 16.9% with rates increasing to 2015. Girls were more likely to self-harm The mean age of starting self-harm was 13 years, C utting being the most common type (45%).

21. Key elements Self-inflicted Deliberate Alters body tissue Purpose to cause harm

22. Self injury behaviour Carving / tattooing Scratching Banding Marking Picking Pulling skin and hair

23. Burning/abrasions Ingestion of sharps / toxins cutting Biting Head banging Bruising Hitting Excessive body piercing

24. Classification Three types of DSH patients: ‘mild’ type, ‘severe’ type, and ‘mixed’ type in between.

25. The mild type of DSH encompasses mostly relatively nonviolent methods followed by non-serious physical injury. Characteristics associated with mild forms of attempted suicide/deliberate self-harm are: Young age, living together low level of suicidal preoccupation, low suicidal intent In mixed type, persons show mixed characteristics.

26. The severe category consists mostly of relatively hard methods followed by serious physical consequences. Characteristics associated with severe forms of attempted suicide/deliberate self-harm are : Older age (over 40), Many precautions to prevent discovery, High level of suicidal preoccupation, high suicidal intent, Previous attempted suicides, Drug dependence, Poor physical health, Previous psychiatric treatment

27. Causes Psychiatric disorders Autism spectrum disorders Borderline personality disorder Dissociative disorders Bipolar disorder Eating disorder Depression Phobias   Conduct disorders

28. Schizophrenia and self harm Schizophrenia may also be a contributing factor for self-harm. Those diagnosed with schizophrenia have a high risk of suicide, which is particularly greater in younger patients .  Patients of schizophrenia are known to attempt self-harm due to command hallucination, catatonic excitement, religious preoccupations or because of associated depression. Major self-mutilation includes amputation of limbs or genitals and eye enucleation. Minor self-mutilation includes self-cutting and self-hitting.

29. Psychological Abuse during childhood Bereavement T roubled parental or partner relationships. Factors such as war, poverty, and unemployment  Feelings of entrapment, defeat, lack of belonging, and perceiving oneself as a burden

30. Drugs and alcohol Benzodiazepine dependence   benzodiazepine withdrawal Alcohol Smoking Cannabis use - A more recent  meta-analysis  on literature concerning the association between  cannabis  use and self-injurious behaviors to be 95% ( Journal of Affective Disorders, 2020 .  278: 85–98)

31. Substance abuse is also considered a risk factor are some personal characteristics such as poor problem-solving skills and impulsivity. There are parallels between self-harm and  Münchausen syndrome , a psychiatric disorder in which individuals  feign  illness or trauma

32. Pathophysiology Self-harm is not typically suicidal behavior, although there is the possibility that a self-inflicted injury may result in life-threatening damage. The motivations for self-harm vary, as it may be used to fulfill a number of different functions

33. Emotion Relief (92%, at least one) To stop bad feelings (immediate relief) To stop feeling angry or frustrated or enraged To relieve anxiety or terror To relieve feelings of aloneness, emptiness or isolation To stop feeling self-hatred, shame To obtain relief from a terrible state of mind To control feelings (to exert control)

34. Physical pain distracts from emotional pain To disassociate from intolerable feelings To transfer emotional pain into physical pain Physical pain is easier to deal with than emotional pain There is a positive statistical correlation between self-harm and emotional abuse [Meltzer, Howard; et al. (2000)]

35. Means of communicating distress Make internal wounds external (visible) Event markers (memorial for traumatic events) Creates euphoria. Wanting to fit in Feeling emotionally dead inside Self harm feels alive and confirms existence Coping strategy

36. To punish yourself (63% of non-suicidal self-injury) Replicates earlier abuse Only 13 % wanted to punish someone or make someone feel guilty A functional approach to the assessment of self-mutilative behavior. Journal of Consulting and Clinical Psychology 72: 885-890.

37. Emotional pain vs brain Emotional pain activates the same regions of the brain as physical pain S o emotional stress can be a significantly intolerable state for some people T he  sympathetic nervous system  controls arousal and physical activation (e.g., the  fight-or-flight response ) The sympathetic nervous system innervates (e.g., is physically connected to and regulates) many parts of the body involved in stress responses.

