1. Therapy can help to restore the victim’s sense of adequacy and control over her life and also assists in relieving feelings of helplessness, dependence and obsession with the assault that frequently follows the rape.

G.  Post-Traumatic Stress Disorder (PTSD)

1.  Exposure: the person has been exposed to a traumatic event in which both the following were present:

1. The person experienced, witnessed or was confronted with an event or events that

involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person’s response involved intense fear, helplessness, or horror (in children this ma by expressed instead by disorganized or agitated behavior).

2.  Reexperience: the traumatic event is persistently reexperienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images,     

thoughts, or perceptions (in young children, repetitive play may occur in which themes or aspects of the trauma are expressed)

2. Recurrent distressing dreams of the event

(in young children, there may be frightening dreams without recognizable content)

3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). 

(young children may demonstrate trauma-specific reenactment).

4. Intense psychological distress at exposure to internal or external cues that symbolize

or resemble an aspect of the traumatic event.

5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

3.  Avoidance: persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma.
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g. Does not expect to have a career, marriage, children, or a normal life span).

4.  Increased Arousal: persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response

1. Duration: of symptoms in 2,3 and 4 is more than 1 month
2. Significant Distress/Impairment: the disturbance causes significant distress or impairment in social, occupational, or other important areas of functioning.

H.  Child Abuse

1. Statistics

1. 3 million cases of child abuse and neglect were reported to public social service agencies

in 1994, of this about 1 million cases were confirmed.

2. In the US child abuse and neglect cause 2,000–4,000 deaths yearly and 150,000–200,000

new cases of sexual abuse are reported.

3. About 1 out of every 3–4 girls and 1 out of every 7-8 boys will be sexually assaulted by

age 18.

4. Many maltreated children go unrecognized and many are reluctant to report the abuse.
5. 32% less than 5 years

27% 5-9 years

27% 10-14 years

14% 15-18 years

6. Most child abuse is from parents (75%), relatives (15%) or unrelated caretakers (10%).

B.  Etiology

1. Often abusive parents have themselves been victims of physical and sexual abuse and of

long-term exposure to violent home lives of pain and physical torment –powerful promoters of aggression.

2. Stressful living conditions, social isolation, lack of a support system may contribute to

physical abuse of children.

3. Parents may have mental disorder, resulting in impaired judgement.
4. Children who are premature, mentally retarded, physically disabled, cry excessively,

unusually demanding (difficult child), or hyperactive may be at high risk for abuse or neglect.

5. Abusive parents have inappropriate expectations of their children and may often turn to

them (the child) for reassurance, nurturing, comfort, protection, and expect a loving response.

6. The perpetrator of physical abuse is more often the mother than the father.
7. Men are the perpetrators in about 95% of cases of sexual abuse of girls and about 80% of cases of sexual abuse of boys. The perpetrators are usually known to the child.

C.  Assessment

1. Physical indicators of physical abuse

1. Suspicious bruises and marks that form symmetrical patterns, e.g. Injuries to both sides of the face and regular patterns on the back, buttocks and thighs. Accidental

injuries are unlikely to result in symmetrical patterns.

2. Bruises may have the shape of the instrument used to make them –belt buckle, or cord.
3. Burns by cigarettes result in symmetrical round scars and burns from boiling water

look like socks or gloves.

4. Retinal hemorrhages in infants may be due to shaking.

D.  Sexual Abuse

-May start as early as infancy and as late as adolescence.

-Overwhelming fear, shame, guilt contribute to child’s reticence (unwillingness) to disclose and complicates the ability to identify the abuse.

1.  Physical indicators

1. Bruises, pain, and itching in the genital area/region.
2. Genital/rectal bleeding
3. Recurrent urinary tract infections and vaginal discharges may be related to abuse.
4. Sexually transmitted diseases and difficulty in walking and sitting raise suspicions

of sexual abuse.

5. Young children with detailed knowledge of sexual acts have usually witnessed or

participated in sexual behaviors. They often exhibit their sexual knowledge through play and may initiate sexual behaviors with their peers.

6. Retractions and contradictions in the child’s reports are typical and anxiety may prevent full disclosure.

2.  Difficulties

1. Alleged sexual abuse of a preschool-age child is particularly difficult to evaluate  

because of the child’s immature cognitive and language development.

