Module 4: Somatic Symptom and Related

Disorders (Somatoform Disorder)

INTRODUCTION
It is common to experience and communicate psychological distress in the form of physical
symptoms and to seek medical attention for these symptoms. Often, these physical symptoms
remain poorly explained and are associated with increased medical visits, unnecessary medical
tests, and the performance of procedures that may result in iatrogenic complications.
For many decades, the term “somatization” was used to describe these phenomena. This was
gradually replaced by more descriptive terms such as “medically unexplained symptoms,”
“unexplained symptoms,” and “functional somatic symptoms.” The word “idiopathic”
(meaning “arising spontaneously or from an obscure or unknown cause”) is probably the most
technically correct way to label the physical symptoms displayed by many patients with
psychiatric disorders that remain poorly explained after detailed medical scrutiny and
laboratory/radiologic assessments.
The evidence for the “psychogenesis” of many of these somatic presentations was originally
derived from theoretical postulates such as Wilhelm Stekel’s notion of somatization and has
been nurtured by the frequent association of these symptoms with psychological distress and
psychopathology.
However, many of these somatic manifestations can arise spontaneously, and their causes can
remain obscure or unknown. The most distinctive characteristic of many patients with somatic
symptom disorders (SDDs) is not the symptoms they complain about but the way in which they
present and interpret them.
Despite the relevance that these idiopathic physical symptoms have to medicine and psychiatry,
their definition is difficult, and their classification remains controversial. This has led to
frequent revisions of nomenclatures that alter the criteria used to designate “cases” and
complicate the clinical recognition and management of these syndromes, recently and notably
in Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Everyone experiences somatic symptoms with a certain frequency, and most are able to cope
with them effectively. However, some people’s lives are overwhelmed by their somatic
concerns. Sometimes, the somatic concerns stem from well-established major medical
illnesses; sometimes, the origins of the concerns are never quite clear.
What is common in both situations is that patients’ lives are shadowed by disproportionate and
excessive thoughts, feelings, and behaviors that center on the perceived somatic sensations.
DSM-5 incorporated this perspective because the older perspective (simply counting or
cataloging symptoms labelled as medically unexplained) embodied in the previous somatoform
disorders’ category in DSM-III and IV was unreliable, and such a perspective often put the
doctor and the patient at odds over the question of the legitimacy and “reality” of the patient’s
symptoms and personal suffering. In fact, research has shown that regardless of medical
explanations, multiple physical symptoms predict disability and psychopathology.

DEFINITION
According to the fifth edition of the American Psychiatric Association’s DSM-5, the key
characteristic of SSDs is the presence of one or more persistent somatic symptoms that are
associated with excessive thoughts, feelings, and behaviours related to the symptoms.
The stipulation that these symptoms be medically unexplained has been removed because of
the recognition that such a distinction in itself is unreliable and because psychiatrists commonly
treat patients with medically established diagnoses who are troubled by or preoccupied with
their physical symptoms disproportionately.
Furthermore, DSM-5 acknowledges that frequently, SSDs co-occur with other psychiatric
disorders.
The diagnosis of a somatic symptom disorder is only made when there is significant distress or
impairment associated with these chronic somatic symptoms.
The SSD group in DSM-5 includes the following disorders: “somatic symptom disorder,”
“illness anxiety disorder,” “functional neurologic symptom disorder (conversion disorder),”
“psychological factors affecting another medical condition,” and “factitious disorder.”
Somatic syndromes that are below threshold are classified under two residual categories, “other
specified” and “unspecified somatic symptom and related disorders.”
In the DSM-5 field trials, somatic symptom disorder showed high levels of reliability, more
robust even than those for more traditional diagnoses.

1) SOMATIC SYMPTOM DISORDER

Individuals with somatic symptom disorder often present with multiple somatic symptoms at
one time.
These symptoms are significant enough to impact their daily functioning, such as preventing
them from attending school, work, or family obligations.
The symptoms can be localized (i.e., in one spot) or diffused (i.e., entire body), and can be
specific or nonspecific (e.g., fatigue).
Individuals with somatic symptom disorder often report excessive thoughts, feelings, or
behaviors surrounding their somatic symptoms (APA, 2022).
For example, individuals with somatic symptom disorder may spend an excessive amount of
time or energy evaluating their symptoms, as well as the potential seriousness of their
symptoms. A lack of medical explanation is not needed for a diagnosis of somatic symptom
disorder, as it is assumed that the individual’s suffering is authentic. Somatic symptom disorder
is often diagnosed when another medical condition is present, as these two diagnoses are not
mutually exclusive.
Somatic symptom disorder patients generally present with significant worry about their illness.
Their interpretation of symptoms is often viewed as threatening, harmful, or troublesome
(APA, 2022).
Because of their negative appraisals, they fear that their medical status is more serious than it
typically is, and high levels of distress are often reported.
Oftentimes, these patients will “shop” at different physician offices to confirm the seriousness
of their symptoms.

2) ILLNESS ANXIETY DISORDER

Illness anxiety disorder, previously known as hypochondriasis, involves an excessive
preoccupation with having or acquiring a serious medical illness.
The key distinction between illness anxiety disorder and somatic symptom disorder is that an
individual with illness anxiety disorder does not typically present with any somatic symptoms.
Occasionally an individual will present with a somatic symptom; however, the intensity of the
symptom is mild and does not drive the anxiety.
 Acquiring a serious illness drives concerns and they will even avoid visiting a sick relative or
friend for fear of jeopardizing their own health.
Individuals with illness anxiety disorder generally are cleared medically; however, some
individuals are diagnosed with a medical illness.
In this case, their anxiety surrounding the severity of their disorder is excessive or
disproportionate to their actual medical diagnosis.
While an individual’s concern for an illness may be due to a physical sign or sensation, most
individual’s concerns are derived not from a physical complaint, but their actual anxiety related
to a suspected medical disorder.
This excessive worry often expands to general anxiety regarding one’s health and disease.
Unfortunately, this anxiety does not decrease even after reassurance from a medical provider
or negative test results, even when provided by multiple physicians and diagnostic tests.
As one can imagine, the preoccupation and anxiety associated with attaining a medical illness
severely impacts daily functioning.
The individual will often spend copious amounts of time scanning and analyzing their body for
“clues” of potential ailments.
Additionally, an excessive amount of time is often spent on internet searches related to
symptoms and rare illnesses.
Illness becomes a central feature of the person’s identity and self-image. Although extreme,
some cases of invalidism have been reported due to illness anxiety disorder (APA, 2022).