38. Warning signs Unexplained, frequent injuries including cuts and bruises Wearing of long pants/sleeves in warm weather Low self-esteem Overwhelmed by feelings Inability to function at home, school or work Inability to maintain stable relationships

39. Immediate consequences Feels alive, functioning, able to act Clears the mind, helps to focus Release of endorphins Tension reduction Relief from stress or feelings Calmness Relaxation Sleep

40. Late consequences Feel of Guilt, shame or stigma Feelings of isolation and Abandonment Infection either from wounds or sharing tools Severe, possibly fatal injury Permanent scars or disfigurement.

41. Self harm cycle

42. Course and prognosis Repetition is one of the core characteristics of suicidal behaviour . Among DSH patients ‘repeaters’ are more common than ‘first- evers ’. Between 30 and 60 per cent of DSH patients engaged in previous acts, and between 15 and 25 per cent did so within the last year. Psychosocial characteristics of repeaters are substance abuse, depression, hopelessness, personality disorders, unstable living conditions/living alone, criminal records, previous psychiatric treatment, and a history of stressful traumatic life events.

43. Facts Self injury behaviors are found in about 75% of borderline personality disorder. The frequency with which self destructive behaviors occur (e.g., unprotected sex with strangers, drinking while taking antabuse) would increase this rate into 90% range. A common belief regarding self-harm is that it is an  attention-seeking  behavior; however, in many cases, this is inaccurate. Many self-harmers are very self-conscious of their wounds and scars and feel guilty about their behavior, leading them to go to great lengths to conceal their behavior from others.

44. Studies of individuals with developmental disabilities (such as  intellectual disability ) have shown self-harm being dependent on environmental factors such as obtaining attention or escape from demands [Iwata, B. A.; et al. (1994)] Such self-injurious acts occur in people who have histories of suicidal attempts (62%), with an average frequency of about three attempts

45. ICD 10 Criteria of DSH In annexure under - other conditions from ICD-10 often associated with mental and behavioural disorders. It covers the associated diagnoses most likely to be encountered in ordinary clinical practice. It covers 21 chapters in which, Chapter XX – external causes of morbidity and mortality. Under which comes intentional self harm (X60 – X84)

46. DSM V criteria of Non suicidal self injury In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his body or sort likely to induce bleeding, bruising or pain with the intention that injury will lead to only minor or moderate physical harm(i.e., there is no suicidal intent) The individual engaging self-injurious behavior with one or more of the following expectations To obtain relief from a negative feeling or cognitive state To resolve an interpersonal difficulty To induce a positive feeling state

47. C. The intentional self injury is associated with at least one of the following Interpersonal difficulties or negative thoughts or feelings depression, anxiety, tension, anger Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control Thinking about self injury that occurs frequently, even when it is not acted upon.

48. D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of religious or cultural ritual) and is not restricted to picking a scab or nail biting. E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic or other important areas of functioning F. The behavior does not exclusively occur during psychotic episodes, delirium, substance intoxication, or substance withdrawal. The behavior is not better explained by other mental disorders.

49. Assessment scales of DSH The Deliberate Self-Harm Inventory General Self-Harm Questionnaire C linician-administered rating scale of self-destructive behavior Self-harm behavior survey ( Favazza ) Functional assessment of self-mutilation (Lloyd)

50. The Deliberate Self-Harm Inventory The Deliberate Self-Harm Inventory (Gratz, 2001) is a 17-item self-report questionnaire developed to assess deliberate self-harm. It is behaviorally based and assesses aspects of deliberate self-harm such as frequency, severity, duration, and type of self-harming behavior.

