Sandbox:Vindhya

_NO TOC_ Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2]

Classification of suicidal ideation

Classification	Definition	Examples
Suicidal events Completed suicide	A self-injurious behavior that resulted in fatality and was associated with at least some intent to die as a result of the act.	example:1) After a long argument with his girlfriend, which resulted in the end of their relationship, the patient collected a rope and rode his bike to an isolated area where he fatally hanged himself. A suicide note was later found. 2) After four documented attempts at suicide, the patient stole his uncle’s gun and shot himself and was fatally injured
Suicide attempt	A potentially self-injurious behavior, associated with at least some intent to die, as a result of the act. Evidence that the individual intended to kill him/ herself, at least to some degree, can be explicit or inferred from the behavior or circumstance. A suicide attempt may or may not result in actual injury	Example:fter a fight with her friends at school, in which they discontinued speaking with her, the patient ingested approximately 16 aspirin and eight other pills of different types on the school grounds. She said that she deserved to die, which was why she swallowed the pills. 2) The patient used a razor blade to lacerate his wrists, his antecubital fossae, and his back bilaterally. He told his therapist that the “the main objective was to stop feeling like that,” and he knew that he could die but didn’t care. According to the patient, he also ingested a bottle of rubbing alcohol because in his health class he heard “that the medulla will get more suppressed that way,” thereby increasing y increasing the chances that he would be “successful” and die
[Preparatory acts towards imminent suicidal behavior	The individual takes steps to injure him- or herself, but is stopped by self or others from starting the self-injurious act before the potential for harm has begun	her had gone to school and retrieved a recent “bad” report card. He was fearful of his father’s reaction. Upon his return home, a 5- to 6-hour argument with his parents ensued, and he took a vegetable (broad, sharp) knife and went to his room. He reported putting the knife to his wrist but never puncturing the skin. 2) The patient stated that he “couldn’t stand being depressed anymore” and “wanted to die.” He decided to hang himself. He tied a telephone cord to the door knob and placed the cord loosely around his neck. Then, he stopped himself and did not follow through with the attempt.
Suicidal ideation	Passive thoughts about wanting to be dead or active thoughts about killing oneself, not accompanied by preparatory behavior.a	Active: The patient reported to the doctor that he was thinking about hanging himself in the closet. He was taken to the hospital and admitted. Passive: The patient reported ideas about wanting to be dead but denied acting on these feelings.

Classification of suicidal ideation

Classification	Definition	Examples
Non-Suicidal events Self-injurious behavior, no suicidal intent	Self-injurious behavior associated with no intent to die. The behavior is intended purely for other reasons, either to relieve distress (often referred to as “self-mutilation,” e.g., superficial cuts or scratches, hitting/banging, or burns) or to effect change in others or the environment	The patient was feeling ignored. She went into the family kitchen where her mother and sister were talking. She took a knife out of the drawer and made a cut on her arm. She denied that she wanted to die at all (“not even a little”), but she just wanted them to pay attention to her. 2) The patient reported feeling agitated and anxious after a fight with her parents. She went into her room, locked the door, and made several superficial cuts on the inside of her arms. She stated that she felt relieved after cutting herself and that she did not want to die. She reported that she had done this before at times of distress and that it usually helped her feel better. 3) The patient was in class, where a test was about to begin, and stabbed himself with a pencil in order to be taken to the nurse’s office. 4) A 14-year-old girl wrote her name on her arm with a penknife and said that she often does so in order to reduce her anxiety. 5) The patient was noted to have multiple superficial burns on his arms. Upon questioning, he denied trying to kill himself
Other, no deliberate self-harm	No evidence of any suicidality or deliberate self-injurious behavior associated with the event. The event is characterized as an accidental injury, psychiatric or behavioral symptoms only, or medical symptoms or procedure only	1) The patient had a cut on the neck from shaving. 2) The patient was hospitalized for worsening of OCD or depressive symptoms with no suicidal thoughts or actions or 3) aggressive behavior. 4) Hospitalization was because of an infection, rhinoplasty, or pregnancy