In relation to somatic symptom and related disorders, note the following:

• For somatic symptom disorder …… the patient presents with multiple somatic
symptoms at one time that are significant enough to impact their daily functioning
• For illness anxiety disorder … the patient does not typically present with any
somatic symptoms but if they do, the symptoms are just mild in intensity

3) FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER

(CONVERSION DISORDER)
Functional neurological symptom (conversion) disorder occurs when an individual presents
with one or more symptoms of altered voluntary motor or sensory function (APA, 2022).
Common motor symptoms include weakness or paralysis, abnormal movements (e.g.,
tremors), and gait abnormalities (i.e., limping).
Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing.
Less commonly seen are epileptic seizures and episodes of unresponsiveness resembling
fainting or coma (Marshall et al., 2013).
The disorder was called “conversion disorder” in prior versions of the DSM and in the
psychiatric literature.
As noted, “The term 'conversion” originated in psychoanalytic theory, which proposes that
unconscious psychic conflict is 'converted' into physical symptoms” (APA, 2022).
The most challenging aspect of functional neurological symptom disorder is the complex
relationship with a medical evaluation.
While a diagnosis of conversion disorder requires that the symptoms not be explained by a
neurological disease, just because a medical provider fails to provide evidence that it is not a
specific medical disorder is not sufficient.
Therefore, there must be evidence of an incompatibility of the medical disorder and the
symptoms.
For example, an individual experiencing a seizure would require a normal simultaneous
electroencephalogram (EEG), indicating that there is no epileptic activity during what was
previously thought of as an epileptic seizure.

4) FACTITIOUS DISORDER
Factitious disorder differs from the three previously discussed somatic disorders in that there
is deliberate falsification of medical or psychological symptoms imposed on oneself or on
another, with the overall intention of deception.
While a medical condition may be present, the severity of impairment related to the medical
condition is more excessive due to the individual’s need to deceive those around them.
Even more alarming is that this disorder is not only observed in the individual leading the
deception— it can also be present in another individual, often a child or an individual with a
compromised mental status who is not aware of the deception behind their illness.
Some examples of factitious disorder behaviors include, but are not limited to, altering a urine
or blood test, falsifying medical records, ingesting a substance that would indicate abnormal
laboratory results, physically injuring oneself, and inducing illness by injecting or ingesting a
harmful substance.
Although most individuals with factitious disorder seek treatment from health care
professionals, some choose to mislead community members either in person or online about
the illness or injury (APA, 2022).
While it is unclear why an individual would want to fake their own (or someone else’s) physical
illness, there is some evidence suggesting that factors such as depression, lack of parental
support during childhood, or an excessive need for social support may contribute to this
disorder (McDermott, Leamon, Feldman, & Scott, 2012; Ozden & Canat, 1999; Feldman &
Feldman, 1995).
Individuals with factitious disorder are at risk for experiencing psychological distress or
functional impairment causing harm to themselves and others such as family, friends, heath
care professionals, and faith leaders.
The DSM-5-TR states, “Whereas some aspects of factitious disorders might represent criminal
behavior, such criminal behavior and mental illness are not mutually exclusive” (APA, 2022,
pg. 368).

EPIDEMIOLOGY
The prevalence rates for somatic disorders are often difficult to determine; however, overall
estimates of somatic symptom disorder are around 4-6%. There is a trend that females report
more somatic symptoms than males; thus, more females are diagnosed with somatic symptom
disorder than males (APA, 2022).
Seeing as illness anxiety disorder is a newer diagnosis (replacing hypochondriasis), prevalence
rates are largely based on the previous disorder. Previous findings suggest that illness anxiety
disorder occurs in 1.3% to 10% of the general population and is equal among males and
females.
Prevalence rates of factitious disorder are largely unknown, likely due to the use of deception
in individuals diagnosed with the disorder. Additionally, health care professionals infrequently
record the diagnosis, even in recognized cases (APA, 2022).
And like the other somatic symptom disorders, the prevalence of functional neurological
symptom disorder is unknown, even though transient functional neurological symptoms are
common.
In the United States and northern Europe, research shows that the incidence of individual
persistent functional neurological symptoms to be around 4-12 of every 100,000 annually
(APA, 2022).

COMORBIDITY
Given that half of psychiatric patients also have an additional medical disorder, 35% have an
undiagnosed medical condition, and approximately 20% reported medical
problems caused their mental condition, it should not come as a surprise that somatic disorders,
in general, have high comorbidity with other psychological.
More specifically, anxiety and depressive disorders are among the most commonly co-
diagnosed disorders for somatic disorders. While there is not a lot of information regarding
specific comorbidities among somatic symptom and related disorders, there is some evidence
to suggest that those with illness anxiety disorder are at risk of developing OCD and personality
disorders.
Similarly, personality disorders are more common in individuals with functional neurological
symptom disorder than the general public. Somatic symptom disorder is also comorbid with
PTSD and OCD. (APA, 2022). No comorbidity information is given for factitious disorder.
There is also high comorbidity between somatic disorders and other physical disorders
classified as central sensitivity syndromes (CSSs), due to their common central sensitization
symptoms, yet medically unexplained symptoms. Disorders included in this group are
fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome.
Comorbidity rates are estimated at 60% for these functional syndromes and somatic pain
disorder.