51. General Self-Harm Questionnaire This is a brief questionnaire containing some of the common items traditionally used in the literature to measure deliberate self-harm. It is used to assess the construct validity of the DSHI

52. Treatment Pharmacotherapy As many psychiatric disorders are associated with a higher risk of self-harm, pharmacological treatment of these conditions documented should be considered. For depression –SSRIs, SNRIs, TCAs or MAO  ( NICE, 2009a) For anxiety - 1. Offer a selective serotonin reuptake inhibitor (SSRI) and psychotherapy 2. Do not offer a benzodiazepine or antipsychotic ( NICE, 2011a)

53. For schizophrenia (NICE, 2009b) - oral antipsychotic medication such as R isperidone (Risperdal, Janssen),  O lanzapine (Zyprexa, Eli Lilly),  Q uetiapine (Seroquel, AstraZeneca), (Geodon, Pfizer) A ripiprazole  Offer clozapine who have an inadequate or no response to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs

54. Psychotherapy Two long-term–based treatments : Cognitive behavioral therapy (CBT) Dialectical behavioral therapy (DBT) Others therapies include - Developmental group therapy, Psychodynamic therapy, and In-home Interpersonal Psychotherapy.

55. Borderline personality disorder Psychotherapy is considered the primary treatment for borderline personality disorder (BPD). Currently, there are four comprehensive psychosocial treatments for BPD. Two of these treatments are considered psychodynamic in nature: mentalization-based treatment and transference-focused psychotherapy. The other two are considered to be cognitive-behavioral in nature: dialectical behavioral therapy and schema-focused therapy.

56. Mentalization-based treatment Bateman and Fonagy developed mentalization-based treatment (MBT) for patients with BPD. This treatment aims to increase a patient's curiosity about and skill in identifying his or her feelings and thoughts and those of other people as well. They speculate that this difficulty in mentalization arouse because of difficulties in early attachment.

57. Transference-focused psychotherapy. TFP is based on Kernberg's conceptualization of the core problem of BPD . Kernberg suggests that excessive early aggression has led the young child to split his or her positive and negative images of him or herself and his or her mother. In either case, the pre-borderline child is unable to merge his or her positive and negative images and attendant affects to achieve a more realistic and ambivalent view of him or herself and others. The primary goal of TFP is to reduce symptomatology and self-destructive behavior through the modification of representations of self and others as they are enacted in the here and now transference

58. D ialectical behavioral therapy Linehan(1993) has suggested that the core feature of BPD is emotional dysregulation. She suggests that this lability may be due to both inborn biological vulnerabilities and an invalidating childhood environment. In any case, the person with BPD is easily upset, becomes extremely upset very rapidly, and takes a good deal of time to calm down.

59. This treatment consists of skills groups, individual therapy as well as phone coaching for patients, and a consultation team for clinicians treating them. DBT resulted in a significantly better retention rate and significantly greater reductions of self-mutilating and self-damaging impulsive behaviors, particularly among those with a history of frequent self-mutilation

60. S chema-focused therapy  Borderline patients are thought to have four dysfunctional life schemas that maintain their psychopathology and dysfunction: detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. Change is achieved through a range of behavioral, cognitive, and experiential techniques that focus on the therapeutic relationship, daily life outside therapy, and past experiences (including traumatic experiences). 

61. Supportive Telephone Calls and Letters Treatments consisting of supportive telephone calls, SMS, or written contacts after discharge of the suicidal patient from the emergency department or hospital showed preventive effects. Involving community resources with the goal that the social intervention should give support to the patient in breaking through loneliness and finding social networks, and in this way, enhancing a sense of meaning in their lives is essential.

62. Self mutilation “Self mutilation refers to intentional, non lethal, repetitive body harm or disfigurement that is socially disagreeable”. (Pearson, 2011)

63. Categories Major Stereotypic Moderate or superficial (Pearson, 2011)

64. Major : Extreme acts that occur suddenly and cause considerable damage Associated with the psychotic state or intoxication. Stereotypic : Repetitive, often rhythmic self-injurious Found in autistic, mentally retarded, and in about a third of individuals with Tourette’s syndrome.

65. Moderate or superficial : Type that mental health professional are most likely to encounter Includes hair pulling, skin scratching, picking, cutting and carving. Eg – trichotillomania

66. Can be : Compulsive – repetitive, ritualistic behavior that occurs many times in a day Episodic – occasional and usually a symptom of another disorder Repetitive – addictive and part of their identity

67. Attempted Suicide - definition Attempted suicide is self injury with a desire to end one's life but does not lead to death .( Nazem et al.,2008;23:1573–9) Suicide attempt can be defined as a non-fatal self-directed potentially injurious behavior with an intent to die ( Krug E. Vol. 1. Genèva : World Health Organization; 2002)

68. Historical facts of suicide Suicides played prominent roles in ancient legend and history, like Ajax the Great  who killed himself in the  Trojan War , and  Lucretia  whose suicide around 510 B.C. initiated the revolt that displaced the  Roman Kingdom  with the  Roman Republic .

