The ‘Definitional Problem’ Strikes Again
Phillip M. Kleespies, Ph.D.
VA Boston Healthcare System

In the year 2000, the Veterans Administration’s National Center for Patient Safety asked all local VA Patient Safety Committees to track patient parasuicidal behaviors at their respective facilities and then to suggest interventions to reduce the frequency of these behaviors. This request generated 94 aggregated root cause analyses for parasuicidal behavior that were submitted by 59 different VA facilities between October 1, 2000, and March 31, 2003. The report that synthesized this data was entitled Parasuicidal Aggregate Review and Selected Suicide Root Cause Analysis: Actions and Implementation Strategies to Reduce Suicidal Events in the VA System: Final report. It concluded that “the reduction of suicidal and parasuicidal behavior is a challenge because it is under-reported and there are a variety of definitions of parasuicide, making outcome difficult to measure” (p. 28). The VA’s National Center for Patient Safety had thus encountered what those engaged in the study of suicidal and self-injurious behavior have struggled with for decades if not centuries; or, in the words of O’Carroll, et al, (1996),

Despite hundreds of years of writing and thinking about suicide, and many decades of focused suicide research, there is to this day no generally accepted nomenclature for referring to suicide-related behaviors, not even at the most basic conversational level (p. 238).

The term parasuicide was first suggested by Kreitman, et al, (1969) when he and others grappled with the observation that the term attempted suicide was being used to refer to patients who injured themselves, but, in fact, were not attempting suicide. Kreitman thought of the term parasuicide as referring to self-injurious behavior that simulates or mimics attempted suicide, but is not suicidal in intent. His hope seemed to be that a variety of behaviors, sometimes referred to as suicidal gestures, manipulative suicide attempts, and/or self-mutilation, could be categorized as parasuicidal events and that this classification would help us to distinguish those behaviors that were more truly suicidal. The concept parasuicide, however, was never more clearly defined, and it became used by different investigators with different meanings and inclusive of different behaviors. Just as an example, Linehan (1993) used it to refer to actual suicide attempts as well as to selfinjuries such as self-mutilation, while Diekstra and Garnefski (1995) excluded habitual self-injury (i.e., self-mutilation) from their definition.

Why have these behaviors been so difficult to define and to study? First of all, human intentionality is often complex, mixed, and fluid. With suicidal or self-injurious behavior, there can be degrees of intent to die, intent to influence others, and intent to regulate self. Second, research on suicidal behavior seldom, if ever, includes patients who are clearly suicidal. If a study subject becomes actively suicidal, ethics demands that we intervene to save the patient and remove him or her from the study. Third, we are attempting to study an exceedingly rare event. In 2002, for example, suicide had a base rate of 11.0 per 100,000 in the general U.S. population. Estimates of the suicide rate in the psychiatric population are about five-fold that of the general population, or approximately 55 per 100,000. We don’t have the clinical acumen or assessment instruments to accurately detect such rare events and to know who the truly suicidal are.

Given these difficulties in attempting to know and understand suicidal and self-injurious behaviors, the Suicidal and Parasuicidal Aggregate Review Committee at VA Boston decided to forego an “a priori” category system and to launch a quality improvement-type investigation of the range of self-injurious behaviors that we see in our healthcare system. We have taken self-injurious behavior to mean any intentional, self-inflicted, physical harm to the individual. The behaviors that are included as self-injurious can range from the individual who inflicts a superficial scratch to relieve tension to the individual who takes a lethal amount of medication and is accidentally found unconscious. We also track any completed suicides in the system. Since instances of self-harm or self-injury are recorded in the morning reports and in medical center incident reports, it is possible to conduct a post self-injury debriefing interview within a few days of the particular event. We have developed a semi-structured debriefing interview that is based on the available evidence in the literature on characterizing and assessing the seriousness of suicidal and self-injurious behavior. It is available as an overprinted form in the electronic progress note package of the VA Boston medical record. Fundamental to the interview is that self-injurious behaviors are discriminated from each other by the intent of the individual. Thus, there is an effort in the interview to obtain a measure of intent to die and a measure of the perceived lethality of the act.