Classification of suicidal ideation

Classification	Definition	Examples
Indeterminate or potentially suicidal events Self-injurious behavior, suicidal intent unknown	Self-injurious behavior where associated intent to die is unknown and cannot be inferred. The injury or potential for injury is clear, but why the individual engaged in that behavior is unclear.	1) The patient cut her wrists after an argument with her boyfriend. 2) The patient was angry at her husband. She took 10 to 15 diazepam tablets and flushed the rest down the toilet. Her husband called the police for help, and she was taken to the hospital. She was groggy and stayed overnight in the hospital. 3) A 9-year-old patient had spoken about suicide frequently. After learning that his baseball coach was retiring, he began scratching his arm with a pencil.
Not enough information	Insufficient information to determine whether the event involved deliberate suicidal behavior or ideation. There is reason to suspect the possibility of suicidality but not enough to be confident that the event was not something other, such as an accident or psychiatric symptom. An injury sustained on a place on the body consistent with deliberate self-harm or suicidal behavior (e.g., wrists), without any information as to how the injury was received, would warrant placement in this category	1) A child who “stabbed himself in [the] neck with a pencil.” The event may have been deliberate as opposed to accidental, as suggested by “stabbed,” but not enough information was provided to determine whether the event was deliberate. 2) A cut on the neck.

Causes by Organ System

Cardiovascular	No underlying causes
Chemical / poisoning	Mesothelioma
Dermatologic	No underlying causes
Drugs	Alcohol, Dextromethorphan, antihistamines at high doses,Barbiturates, Benzodiazepines, Cimetidine,Pergolide, Sodium oxybate,Anticholinergic drugs,Atropine, scopalamine, Jimson weed, Antidepressants, Antiepileptics,Isotretinoin, Varenicline, Ziconotide,Cocaine,Amphetamines, LSD, Psilocybin, Mescaline, MDMA (ecstasy), PCP
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	AIDS,Leprosy, Malaria, Mumps, Flu, Lyme disease, Syphilis
Musculoskeletal / Ortho	Amyotropic lateral sclerosis, Ewing's sarcoma, Polyradiculitis
Neurologic	Multiple sclerosis, Alzheimer's disease, Parkinsons, Lewy bodydementia Adult-onset vanishing white matter leukoencephalopathy, Late-onset metachromatic leukodystrophy
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Brain tumor
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric
Pulmonary	No underlying causes
Renal / Electrolyte	Hypocalcemia, Hypernatremia, Hyponatremia, Hypokalemia, Hypomagnesemia, Hypermagnesemia, Hypophosphatemia
Rheum / Immune / Allergy	Lupus
Sexual	No underlying causes
Trauma	No underlying cause
Urologic	No underlying causes
Miscellaneous	Sarcoidosis

Psychoactive drugs

Psychotic states may occur with Psychoactive drug intoxication or withdrawal. Drugs whose use, abuse or withdrawal are implicated include:

• Alcohol
• OTC drugs, such as:
  • Dextromethorphan
  • Certain antihistamines at high doses.
  • Cold Medications (ie. containing PPA, or phenylpropanolamine)
• prescription drugs, such as:
  • Barbiturates
  • Benzodiazepines
  • Cimetidine
  • ezogabine
  • Pergolide

• • Sodium oxybate

• • Anticholinergic drugs
    • Atropine
    • Scopolamine
    • Jimson weed
  • Antidepressants
  • Antiepileptics
  • Medications (usually cold medications) that contain phenylpropanolamine or PPA
  • Other medications- Iloperidone, Isotretinoin, Varenicline, Ziconotide

• "Street" drugs, such as:
  • Cocaine
  • Amphetamines
  • Hallucinogens such as
    • LSD
    • Psilocybin
    • Mescaline
    • MDMA (ecstasy)
    • Nabilone
    • PCP

Intoxication with drugs that have general depressant effects on the central nervous system (especially alcohol and barbiturates) tend not to cause psychosis during use, and can actually decrease or lessen the impact of symptoms in some people. However, withdrawal from barbiturates and alcohol can be particularly dangerous, leading to psychosis or delirium and other, potentially lethal, withdrawal effects.

Some studies indicate that cannabis use may lower the threshold for psychosis, and thus help to trigger full-blown psychosis in some people. Early studies have been criticized for failing to consider other drugs (such as LSD) that the participants may have used before or during the study, as well as other factors such as pre-existing ("comorbid") mental illness. However, more recent studies with better controls have still found a small increase in risk for psychosis in cannabis users.

It is not clear whether this is a causal link, and it is possible that cannabis use only increases the chance of psychosis in people already predisposed to it; or that people with developing psychosis use cannabis to provide temporary relief of their mental discomfort. The fact that cannabis use has increased over the past few decades, whereas the rate of psychosis has not, suggests that a direct causal link is unlikely for all users.

References

Posner K, Melvin GA, Stanley B, Oquendo MA, Gould M: Factors in the assessment of suicidality in youth. CNS Spectr 2007; 12: 156–162