69. One early  Greek  historical person to commit suicide was  Empedocles  around 434 B.C. One of his beliefs was that Death was a transformation. It is possible this idea influenced his suicide. Empedocles died by throwing himself into the Sicilian volcano, Mount Etna.   Empedocles  

70. In the  Middle Ages , the Christian church  excommunicated  people who attempted suicide and those who died by suicide were buried outside consecrated graveyards. In  ancient  times, suicide sometimes followed defeat in battle, to avoid capture and possible subsequent torture, mutilation, or  enslavement by the enemy. During the  Cultural Revolution  in China (1966–1976), numerous publicly known figures, especially intellectuals and writers, are reported to have committed suicide, typically to escape persecution

71. The WHO report “Preventing suicide: a global imperative” published in 2014 estimates that over 800,000 people die by suicide, and more than 20 million attempt suicide each year. This implies that every 40 seconds, a person dies by suicide somewhere on the globe, and every 1.5 seconds, someone will attempt to take his/her own life. Annual global suicide rates are 15 for males, 8 for females, and 11.4 per 100,000 population. Epidemiology

72. Epidemiology Suicide occurs in all regions of the world and throughout the life span, and it accounts for 1.4 percent of all deaths worldwide, by that, ranking as the 15th leading cause of death. Among young people 15 to 29 years of age, suicide is the second leading cause of death globally

73. Etiology of suicidal behavior Psychiatric disorders Major depressive disorder (MDD), Bipolar disorders, Anxiety disorders, Alcohol and Substance misuse, Schizophrenia, Eating / personality disorders, Different types of trauma, Chronic somatic disorders, and Current stressful life events

74. Epigenetics Exposure to early-life maltreatment can affect molecular mechanisms involved in the regulation of behavior through methylation and histone modification This induce behavioral deviations during the early development, and possibly later in life. This mechanism is called epigenetics. Childhood abuse and other detrimental environmental factors seem to target the epigenetic regulation of genes involved in the synthesis of neurotrophic factors and neurotransmission.

75. Biological aspects : Serotonergic system Serotonin is involved in brain development, behavioural regulation, modulation of sleep, mood, anxiety, cognition, and memory and is shown to be disturbed in various psychiatric disorders. Asberg and colleagues observed that depressed individuals who had either attempted suicide by violent means or subsequently died by suicide in the study follow-up period were more likely to have lower CSF 5-HIAA levels.

76. 5-hydroxyindoleacetic acid (5-HIAA) is the major metabolite of serotonin and level of CSF 5-HIAA is a guide to serotonin activity in parts of the brain. Multiple postmortem studies of suicide, report lower brainstem levels of 5-HIAA and serotonin In depressed and non-depressed suicides there is evidence that 5-HT2A receptors are upregulated Aggressive/ impulsive traits, related to serotonergic dysfunction, are potentially an aspect of the diathesis for suicidal behaviour .

77. Noradrenergic system Investigating the functioning of stress response systems in suicidal individuals is important for elucidating neurobiological concomitants of suicidal behavior The noradrenergic system and the HPA axis are two key stress response systems.

78. Lower functional reserve of the noradrenergic system, which if accompanied by an exaggerated stress response with greater release of noradrenaline It may result in norepinephrine depletion leading to depression and hopelessness, both of which are contributory factors to suicidal behavior. Noradrenergic and HPA axis responses to stress in adulthood appears to be greater in those reporting an abusive experience in childhood.

79. Other biological changes There is a well-documented relationship between thyroid dysfunction and depression Abnormal TSH response to challenge tests has also been associated with poor response to antidepressant treatment and a higher relapse rate, which may increase risk for suicidal behavior. Long chain polyunsaturated fatty acids, particularly omega-3, may also be a mediating factor in the relationship between low cholesterol and increased risk for depression and suicidal behavior.