We have piloted the debriefing interview over the past year. It consists of three sections. In Section I, the patient is asked for (1) the date, time, and day of the week when the event occurred, (2) a brief description of what he or she did, and (3) a Likert scale rating of his or her intent to die (ranging from “6 “– definitely wanted to die to “0” – no intent to die). If the patient gives a rating of greater than zero intent to die, the interviewer completes Section II (Self-Injury with Intent to Die) with the patient. If the patient gives a rating of zero intent to die, the interviewer skips to Section III (Self-Injury with No Intent to Die).

In Section II of the interview, the pt is asked: (1) to state a reason for his or her self-injury; (2) to describe the method used; (3) to give a Likert scale rating of perceived lethality (ranging from “6” – definitely thought it would be lethal to “0” definitely thought it would not be lethal); (4) to state how much physical damage was done; (5) to state whether consciousness was lost or disturbed; (6) to indicate what level of medical response was needed to deal with the injury (admission to ICU, treatment in Urgent Care Clinic, etc.); (7) to state whether he or she was under the influence of alcohol or drugs at the time; (8) to indicate if he or she had made a plan or if this action was an impulsive decision; (9) to state whether he or she had told others of his or her suicidal or self-injurious thoughts; (10) to indicate if other people were close by and/or likely to contact him or her; (11) to state whether he or she hoped to be found or saved; and (12) to report how he or she feels about the outcome.

As noted above, if the patient indicates that he or she had no intent to die, the interviewer skips to Section III. Section III has a number of items in common with Section II (i.e., a reason for the self-injury, the method used, how much physical damage was done, whether consciousness was lost, the level of medical response, and whether the patient was under the influence of alcohol or drugs at the time). Section III deviates from Section II, however, in that the patient is asked: (1) to indicate if this self-injury was a single event or part of a cluster of acts (e.g., cutting, burning, etc.); (2) if it was part of a cluster, how many acts were in the series and over what period of time; and (3) if it was a single event, how many times these isolated events have occurred in the past.

In the pilot year with the debriefing interview, we have decided that it will be necessary to add two items to the interview. For comparative purposes, we are adding an item that asks for the interviewer’s rating of the patient’s intent to die. This item will also allow us to obtain a measure of inter-rater reliability. We are adding a second item that asks the interviewer to indicate if he or she felt that the patient gave reliable information, or, if not, what the reason was that it was not reliable (e.g., psychosis, sedation, etc.).

Within the first year of this quality improvement project, we have collected data on 40 instances of self-injury in our healthcare system. We are beginning to analyze this initial data. It is hoped that in the future, with our now refined post self-injury interview, we will be able to generate information about such things as the frequency of suicide attempts in our system in which there was serious intent to die, the frequency of self-injuries in which there was a lesser intent, the frequency of self-injuries that had no suicidal intent, the methods of self-injury that we are likely to encounter, the extent of injuries, how frequently alcohol or drugs may contribute to self-injurious behavior, what sorts of self-injuries were likely to be planned and what sort were more likely to be impulsive, and so forth. From a quality management perspective, it is hoped that this improved method of tracking and monitoring self-injurious behavior will result in the discovery of systemic changes that may reduce its incidence, particularly the incidence of those behaviors that result in serious damage to the individual. In the future, I hope to report further on the results of this endeavor.

References

Diekstra, R., and Garnefski, N. (1995). On the nature, magnitude, and causality of suicidal behaviors: An international perspective. In M. Silverman and R. Maris (Eds.): Suicide Prevention: Toward the year 2000. NY: Guilford Press.

Kreitman, N., Philip, A., Greer, S., and Bagley, C. (1969). Parasuicide. British Journal of Psychiatry, 115, 746-747.

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. NY: Guilford Press.

Mills, P., Neily, J., Luan, D., Osborne, A., and Howard-Hirschler, K. (2004). Parasuicidal aggregate review and selected suicide root cause analysis: Actions and implementation strategies to reduce suicidal events in the VA system: Final report. Unpublished manuscript, VHA National Center for Patient Safety.

O’Carroll, P., Berman, A., Maris, R., Moscicki, E., Tanney, B., and Silverman, M. (1996). Beyond the Tower of Babel: A
nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26, 237-252.