ETIOLOGY
A) Psychodynamic
Psychodynamic theory suggests that somatic symptoms present as a response against
unconscious emotional issues.
Two factors initiate and maintain somatic symptoms: primary gain and secondary gain.
Primary gains produce internal motivators, whereas secondary gains produce external
motivators.
When you relate this to somatic disorders, the primary gain, according to psychodynamic
theorists, provides protection from the anxiety or emotional symptoms and/or conflicts.
This need for protection is expressed via a physical symptom such as pain, headache, etc.
The secondary gain, the external experiences from the physical symptoms that maintain these
physical symptoms, can range from attention and sympathy to missed work, obtaining financial
assistance, or psychiatric disability, to name a few.
B) Cognitive
Cognitive theorists often believe that somatic disorders are a result of negative beliefs or
exaggerated fears of physiological sensations.
Individuals with somatic related disorders may have a heightened sensitivity to bodily
sensations.
This sensitivity, combined with their maladaptive thought patterns, may lead individuals to
overanalyze and interpret their physiological symptoms in a negative light.
For example, an individual with a headache may catastrophize the symptoms and believe that
their headache is the direct result of a brain tumor, as opposed to stress or other inoculate
reasons.
When their medical provider does not confirm this diagnosis, the individual may then
catastrophize even further, believing they have an extremely rare disorder that requires an
evaluation from a specialist.
C) Behavioral
Keeping true with the behavioral approach to psychological disorders, behaviorists propose
that somatic disorders are developed and maintained by reinforcers.
More specifically, individuals experiencing significant somatic symptoms are often rewarded
by gaining attention from other people.
These rewards may also extend to more significant factors, such as receiving disability
payments.
While the behavioral theory of somatic disorders appears to be like the psychodynamic theory
of secondary gains, there is a clear distinction between the two – behaviorists view these gains
as the primary reason for the development and maintenance of the disorder, whereas
psychodynamic theorists view these gains as secondary, only after the underlying conflicts
create the disorder.
D) Sociocultural
There are a couple of different ways that sociocultural factors contribute to somatic related
disorders.
First, there is the social factor of familial influence that likely plays a significant role in the
attention to somatic symptoms.
Individuals with somatic symptom disorder are more likely to have a family member or close
friend who is overly attentive to their somatic symptoms or report high anxiety related to their
health.
Culturally, Western countries express less of a focus on somatic complaints compared to those
in the Eastern part of the world.
This may be explained by the different evaluations of the relationship between mind and body.
For example, Westerners tend to have a view that psychological
symptoms sometimes influence somatic symptoms, whereas Easterners focus more heavily
on the mind-body relationship and how psychological and somatic symptoms interact with
one another.
These different cultural beliefs are routinely seen in research where Asian populations are more
likely to report the physical symptoms related to stress than the cognitive or emotional
problems.

TREATMENT
Treatment for these disorders is often difficult as individuals see their problems as completely
medical, and therefore, do not think psychological intervention is necessary.
Once an individual does not find relief from their symptoms after meeting with several different
physicians, they often do willingly engage in psychotherapy, psychopharmacology, or both.
Among the most effective treatment approaches is the biopsychosocial model of treatment.
This approach considers the various biological, psychological, and social factors that influence
the illness and presenting symptoms.
This treatment is often achieved through a multidisciplinary approach where the symptoms are
managed by many providers, usually including a physician, psychiatrist, and psychologist.
The interdisciplinary approach involves a higher level of care as the multiple disciplines
interact with one another and identify a treatment goal.
This approach, although more difficult to find, particularly in more rural settings, is presumed
to be more effective due to the integration of health care providers and their ability to work
together to treat the patient uniformly.

PSYCHOTHERAPY
Psychodynamic. Interpersonal psychotherapy, a type of psychodynamic therapy, has been
found to be efficacious in treating somatic disorders.
Interpersonal psychotherapy focuses on the relationship between self-experience and the
unconscious, and how these factors contribute to body dysfunction.
This type of treatment has been shown to reduce anxiety, depression, and improve the overall
quality of life immediately following treatment; however, effects appear to diminish over time.

CBT. Traditional cognitive-behavioral therapies (CBT) have been employed to address the
cognitive attributions and maladaptive coping strategies that are responsible for the
development and maintenance of the disorder.
The most common misattribution for these disorders is catastrophic thinking, or the rumination
about worst-case scenario outcomes.
Additionally, goals of CBT treatment are the acceptance of the medical condition, addressing
avoidance behaviors, and mediating expectations of treatment.

Behavioral. Behavioral therapies have also been shown to effectively manage complex
chronic somatic symptoms, particularly pain.
The behavioral approach involves bringing attention to physiological symptoms, the
individual’s attribution to those symptoms, and the subsequent anxiety produced by the
negative attributions.

Psychopharmacology
Psychopharmacological interventions are rarely used due to possible side effects and unknown
efficacy.
Given that these individuals already have a heightened reaction to their physiological
symptoms, there is a high likelihood that the side effects of medication would produce more
harm than help.
With that said, psychopharmacological interventions may be helpful for those individuals who
have comorbid psychological disorders such as depression or anxiety, which may negatively
impact their ability to engage in psychotherapy
PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL
CONDITIONS
Although previously known as psychosomatic disorders, the DSM-5-TR has identified
physical illnesses that are caused or exacerbated by biopsychosocial factors as psychological
factors affecting other medical conditions.
This disorder is different than all the previously mentioned somatic related disorders as the
primary focus of the disorder is not the mental disorder, but rather the physical disorder.
Psychological or behavioral factors adversely affect the medical condition by, “…influencing
its course or treatment, by constituting an additional well-established health risk factor, or by
influencing the underlying pathophysiology to precipitate or exacerbate symptoms or to
necessitate medical attention” (APA, 2022, pg. 365).
It is believed that a lack of positive coping strategies, psychological distress, or maladaptive
health behaviors exacerbate these physical symptoms.

