[ Pobierz całość w formacie PDF ]
family, or reunion with a deceased loved one.
Negative consequences of suicide such as emo
tional pain to the family should be discussed. Ask
about anything the patient may feel they have to
live for, and assess evidence of plans for the
future, such as a trip to see children, or concern
that hospitalization may interfere with an important
event.
Evaluate concurrent depressive symptoms, feel
ings of hopelessness, substance abuse, anxiety,
and psychosis. Ask about command auditory
hallucinations. Consider features of personality
disorders in the assessment of suicidal ideation,
such as poor impulse control, mood lability, unsta
ble self-esteem, unstable relationships, and other
cluster B personality traits.
Past psychiatric history: Ask about all past
psychiatric symptoms, diagnoses, treatments, and
previous suicide attempts. Suicide is more likely to
occur in patients just recovering from suicidal
depression or in the few weeks to months follow
ing discharge from the hospital. Patients with a
history of suicide attempts are at greater risk.
Suicide is most commonly associated with major
depression, but also occurs with significantly
increased rates in bipolar disorder, schizophrenia,
substance abuse disorders, borderline personality
disorder, antisocial personality disorder, cognitive
disorders, organic mental disorders, anxiety
disorders, and adjustment disorders.
Substance abuse history: Ask about all sub
stances used. Alcohol abuse and dependence is
most commonly associated with suicide, espe
cially in the presence of comorbid psychiatric
disorders. Heroin dependence is also associated
with increased rates of suicide. Ask about avail
ability of lethal amounts of the substance abused
and method of use. Substance abuse can some
times be perceived as a form of suicidal behavior,
and accidental overdose is a frequent cause of
death in substance abusers.
Social history: Ask about marital status, living
situation, social support, family conflict, employ
ment, legal trouble, financial trouble, illness in the
family, recent loss of a loved one, and feelings of
social isolation. Divorce, unemployment, living
alone, poor social support, and loss of a loved one
are significant risk factors for suicide.
Family history: A history of suicide in the family
increases the risk for suicide. Also ask about
family history of psychiatric illness and treatment.
Past medical history: Comorbid medical illness
increases the risk of suicide. Epilepsy, multiple
sclerosis, cardiovascular disease, Huntington s
disease, dementia and AIDS are all associated
with depression and increase the risk of suicide.
Other medical problems that occur with mood
disorders also increase suicidal risk and include:
Cushing s disease, anorexia nervosa, porphyria,
cerebrovascular disease, and cirrhosis.
Medications: Ask about all medications, espe
cially ones potentially lethal in overdose, such as
barbiturates, anticonvulsants, and tricyclic antide
pressants.
Mental Status Exam
General appearance: Withdrawn, uncooperative,
with poor eye-contact.
Speech: Not spontaneous, soft, slow, with paucity
of speech.
Mood: Depressed, sad, angry, hopeless,
worthless
Affect: Constricted, dysphoric, congruent
Thought process: Linear, but may have in
creased response latency.
Thought content: Possible ruminations of guilt or
obsessive thoughts about suicide methods.
Perceptual: Possible auditory hallucinations with
commands to just do it or end it.
Suicidality: Positive ideation with plans to jump in
front of traffic, history of attempts via overdose;
the patient may be unable to commit to contacting
someone if feeling suicidal, or he may be unable
to agree not to hurt himself (ie, commit to safety).
Homicidality: Denies
Sensorium/cognition: Memory and concentration
may be impaired. Perform the mini-mental state
exam in patients with suspected dementia or
cognitive impairment related to depression.
Impulse control: Variable. A history of poor
impulse control increases the risk of suicide.
Judgment: Impaired. The patient may not under
stand how their behavior will affect family and
friends.
Insight: Fair. The patient wishes to die but may
not understand the significance of the underlying
illness.
Reliability: Fair; reliability is crucial in assessing
commitment to safety.
Laboratory data: Complete blood count, chemis
try, urinalysis with toxicology screen and blood
alcohol level, and urine pregnancy test.
Diagnostic testing: Testing should be done
according to the differential diagnosis and de
pending on symptom presentation.
Differential diagnosis:
Axis I: Major depression, bipolar I disorder,
schizophrenia and other psychotic disorders,
alcohol and other substance abuse disorders,
dementia, adjustment disorder, panic and other
[ Pobierz całość w formacie PDF ]