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INTRODUCTION

ICD-10 Diagnostic Codes

R45.851 Suicidal Ideations

A condition characterized by suicidal thoughts or ideation.

T14.91 Suicide Attempt

A condition characterized by self-inflicted harm in an attempt to end one's own life; the unsuccessful attempt to kill oneself.

Z91.5 Personal History of Self-harm

A personal history of para-suicide, self-poisoning, or a suicide attempt. ICD-10 does not define para-suicide, but lists as synonyms or specific examples of self-harm the following: attempted suicide, deliberate self-poisoning, and attempted self-mutilation or self-harm by physical trauma.

 

Reproduced with the permission of the World Health Organization from ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th Revision.

GENERAL CONSIDERATIONS

Patients with strong or repetitive thoughts or urges to kill or hurt themselves, or who have acted deliberately to do so, pose a serious clinical challenge for assessment, treatment, and classification. Classification is challenging because although, at one extreme, there are those individuals who kill themselves with explicitly declared intent, in many more cases (as discussed in this chapter) the individual's intent and wish to die (or merely to self-injure) may be more ambiguous, ambivalent, and/or difficult to determine and variable over time. Similarly, the continuum from passing thought/urge, through persistent preoccupation, to tentative gesture, or on to action deliberately intended to harm or kill oneself is often difficult to demarcate clearly. As a result, working clinical and epidemiological definitions have varied.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013) distinguishes two proposed conditions for further study: Suicidal Behavior Disorder and Non-suicidal Self-Injury. As a feature of suicidal behavior disorder, suicide attempts are defined as a self-inflicted behavior done in the expectation that it will lead to death. In contrast, Nonsuicidal Self-Injury consists of deliberate self-inflicted bodily damage with the expectation that the injury will not be lethal, but will lead to only mild physical harm. The proposed criteria also suggest the self-injurious behavior is not motivated by a wish to die, but rather to attain some positive feeling, relief from a negative state of mind, or to achieve some interpersonal end.

As discussed in this chapter, discerning intent in acts of self-harm is not always straight-forward, and there is much overlap in the risk factors for attempted suicide and nonsuicidal self-injury.

A. Epidemiology

1. Completed suicide

Completed suicide is rare in prepubertal children, with an annual rate in the United States on the order of 2.1 per 100,000 for children ages 10–14 in 2014. Completed suicide in adolescents, however, is the third leading cause of mortality in the United States in this otherwise generally healthy age group, and in 2014 it accounted for the death of 8.7 teens, ages 15–19, per 100,000 (with the rates in that age group 13.0 per 100,000 for boys and 4.2 per 100,000 for girls). The most recent international data ...

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