PSYCHOPHYSIOLOGICAL DISORDERS
The most common types of psychophysiological disorders are headaches (migraines and
tension), gastrointestinal (ulcer and irritable bowel), insomnia, and cardiovascular-related
disorders (coronary heart disease and hypertension).
Headaches. Among the most common types of headaches are migraines and tension
headaches (Williamson, 1981).
Migraine headaches are often more severe and are explained by a throbbing pain localized to
one side of the head, frequently accompanied by nausea, vomiting, sensitivity to light, and
vertigo.
It is believed that migraines are caused by the blood vessels in the brain narrowing, thus
reducing the blood flow to various parts of the brain, followed by the same vessels later
expanding, thus rapidly changing the blood flow.
Tension headaches are often described as a dull, constant ache localized to one part of the head
or neck; however, it can co-occur in multiple places at one time.
Unlike migraines, nausea, vomiting, and sensitivity to light do not often occur with tension
headaches.
Tension headaches, as well as migraines, are believed to be primarily caused by stress as they
are in response to sustained muscle contraction that is often exhibited by those under extreme
stress or emotions.
In efforts to reduce the frequency and intensity of both migraines and tension headaches,
individuals have found relief in relaxation techniques, as well as the use of biofeedback training
to help encourage the relaxation of muscles.
Gastrointestinal. Among the two most common types of gastrointestinal psychophysiological
disorders are ulcers and irritable bowel syndrome (IBS).
Ulcers, or painful sores in the stomach lining, occur when mucus from digestive juices are
reduced, allowing digestive acids to burn a hole into the stomach lining.
Among the most common type of ulcers are peptic ulcers, which are caused by the bacteria H.
pylori.
While there is evidence to support the involvement of stress in the development of dyspeptic
symptoms, the evidence linking stress and peptic ulcers is slowly growing
Researchers believe that while H. pylori must be present for a peptic ulcer to develop, increased
stress levels may impact the amount of digestive acid present in the stomach lining, thus
increasing the frequency and intensity of symptoms.
IBS is a chronic, functional disorder of the gastrointestinal tract. Common symptoms of IBS
include abdominal pain and extreme bowel habits (diarrhoea or constipation).
It affects up to a quarter of the population and is responsible for nearly half of all referrals to
gastroenterologists.
Because IBS is a functional disorder, there are no known structural, chemical, or physiological
abnormalities responsible for the symptoms.
However, there is conclusive evidence that IBS symptoms are related to psychological distress,
particularly in those with anxiety or depression.
Although more research is needed to pinpoint the timing between the onset of IBS and
psychological disorders, preliminary evidence suggests that psychological distress is present
before IBS symptoms.
Therefore, IBS may be best explained as a somatic expression of associated psychological
problems.
Insomnia. Insomnia, the difficulty falling or staying asleep, occurs in more than one-third of
the population, with approximately 10% of patients reporting chronic insomnia.
While exact pathways of chronic psychophysiological insomnia are unclear, there is evidence
of some biopsychosocial factors that may predispose an individual to develop insomnia such
as anxiety, depression, and overactive arousal systems.
Part of the difficulty with insomnia is the fact that these psychological symptoms can impact
one’s ability to fall asleep; however, we also know that lack of adequate sleep also predisposes
individuals to increased psychological distress.
Due to this cyclic nature of psychological distress and insomnia, intervention for both sleep
issues as well as psychological issues is vital to managing symptoms.
Cardiovascular. Heart disease has been the leading cause of death for the past several decades.
Researchers have identified that depression is a predictor of early-onset coronary heart
disease.
More specifically, there is a five-fold increase of depression in those with coronary heart
disease than the general population.
Additionally, anxiety and anger have also been identified as an early predictor of cardiac events,
suggesting psychological interventions aimed at reducing anxiety and establishing positive
coping strategies for anger management may be effective in reducing future cardiac events.
Hypertension. Also called or chronically elevated blood pressure, is also found to be affected
by psychological factors.
More specifically, constant stress, anxiety, and depression have all been found to impact the
likelihood of a cardiac event due to their impact on vasoconstriction.
Elevated inflammatory markers such as C-reactive protein, which is indicative of plaque
instability, has been found in chronically depressed individuals, thus predisposing them to
potential heart attacks.

TREATMENTS FOR PSYCHOLOGICAL FACTORS AFFECTING

OTHER MEDICAL CONDITIONS
As more information regarding contributing factors to psychophysiological disorders is
discovered, more psychological treatment approaches have been developed and applied to
these medical problems.
The most common types of treatments include relaxation training, biofeedback, hypnosis,
traditional CBT treatments, group therapy, as well as a combination of the previous treatments.
Relaxation training. Relaxation training essentially teaches individuals how to relax their
muscles on command.
While relaxation is used in combination with other psychological interventions to reduce
anxiety (as seen in PTSD and various anxiety disorders), it has also been shown to be effective
in treating physical symptoms such as headaches, chronic pain, as well as pain related to
specific causes (e.g., injection sites, side effects of medications).
Biofeedback. Biofeedback is a unique psychological treatment in which an individual is
connected to a machine (usually a computer) that allows for continuous monitoring of
involuntary physiological reactions.
Measurements that can be obtained are heart rate, galvanic skin response, respiration, muscle
tension, and body temperature, to name a few.
There are a few different ways in which biofeedback can be administered.
The first is clinician-led. The clinician will actively guide the patient through a relaxation
monologue, encouraging the patient to relax muscles associated near the pain region (or within
the entire body).
While going through the monologue, the clinician is provided with real-time feedback about
the patient’s physiological response.
Research studies have routinely supported the use of biofeedback, particularly for those with
pain and headaches that have not been responsive to pharmacological interventions.
Another option of biofeedback is through computer programs developed by psychologists.
Hypnosis. Hypnosis, which some argue is just an extreme sense of relaxation, has been
effective in reducing pain and managing anxiety symptoms associated with medical
procedures.
Through extensive training, an individual can learn to engage in self-hypnosis or obtain
recorded hypnosis monologues to assist with the management of physiological symptoms
outside of hypnosis sessions.
While additional research is still needed within the field of hypnosis, studies have indicated
that hypnosis is effective in not only treating chronic pain, but also assists with a reduction in
anxiety, improved sleep, and improved overall quality of life.
Group Therapy. Group therapy is another effective treatment option for individuals with
psychological distress related to physical disorders.
These groups not only aim to reduce the negative emotions associated with chronic illnesses,
but they also provide support from other group members that are experiencing the same
physical and psychological symptoms.
These groups are typically CBT based and utilize cognitive and behavioral strategies in a group
setting to encourage acceptance of disease while also addressing maladaptive coping strategies.