80. Suicide after DSH Suicide is one of the major outcomes of DSH. Prospectively, DSH patients have a high risk of dying by suicide. Between 10 and 15 per cent eventually die because of suicide. The connection between DSH and suicide lies between 0.5 and 2 per cent after 1 year and above 5 per cent after 9 years. Mortality by suicide is higher among DSH patients who have engaged in previous acts of DSH.

81. Warning signs of suicidal ideation Isolating yourself from your loved ones Feeling hopeless or trapped Talking about death or suicide Giving away possessions An increase in substance use or misuse Increased mood swings, anger, rage, and/or irritability Engaging in risk-taking behavior like using drugs or having unprotected sex Accessing the means to kill yourself, such as medication, drugs, or a firearm Acting as if you're saying goodbye to people Feeling extremely anxious

82. Suicidal ideation S uicidal ideation means wanting to take your own life or thinking about suicide. However, there are two kinds of suicidal ideation: passive and active.  Passive suicidal ideation  occurs when you wish you were dead or that you could die, but you don't actually have any plans to commit suicide. Active suicidal ideation,  on the other hand, is not only thinking about it but having the intent to commit suicide, including planning how to do it.

83. Prevalence of suicidal ideation The lifetime prevalence of suicidal ideation for the general world population is about 9% and about 2% within a 12-month period. According to the 2017 National Survey on Drug Use and Health (NSDUH) by the Substance Abuse and Mental Health Services Administration (SAMHSA), 4.3% of U.S. adults ages 18 and older had thoughts about suicide, with the highest prevalence among adults ages 18 to 25.

84. Suicidal intent Intent refers to the desire to end one’s life, and includes the person’s knowledge of the risk and the means to achieve the desired outcome ( O'carroll PW, 2007 ) Suicide intent is a complicated construct that comprises 2 major elements: T he level of planning and forethought preceding an act of suicide (objective planning), and The intended outcome and perceived lethality of the act (perceived intent

85. Low intent suicide – with less or no intent to kill oneself. High intent suicide – with strong desire to kill oneself. Suicidal intent correlates highly with medical lethality when the attempter has sufficient knowledge to assess properly the probable outcome of his attempt (Haw C et al., Suicide and Life-Threatening Behavior. 2003;33:353–364)

86. Lethality Lethality is the inherent danger and the potential for death associated with the suicidal act ( Berman, Shepard, & Silverman, 2003 ). A minimal association between the degree of suicide intent and the extent of medical lethality has been found, indicating that suicide intent and lethality are independent dimensions of suicide attempt behavior.  the lethality of a suicide attempt may be determined less by their intent to die than by their access to lethal methods ( Spirito & Overholser , 2003 ).

87. Attempted suicide vs self injury behaviour

88. Psychometric scales used in suicide risk assessment. The Suicide Intent Scale (SIS), Scale for Suicidal Ideation (SSI-C), The Beck Hopelessness Scale, The Columbia Suicide Severity Rating Scale (C-SSRS).

89. The Suicide Intent Scale (SIS) The suicide intent scale was developed by Aaron T. Beck and his colleagues at the University of Pennsylvania for use with patients who attempt suicide but survive. It is important to understand a patient's will to die in order to assess the severity of the suicide attempt. Some attempted suicides are carried out with little to no intention of cessation of life, while others clearly have no other goal The suicide intent scale is an attempt to redefine the meaning of attempted suicide, placing them on a scale based on intent.

90. Treatment Treatment in prevention of suicide requires a complex approach of psychosocial, psychotherapeutic, and psychopharmacological interventions The choice of treatment depends on the condition of the patient. The combination of pharmacological treatment with psychotherapy should always be taken into consideration as part of a complex treatment strategy

91. Pharmacological Antidepressants Selective serotonin reuptake inhibitors (SSRIs) are nowadays widely used in the treatment of suicidal patients with MDD and related conditions Adverse outcomes in some patients during treatment with SSRI antidepressants like agitation, restlessness, irritability, dysphoria, anger and insomnia can worsen the suicide risk in these patient .