2. Patient and careful evaluations by experienced, objective professionals are   necessary and leading questions must be avoided.

3.  Long-term Effects

1. Depressive feelings combined with shame, guilt and a sense of permanent damage are commonly reported among children who have been sexually abused.
2. PTSD and dissociative disorder are common in adults who have been sexually abused as children.

1. Professional Responsibility

1. In cases of suspected child abuse and neglect, physicians should diagnose the suspected

maltreatment, secure the child’s safety by admitting the child to a hospital or by arranging out-of-home placement.

2. Report case to appropriate social service department, child protection unit, or central

registry.

3. Make assessment with help of a history, physical exam, skeletal survey, and photographs
4. Request social workers to report and appropriate medical consults. Consult with members of child abuse committee with in 72 hours. Arrange program of care and social services follow-up.
5. Professionals included as mandated child abuse reporters are: physicians, psychologists, school officials, police officers, hospital personnel engaged in treatment of patients, district attorneys, and providers of child day care and foster care.

I.  Suicide

1. Statistics

1. Each year about 30,000 people die by suicide in the US (successful suicides).
2. The number of attempted suicides are 8-10 times as high (@ 300,000)
3. Lost in the reporting/statistics are intentional misclassifications of the cause of death,

accidents of undetermined cause and so called "chronic suicides" (e.g. deaths through alcohol and other substance abuse, consciously poor adherence to medical regimes for diabetes, obesity and hypertension).

4. An estimated 75 suicides a day in the US, about 1 every 20 minutes.
5. Total suicide rate has remained fairly constant over the years, it is currently 12 per 100,000.
6. Currently ranked as 9^th overall cause of death in the US.
7. US is at the mid-point of the national rates for industrialized countries –Scandinavia, Switzerland, Germany, Austria, Eastern European countries, and Japan are the highest

(more than 25/100,000).

8. Prime suicide site of the world is the Golden Gate Bridge in San Francisco, more than 800 since it opened in 1937.

                    9.   Prediction (Associated Factors)

A.  Age

1. Suicide rates increase with age
2. Although are only 10% of the total population, older adults account for 25% of suicides.
3. Rate for those 75/older is more than 3 times the rate of young people.

B.  Alcohol Dependence

1. 15% of all alcohol-dependent people commit suicide.
2. Estimated suicide rate for those who are alcoholic is About 270 per 100,000 a year

(between 7,000 and 13,000 alcohol-dependent people commit suicide each year.

3. 80% of all alcohol-dependent suicide victims are male.
4. In general, there is an increased risk for suicide among those who abuse substances (e.g. 20 times greater for heroin-dependent people).

C.  Irritation, Anger, Violence

1. 25% of those with history of impulsive/violent behaviors are at high risk.

D.  Prior Suicidal Behavior

1. A past suicide attempt is perhaps the best indicator that a patient is at increased risk of suicide.
2. 40% of depressed patients who commit suicide have made a previous attempt.
3. The risk of a second suicide attempt is highest within 3 months of the first attempt.
4. 10% of suicide attempts subsequently suicide within 10 years.
5. 19-14% of suicides have a prior suicide attempt.

E.  Male

1. Men commit suicide more than 3 times as often as do women.
2. Women are 4 times more likely to attempt
3. Men’s higher rate of successful suicide is related to the methods they use: firearms,

Hanging, jumping from high places.

4. The suicide rate for males 15-24 years old is still rising rapidly.
5. For men 25-34 years of age, the suicide rate increased almost 30% over the past decade.

1. Unwilling to accept help
2. Longer Depression

1. Social isolation enhances suicidal tendencies among depressed patients.
2. 1/3 or more of depressed patients who commit suicide do so within 6 months of leaving a hospital.

3.  Prior inpatient psychiatric TX

1. Almost 95% of all people who commit/attempt suicide have a diagnosed mental

disorder (depressive disorders account for 80% of that figure, schizophrenia 10%, and dementia/delirium for 5%).

2. Previous psychiatric hospitalization for any reason increases the risk of suicide.
3. Psychiatric patients’ risk for suicide is 3-12 times greater than that of non-patients.