SUICIDE: TYPES, CAUSES AND TREATMENT I

MEANING AND DEFINITION

World Health Organization (1986) defined self-harm as, “an act with non-fatal outcome, in
which an individual deliberately initiates a non-habitual behaviour 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 realizing changes which the
subject desired via the actual or expected physical consequences”.
On the other hand, suicide is defined as the act of deliberately killing oneself. Self-harm is a
complex behaviour that can be best thought of as a maladaptive response to acute and chronic
stress, often but not exclusively linked with thoughts of dying. It is a form of non-fatal, self-
destructive behaviour that is believed to occur when an individual’s sense of desperation
outweighs his/her inherent self-preservation instinct.
The word suicide was first used by the English author Sir Thomas Browne in 1642 in his
treatise “Religio Medici”. The word originated from SUI (of oneself) and CAEDES (murder).
Suicide is a complex phenomenon determined by several factors. It not only affects the
individual but also family and friends.
It also impacts the community and the larger society in terms of loss of valuable human
resource. There are several terms related to suicide: suicidal ideation, attempt and completion
of the act.
Suicidal ideation refers to the thoughts about suicide. This may again consist of ideas of intent
or death wishes; reflecting the degree of seriousness.
Suicide attempt refers to the acts taken by the individual to die. It may result in failure attempts
where the individual could not die despite the attempt to die. In the other case, it is only an
attempt and results in deliberate self harm or intentional self harm. They intentionally injure
themselves but do not have an intention to die.
Completed suicide refers to suicide attempt resulting in death. It is marked by ‘intent’ or
‘intentionality’ and ‘lethality’. Intent is inferred by the nature, elaborateness, confidentiality
and secrecy of the suicide plan; and also attempts to finish the unfinished tasks of life and sort
of trying to wind up things in his life.
Lethality refers to the degree of severeness of the method used for suicide where the person
sees the attempt as a final one.

EPIDEMIOLOGY
Data from developed countries suggest that about 1 in 200 people attempt self-harm. Two thirds
of patients who self-harm are less than 35 years old and two thirds of people in this age group
are female.
There is particular concern that the rate in young men aged 15-24 years of age is rising more
quickly than in any other group. Here, it should be emphasized that self-harm and suicide are
related yet somewhat different phenomena, and this is best illustrated by the differences in their
epidemiological features.
Suicide is more common in older men while self-harm is more common in younger women;
and the gap between the two genders seems to be widening as the rate of suicide among men
is increasing (as is the case also for self-harm in young men).
The importance of deliberate self-harm behaviour is illustrated by the subsequent risk of
suicide, which, in the subsequent year, is at least 100 times more in those who have self-harmed
as compared to the general population and the risk of suicide is about 3% even after 10 (or
more) years of the first attempt.
The risk of repetition of self-harm is also extremely high; up to 40% will go on to repeat,
including 13% in the first year. Self harm is found to be one of the top five causes of acute
medical admissions for both men and women.
Suicide has been found to be the third leading cause of death among the youth worldwide. The
suicide rate in India is comparable to that of Australia and the USA and the increasing rates
during recent decades is consistent with the global trend (Radhakrishnan & Andrade, 2012.
Data on suicide in India are available from the National Crime Records Bureau (NCRB),
Ministry of Home Affairs. As per the report of NCRB (2010), of late, suicide rates show an
increasing trend in India.
NCRB 2010 Report cites consumption of poison as the most common mode of suicide.
Followed by it are hanging, self-immolation, drowning, jumping from buildings as other
commonest modes of suicide in India. Table 1.1 gives the features that predict repetition of
self-harm or eventual suicide.

CAUSES
This aspect can be viewed from several perspectives, such as:

• Individual’s motive for committing the act;

• Intentions at the time of the act;
• Functions served by the act of self-harm;
• Social precipitants; and
• Mental health reasons.
INTENTIONS AND MOTIVES
Self-harm may involve little pre-mediation or may have been contemplated for some time.
Some individuals, especially the elderly, may have serious suicidal ideas before the act and
survive only as a result of misjudgment or chance events. The motivation for self-harm may
appear to be complex and very personal. Given below are examples of motives given by some
individuals who have self-harmed:
“It expresses emotional pain or feelings that I’m unable to put into words!”
“It’s a way to have control over my body because I can’t control anything else in my life”
“I usually feel like I have a black hole in the pit of my stomach, at least if I feel pain it’s better
than feeling nothing”.
Suicidal intent is said to be the extent to which the person wishes to die at the time of
committing the act. While it can be difficult to assess the difference between an attempt to self-
harm and to commit suicide in some situations, as many individuals are ambivalent about the
intent to die and the reported intent may change fairly quickly, it is clear that most people who
attempt self-harm do not wish to die; rather it serves various other functions, e.g. an attempt to
regain some control over oneself; to combat feelings of inner emptiness; or simply to express
unbearable pain.
Functions Served by Self-Harm
Klonsky (2007), on the basis of examination of empirical literature, delineated seven
functions served by the act of self-harm; as shown in Table 1.2.