92. Mood stabilizers Meta-analyses shows that long term lithium treatment is associated with a substantial reduction of the risk for suicide and attempted suicide in patients with bipolar spectrum disorders In bipolar depression, other mood stabilizers, such as anticonvulsants or second-generation antipsychotics have beneficial effects on suicidal behavior. However, lithium is noted to be significantly superior in reducing suicidal behaviors

93. Antipsychotics Suicidal symptoms in schizophrenic patients require, in addition to the standard treatment of the schizophrenia with antipsychotics, an additional medication to control anxiety or agitation. Sedating antipsychotics are mostly used in these cases. Electroconvulsive Therapy Cases of depression with suicidality, which are difficult to treat by other means, can be treated by ECT, which has a rapid onset of action and relief of symptoms

94. Role of media Sensational and irresponsible reporting by different types of media may precipitate or induce suicidal acts through imitation or identification mechanisms in suicidal persons. The WHO issued guidelines on media coverage, describing how the press and broadcasting media should report on suicide in order to avoid copycat effects. It is essential to avoid the description of suicide as courageous or desirable.

95. Legality of attempted suicide Indian scenario According to Article 21 of the Indian constitution, “No person shall be deprived of his life or personal liberty except according to procedure established by the law”. While the constitution covers the right to life or liberty, it does not include the ‘right to die’ Section 309 of the Indian Penal Code (IPC) clearly states as follows: “ Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to one year or with fine or both. ”

96. The law commission, in its 210 th  report, recommended that attempt to suicide warranted medical and psychiatric care and not punishment. In view of the opinions expressed by the WHO, International Association for Suicide Prevention, the Indian Psychiatric Society and the representations received by the commission from various persons, the commission resolved to recommend the government of India to initiate steps for repeal of the anachronistic law contained in section 309, IPC. Thus keeping in view the responses, it has been announced on December 10, 2014, to delete section 309 of IPC from the statute book.

97. International scenario During 19 th  and 20 th  century, most of the developed countries have repealed criminalization of attempted suicide, but some countries including India, continue to treat suicidal attempt as a criminal offense. Attempted suicide has been decriminalized in Ireland as early as 1993 Currently, World Health Organization identified 59 countries across the world that have decriminalized suicide. T he attempted suicide has been decriminalized in whole of Europe, North America, much of South America and few parts of Asia.

98. Decriminalization will reduce the trauma and potential prosecution in the aftermath of a suicidal attempt. However, there is a need to improve the mental health coverage and provide a framework to deliver essential mental health services to all those who attempted suicide.

99. Self harm in animals Self-harm in non-human mammals is a well-established but not widely known phenomenon Zoo or laboratory rearing and isolation are important factors leading to increased susceptibility to self-harm in higher mammals, e.g., macaque monkeys. Non-primate mammals are also known to mutilate themselves under laboratory conditions after administration of drugs. For example,  pemoline ,  clonidine ,  amphetamine , and very high (toxic) doses of  caffeine  or  theophylline  are known to precipitate self-harm in lab animals.

100. Captive birds are sometimes known to engage in  feather-plucking , causing damage to feathers that can range from feather shredding to the removal of most or all feathers within the bird's reach, or even the mutilation of skin or muscle tissue. In dogs, canine obsessive-compulsive disorder can lead to self-inflicted injuries, for example canine  lick granuloma Lick granuloma  from excessive licking Feather plucking in a  Moluccan Cockatoo

101. Conclusion Deliberate self-harm is a major problem in many contemporary societies. DSH seems to reflect the degree of powerlessness and hopelessness of young people with low education, low income, unemployment, and difficulties in coping with life stress There is a need for a better nationwide continuous registration of DSH and related socio-economic conditions. There is also a need for better mental health care management of DSH patients. Development of effective intervention, and prevention programs is a key priority.

102. References Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA:  American Psychiatric Association , 2013. Benjamin James Sadock, Virginia Alcott Sadock, Comprehensive textbook of psychiatry. 10 th Ed. 2007,Philadelphia, chapter 32. Paul H et al., Oxford Textbook of Psychiatry. 2018. New Delhi. Ch 4,957-70.

103. Thank you