4.  Recent loss/separation

1. Deaths of family members, or separation and divorce.

5.  Loss of physical health

1. 32% of all people who commit suicide have had medical attention within 6 months

of death.

2. A physical illness is present in some 25-75% of all suicide victims.
3. Physical illness is estimated to be an important contributing factor in 11-51% of all suicides.
4. The percentage increases with age.
5. Loss of mobility, disfigurement, and chronic intractable pain contribute to suicides and suicide attempts.
6. Certain drugs can produce depression, which in some cases may lead to suicide, including reserpine, corticosteroids, antihypertensives, and some anti-cancer agents.

6.  Unemployed/retired

1. Suicide is higher among unemployed than among employed people.
2. Suicide rates increase during economic recessions and depressions, and times of high unemployment.

7.  Single, widowed, divorced

1. Single, never married, people show nearly double rates than married people.
2. Previously married people show sharply higher rates than do those who never marry.
3. People who commit "anniversary suicides" take their lives on the same day as did a member of their family.

8.  Be Familiar with:

1. Table 33.3-2 (p.871)
2. Table 33.1-3 (p.871)
3. Table 33.2-1 (p.873)
4. Table 33.2-2 (p.874)
5. Theories p.868-69 @ etiology

(Dunkheim, Freud, Menninger)

Assessment

1. Ask about suicidal ideation as part of every mental status examination.
2. The patient should be asked directly: "Are you, or have you ever been suicidal?"

"Do you want to die?"

3. 8 of 10 people who eventually kill themselves give warnings of their intent.
4. 50% say openly that they want to die.
5. Patients admitting to a plan of action is a particularly dangerous sign.

1. General Information

1. There exist many reasons for suicidal behavior: a cry for help, attempt to manipulate

others, result of psychotic episode (delusions, hallucinations), hopelessness and helplessness in the face of insurmountable life problems, or reasoned end to emotional or physical suffering.

2. The individual usually has ambivalent feelings about ending one’s life. This may result

in contradictory messages indicating the person both wants to live and die. The task here is to draw out the person’s feelings of both sides.

3. Most people are intensely suicidal for only a short period of time, usually a matter of days (48 hours).
4. Most people offer some warning or clue to their intentions well before completing the act.
5. Danger is highest when an individual in crisis has both a lethal plan and the means to carry it out.
6. The goal of saving human life supersedes total allegiance to confidentiality. Relatives or local authorities may need to be informed.
7. Maintaining contact with a potentially dangerous person can be a critical ingredient in

preventing suicide or homicide.

8. It is very important that the helpers be:

1. Aware of their own feelings and attitudes about death and suicide.
2. Ready to consult with colleagues or supervisors about the appropriateness of any directive steps taken.
3. Prepared to deal with failure, the completed suicide of a client. Because of this it is important that workers develop a network of supportive colleagues for shared decision making during crisis intervention.

1. Key Variables

1. Plan

How far has the person proceeded in thinking about committing suicide or hurting someone. The more specific and concrete the plan for taking one’s life, the greater the risk. The person who has taken specific steps (written notes, given away important possessions), has chosen a highly lethal method (a gun), and has the means to carry out the plan (has the gun at home, or in the car), is at a significant greater risk than an individual who has fantasized about it.

2. Previous Attempts

A person who has previously attempted suicide is at greater risk than an individual who has not. The probability of success increases with each attempt. The helper should explore what precipitated the attempt, and the intent and outcome of each.

3. Willingness To Make Use Of Outside Resources

Individuals who live alone and have no family or friends are greater risks than those who have others to whom they can turn. The helper must differentiate between the individuals willingness to reach out to others for help and the actual availability of others. The person should assure you that they will contact their support network whenever they are in need.

1. Action Steps with Lethality

1. Begin with the least directive and intrusive avenue possible. Attempt to contract the following:

1. For the person not to commit suicide in the next several days.
2. Get rid of the lethal means for the time being (guns, pills).
3. Do not stay alone over the weekend, and/or promise to call if things become worse. the aim is to buy time, postpone irreversible and final decisions, and whatever steps to separate distraught crisis clients from lethal means to take human life.