Affect regulation: It is believed that an early family environment that does not validate
(support or corroborate) the experiences of the growing child may impair his/her ability to cope
with emotional distress. Individuals from these environments and/or with genetic disposition
for emotional instability are more prone to use self-harm as a maladaptive affect-regulation
strategy.
Anti-suicide: Individuals may use self-harm as a coping mechanism for resisting urges to
attempt suicide. From this perspective, self-harm may be thought of as a means of expressing
suicidal thoughts without risking death.
Feeling generation: It has been suggested that individuals who self-harm may have
experienced dissociation (a perceived detachment of the mind from the emotional state or even
from the body) when loved ones were perceived as absent (e.g. a very erratic or depressed
mother) for prolonged periods (this is psychologically very distressing to the child). Episodes
of dissociation or depersonalization may then recur (later in life) in response to intense
emotions. Causing injury to oneself creates physical sensations that interrupt a dissociative
episode, and leads one to regain a sense of self.
Interpersonal-influence: At times self-harm may be used to influence (or even manipulate)
people. Self-harm has often been conceptualized as a cry for help, a means of avoiding
abandonment, or an attempt to be taken more seriously or otherwise affect people’s behaviour.
For example, an individual might self-injure to elicit affection from a significant other (e.g.
parents, spouse).
Interpersonal boundaries: Individuals who self-harm are thought to lack a normal sense of
self due to insecure attachment with early attachment figure(s) and a subsequent inability to
individuate (form a cohesive self-identity). Self-harm (e.g. cutting) as a deliberate or
autonomous act is perceived as an assertion of one’s identity or autonomy; and thus an
affirmation of a distinction between oneself and others.
Self-punishment: Self-harm can be an expression of anger or derogation towards oneself. It
has been hypothesized that individuals who self-harm have learned from their environments to
punish or invalidate themselves.
Sensation-seeking: Self-harm may be perceived as a means for generating excitement or
exhilaration in a manner similar to Russian roulette (a potentially lethal game of chance in
which participants place a single round in a revolver, spin the cylinder, place the muzzle against
their head and pull the trigger).
SOCIAL FACTORS
Those who are isolated or living in areas of socio-economic deprivation have increased rates
of suicide and deliberate self-harm. Vulnerability or predisposing factors such as early loss or
separation from one or both parents, childhood abuse, unemployment, and absence of living in
a family unit are also found to be contributory.
Evidence also suggests that the person may have suffered an excess of life events, especially
in the month before the self-harm attempt. Frequently, the type of events experienced by
younger people is related to relationship difficulties, but in older people it is more likely to be
health or bereavement related.
Certain factors in the family’s environment may also be important, such as parental discord and
violence, parental depression or substance abuse, role models of suicidal behaviour in the
family, abuse of all kinds (e.g. physical, verbal or sexual) and bereavement.
MENTAL HEALTH FACTORS
Mental health difficulties are frequently seen in individuals who self-harm. Individuals
diagnosed with certain types of mental disorder are much more likely to self-harm. These
include depression, psychotic illnesses like schizophrenia, phobias, alcohol and substance
problems and personality disorders. Sometimes, repetitive self-injury is also seen in individuals
with mental retardation; however, this must be differentiated from the deliberate self-harm
caused with a conscious intent of harming oneself.
Certain psychological characteristics are more commonly found among the group of people
who self-harm; including hopelessness, impulsiveness, aggression, inflexible and impulsive
cognitive style, impaired decision-making, poor coping skills, poor frustration tolerance, and
poor problem-solving abilities.
While nearly all mental disorders have the potential to increase the risk for suicide, studies
show that the most common disorders among people who die by suicide are major depression
and other mood disorders, and substance use disorders, schizophrenia and personality disorders
(Bertolote & Fleischmann, 2002).
Findings regarding the relationship between mental disorders and suicide mostly come from
“psychological autopsy” studies. These in-depth investigations rely on interviews with family,
close friends, and others who were in close contact with the person who died by suicide, in
order to identify factors that likely contributed to the death. Such studies have consistently
found that the overwhelming majority of people who die by suicide—90% or more— had a
mental disorder at the time of their deaths. Often, however, these disorders had not been
recognized, diagnosed, or adequately treated (Bertolote & Fleischmann, 2002).
Depression has been found to increase the risk of suicide. Even in case of bullying, the high
school students who had symptoms of depression at the time they were bullied were found to
have suicidal ideation and behaviour in post-high school follow up. On the other hand, the
bullied youth who did not have co-existing depression had significantly lower risk for later
mental health problems (Klomek, et al, 2011).
UNDERSTANDING SUICIDE

Suicide is precipitated by a wide range of factors that interplay with each other to influence the
act of suicide.

As reported by Gajalakshmi and Peto (2007), a complex array of factors such as poverty, low
literacy level, unemployment, family violence, breakdown of the joint family system,
unfulfilled romantic ideals, inter-generational conflicts, loss of job or loved ones, failure of
crops, growing costs of cultivation, huge debt burden, unhappy marriages, harassment by in-
laws and husbands, dowry disputes, depression, chronic physical illness, alcoholism/ drug
addiction, easy access to means of suicide contribute to committing suicide.

Exposure to completed and attempted suicide in the family has also been found to increase
suicide risk among family members by providing a “social model” of self-harm behaviour (de
Leo & Heller, 2008). Imitative behaviour (“contagion”) plays a role in the precipitation of
suicide. Recent studies have concluded that media coverage of suicide is connected to the
increase—or decrease—in subsequent suicides, particularly among adolescents (Sisask &
Varnik, 2012). High volume, prominent, repetitive coverage that glorifies, sensationalizes or
romanticizes suicide has been found to be associated with an increase in suicides (Bohanna and
Wang, 2012). There is also evidence that when coverage includes detailed description of
specific means used, the use of that method may increase in the population as a whole (Yip et
al., 2012). The emerging phenomenon of “cyber- suicide” in the internet era is a further cause
for concern (Rajagopal, 2004; Birbal [Link]., 2009).

Various theories have attempted to explain suicide. Biological theories cite the role of
neurotransmitters in the causation of suicide and underlie the genetic basis of suicidality. On
the other hand, sociological explanations emphasize the role of society in causing the suicide
[Link], Emile Durkheim explains suicide in terms of social integration and social regulation.
Thus suicide is viewed not on an individual level, but at a community and societal level.

Psychoanalytic theory of Freud talks about ‘death instinct’ as a basic instinctual force which in
some situations may be turned inward to harm oneself. Other theories have also discussed about
sense of hopelessness, stress, extent of perceived threat to life as contributing to suicidal
behaviour.

PREVENTION

The ideal method of protection against self-harm is prevention, i.e., reduction of number of
new cases as well as prevention of further self-harm in individuals who have harmed
themselves at least once.

The former can be attained by using public health measures that can modify social, economic,
and biological conditions, such as reduction of poverty, violence, divorce rates, and promotion
of a healthy lifestyle.

Also, measures for mental health promotion and life-skill training (e.g. in schools) are useful
ways for prevention of slef-harm and suicide.

Clinicians can minimize the risk of self-harm and suicide among their patients/clients by
thoroughly assessing for the presence of psychiatric illnesses, being aware of clinical and social
situations that might precipitate self-harm and initiating treatment with or facilitating access to
treatment for patients with psychiatric disorders.

Also, they can do a careful risk-assessment; provide easy access to help for psychosocial
problems and also scrutinize prescriptions (medication). Educating patients and their families
about mental illness (if any), and the safe storage of medications and pesticides also is useful
in prevention of self-harm and suicide.

