118 Chapter 12
within families may be at least partly genetic. Some of this may be
mediated by the known heritability of depression, substance use and other
psychiatric disorders, but impulsive aggression is a heritable trait that
also seems to be important. Various studies of people who have killed
themselves suggest that abnormalities in serotonergic neurotransmission
might have contributed to increased impulsiveness in response to stress.
Management
Where a current or former patient commits suicide this is likely to be very
distressing for the family and often very unsettling for the clinical team
too. There may be lot of guilt and ‘if only we had...’ talk. Families may
need repeated meetings over time to begin to come to terms with an act
that profoundly breaks the rules of the living and may be highly wounding
for the surviving family and loved ones.
Deliberate self-harm (DSH)
DSH (attempted suicide, parasuicide) refers to any sort of deliberate non-
fatal self-inflicted injury or poisoning, irrespective of the individual’s
motivation or desire to die. It is roughly a thousand times commoner than
completed suicide in childhood or adolescence. Roughly 15–20% of ado-
lescents in the UK and the USA report that they have considered suicide in
the previous 12 months, while 3–7% have deliberately harmed themselves
in the last year, of whom only a minority received medical attention
as a result (with contact being much more for likely for self-poisoning
than for cutting). Under the age of 12, DSH is commoner among boys
than girls. The ratio reverses dramatically during the teenage years, with
females predominating by at least 2:1 (much higher in clinical studies).
Self-poisoning is by far the most common form of DSH, particularly among
females. Rates of DSH have declined steadily since a peak in the 1980s.
Background factors
1 Lack of supportive family relationships. Associated with ‘broken homes’,
placement in residential care, and family environments with low
warmth, high conflict and poor communication. Conflict with parents
often centres on roles, responsibilities and restriction.
2 Family members with a psychiatric disorder. Alcohol abuse is common in
parents, particularly fathers.
3 Most have a current or recent history of psychiatric disorders,ofwhichthe
commonest are depression, anxiety disorders, substance use disorders
and disruptive behavioural disorders. However, the majority do not
have a severe enduring depression.
4 A history of physical or sexual abuse. Children from abusing backgrounds
may be particularly liable to hate themselves.
5 School or work problems are common. Academic attainments are typically
below average, and there have commonly been problems relating to