MANAGEMENT

Important principles of management are:

• Establishing adequate rapport with the patient

• Privacy and maintenance of confidentiality
 • Conduct interview safely and with adequate time
• Let patient tell their story
• Question relatives and friends about what patient has recently said

ILLUSTRATIVE CASE

A 24-year-old man presents to a counsellor’s office complaining of difficulty falling asleep.

During the interview, he says that something is wrong — he has no energy, is crying almost
every day, has lost his usual healthy appetite, and has started using alcohol frequently in an
attempt to fall asleep. He admits that he sees the world as hopeless and has considered driving
his motorcycle into a wall. He says that he would not kill himself, however, because suicide is
a sin, and his parents would be saddened and shamed by such a death. Until his girlfriend left
him two months earlier, he had never had these symptoms. Also due to not being able to sleep,
he is reaching office late since a few days and getting scolded by his boss everyday. In
frustration, he has started engaging in cutting himself whenever the thought of suicide or his
girl-friend occurs to him. He wants help in sleeping but fears the impact of treatment on his
ability to continue his job which involves a lot of driving. History also revealed presence of
depressive symptoms in mother, and frequent fights between the parents. Patient’s premorbid
personality revealed poor frustration tolerance and a high need for achievement.

ASSESSMENT

There are countless ways that someone may self-harm, the most common being cutting, used
by over two thirds of those who self-harm followed by self-poisoning (e.g. overdose of
medications, use of pesticides). The other methods of self-harm include burning, punching, etc.
A person with self-harm may exhibit signs like cuts, scratches, burns or scars, bruises or even
broken bones. There may be other give-aways like missing razors or pills, or razors/medicine
wrappers/ pesticide bottles found in the dustbin.

The purpose of the assessment is to identify factors associated with suicidal behaviour, to
determine the motivation for the act, to identify potentially treatable mental disorders, and to
assess continuing risk of suicidal behaviour. It also includes assessment and treatment of the
patient’s physical condition, having a basic understanding of medico legal issues, and drawing
up and implementing a treatment plan.

All patients presenting with deliberate self-harm should be offered not only a sensitive
assessment of risk, but of psychological and social needs as well. The main issues to be
determined in the assessment process are:

• What were the patient’s intentions?

• Does the patient still want to die?
• Are there current mental health difficulties?
 • What is the risk of further self-harm or suicide (assessment of risk)?
• Are there any current medical or social problems (assessment of need)?

Assessor should regularly inquire about current depression, hopelessness, and suicidal ideation.
The risk of suicide should be considered imminent if the patient reports the intention to die,
has a suicidal plan, and has lethal means available.

Expressions of despair and hopelessness also suggest an imminent risk. A common myth is that
enquiring about suicide would put ideas into the patient’s mind. However, that is not the case
and it is important to ask in detail about whether the patient has any intention of committing
suicide and he/she should be allowed free expression.

Useful questions in relation to hopelessness, wish to die, and suicidal ideas that should be
considered in any evaluation for self-harm can be formulated as follows:

• Are things so bad to make you take such a step?

• Who all are there in your family? What do they think about this?
• How do you see the future?
• Do you think that things would work out?
• Do you ever feel that life isn’t worth going on with?
• Do you think that you might do something to harm yourself?
• What stops you from carrying it out?
• Have you ever felt like this before?
• If so, how frequently and under what circumstances?

On the basis of assessment, a formulation may be reached that includes:

Long-term vulnerability factors: It includes early loss or separation from parents, difficult
relationships with parents, or abuse in early life. Although sexual abuse has been highly
associated with self-harm, emotional or physical abuse is also important. Enduring
psychological characteristics and other psychiatric problems need to be identified.

Short-term vulnerability factors: These are current difficulties in relationships and lack of
social support, work or health related problems, drug and alcohol misuse, or exacerbation of
psychological symptoms.

Precipitating factors: These are usually stressors experienced in the few days immediately
prior to self-harm. Again, relationship problems, financial worry, anniversaries, deaths or other
losses can act as precipitators to the act of self harm.

TREATMENT
A crisis intervention model is often most appropriate, when initiating treatment. At the end of
the interview, the assessor should be able to plan what action is to be taken collaboratively with
the patient. This may involve treating any underlying mental illness or substance abuse
appropriately, counselling, improving lifestyle, helping patient to develop coping skills to
resolve stressful situations.

Useful Tips when Dealing with a Case of Self-Harm

• Understand that self-harming behaviour is an attempt to maintain a certain amount of

control which in and of itself is a way of self-soothing
• Let the person know that you care about him/ her and are available to listen
• Encourage expressions of emotions including anger
• Don’t make judgemental comments or order the person to stop the self-harming
behaviour - people who feel worthless and powerless are even more likely to self-injure

Management of persons who engage in deliberate self-harm should focus on three major areas:

• Immediate medical management of self-harming behaviour

• Management of underlying psychopathology (medications and psychosocial therapies).
• Measures to prevent the recurrence of self-harming behaviour

Support, and especially company, should be mobilized, especially in the short term. A
significant aspect of such intervention is the elimination of the patient’s access to potentially
lethal means of suicide. Other health strategies that may prove important are telephone
helplines, and more global social support measures. The patient may be given a “crisis card”,
which carries advice about seeking help in the event of future suicidal feelings. Self-help
booklets may also be helpful in reducing repeat attempts in those without a borderline
personality disorder.

Some of the specific psycho-therapeutic modalities that have been used with the individuals
who self harm are:

Problem-solving therapy: Problem solving therapy is a brief treatment aimed at helping the
patient to acquire basic problem-solving skills, by taking him through a series of steps:

• Identification of personal problems;

• Constructing a problem list which clarifies and prioritizes them;
• Reviewing possible solutions for a target problem;
 • Implementing the chosen solution;
• Reappraising the problem; and
• Reiterating the process.

The therapy also includes training in problem-solving skills for the future. It usually involves
about six sessions lasting one hour, with some reading materials and work to be undertaken
between sessions. Problem solving therapy has been shown to be an effective treatment for
self-harm and mood and social adjustment.

Dialectical Behaviour Therapy (DBT): This treatment was introduced to primarily help those
who engage in chronic and repetitive self-harm, particularly when they have associated
borderline personality characteristics. This treatment is intensive, involving a year of individual
treatment, group sessions, social skill training, and access to crisis contact. Treatment studies
indicate that DBT is effective in reducing some of the features associated with patients with
borderline personality disorder, particularly self-harming behaviour.

Family therapy: Family therapy has been found to be especially useful for adolescents and
young adults who self-harm. It has been found that many adolescents who self harm have
family problems. Moreover, when an adolescent or young adult engages in self-harm, it can be
a very distressing event for the family members. They may be confused about their role or
feeling guilty about the child’s act. It is important to establish an alliance with family members
(without taking sides) by empathizing with their situation and giving them a reflective listening.

The main aim of family therapy is to help the adolescent and her/his family to resolve the
difficulties that led to self-harm. Family therapy is focussed on improving communication and
problem-solving within the family. It can also help to restore the equilibrium of the family
system if it had been negatively affected by the episode of self-harm. Finally, family therapy
may help in prevention of further episodes of self-harm. Certain key issues may need to be
addressed in family therapy:

Privacy: Parents of children who harm themselves often fear that their child may self-harm
behind closed doors. The youngster demands privacy by stating, “I am independent, leave me
alone,” while at another level he may be testing whether the parents are able to understand the
unsaid, “I am hurt and I need your help.” These conflicting messages need to be dealt in family
therapy sessions wherein the competing tension within each conflict can be taken up in
discussions. The issue of parent-child boundaries must be continually addressed and
appropriate roles must be clearly defined and reinforced.

Suicide and serious harm: A clear contract for ensuring that the adolescent does not intend
and will not seriously harm him/her self may be made (a written and signed “No suicide
contract”). It often has the conditions for immediate hospitalization spelled out. Parents also
need continuous support in setting limits to unacceptable behaviours (saying “No” firmly but
without harshness) despite their worries of sparking a self-harm episode.

Balancing needs and desires: Families often need help on where to draw a line between
freedom and firm limits. The role of the therapist is to facilitate understanding between family
members as to their needs and desires and also to negotiate some practical compromises
between competing interests. Helping families acquire strategies for communicating and
negotiating even in the midst of charged emotional encounters also models to the adolescent
the need to use problem solving strategies and directly address tough issues rather than acting
them out.

Cutting and blame: Often the adolescent who indulges in self-harm attributes it to external
stressors, which is very often the parents and their behaviour, “My parents just don’t understand
me; they think I am still a kid and can’t make any decisions”. On the other side, parents may
take this to heart and assume that they, solely, are responsible for their child’s dysfunctional
behaviour. Thus, the goal in therapy is to place the blame squarely to where it belongs. If it’s
the adolescent’s mistake, then it’s the therapist skills that would come handy in making him/her
accept the mistake without losing face. One way of achieving it is to make the parents talk
about their “faults” when they were adolescents. Also, the adolescent should be appreciated for
honestly accepting their role in their behaviour and the parents can be quieted in their critical,
judgmental and “I told you so” attitude.

Pharmacological and clinical management:

Antidepressants have a proven role when depression or anxiety is detected but are unlikely to
have a role in cases where mood disorder has been carefully excluded. Psychiatric admission
remains a valuable option when risk is high and/or serious mental health problems cannot be
otherwise resolved. Regular follow up reduces the subsequent rate of deliberate self-harm.

Useful tips that can be given to patients for stopping self-harm

 • Writing about how you are feeling.
• Doing relaxation exercise.
• Distraction (doing some pleasurable activity).
• Going for a run, brisk walk, dancing, any form of exercise.
• Talk to a friend or your therapist — have a list of people you can ring.
• Find meaningful activities to do (e.g. voluntary work).
• Do not keep extra medicines/pills or pesticides in the house.
• Do not keep sharp objects (e.g. knife, blade etc.) near you.

Early detection of suicidal ideation and prevention measures are crucial. Various steps such as
community awareness, media guidelines regarding reporting suicide, and helplines can work
in the prevention of suicide. Further, counseling centres and NGOs can also contribute towards
this. A multidisciplinary team consisting of psychiatrist, general physicians, psychiatric nurses,
psychiatric social workers, and NGOs play a significant role in addressing the issue of suicide
that contributes to a major loss of potential human resource.

REFERRAL

Risk of subsequent suicide is particularly high in those with high unresolved suicidal intent,
depressive disorder, chronic alcohol and drug misuse, social isolation, and current physical
illness.

The most common psychiatric condition associated with suicide or serious suicide attempts is
depression, and also rates of depression are substantial after self-harm. Depression is a strong
predictor of further self-harm. Suicidal thoughts and behaviour are state related in depression;
and resolution of the depression will almost invariably alleviate thoughts of suicide. Personality
disorders, alcohol and substance abuse, anxiety disorders, and schizophrenia are also frequently
associated with suicidal behaviour. About 20% of those who attempt self-harm repeat it
multiple times. This group is much more likely to include individuals with persistently
maladaptive ways of coping, typically in the form of unhelpful personality traits. Chronic
alcohol and drug problems are a strong risk factor for self-harm and eventual suicide. Current
intoxication at the time of self-harm may indicate an impulsive (disinhibited) attempt, but its
link with chronic alcohol problems should be explored and taken seriously.
Physical illness can be very distressing, especially when progressive or unpredictable. In a large
multi-centered transnational study, 50% of people had a physical illness at the time of the
attempt for which they had sought help. Frequently, physical illness is a risk factor for complete
suicide without a previously detected attempt. Isolation is a risk factor for suicide and
particularly for self-harm. The majority of suicides in the elderly involve those who are single
or widowed.

Frequent repeaters, those with alcohol and substance use problems, those with physical or
mental illness, and those who are isolated also require input from specialist mental health
professionals. It is also recommended that adolescents and elderly people warrant a mandatory
specialist assessment. Patients with one or more of these risk factors should be offered
enhanced care that may include inpatient or outpatient follow up care, a list of local support
resources, and. where possible, self-help material.