Can you take a look at the following and weigh in on which of the following ideas are used clinically, and what terms are associated with them?
In all cases
Target (object) of behavior = one's own body
Outcome of the behaivor = not relevant to the idea (example, idea #4 - a person jumps in front of a truck with intent to die, but the truck sweves, and the person sustains no injury; the behavior is suicidal, the outcome is just not suicide)
Specific questions:
Is there a difference between the ideas expressed by 1 and 3 ?
If so, is the clinical term "self injurious behaior (SIB)" used to describe both?
Do the cliinical terms in the right hand column terms commonly used to describe the idea?
Are any of the terms used for more than one of the ideas?
Are there other terms that are commonly used that we are missing?
As I ponder it, there is a difference between 1 and 3 for the reasons you suggest. Some developmental disorders do indeed entail self- harming behaviour and although this type of behaviour seems intentional, as people with this disorder tend to self- harm more when stressed, there is no clearly or explicitly articulated intent to self harm. Compare this to some personality disordered patients, some of whom have told me they intentionally self- harm to relieve stress, deal with anger, etc.- but the take home point is that under some circumstances it can be inferred (from explicit patient disclosure) that self- harming is intentional (validating 3 as a concept) whereas self- harming behaviour is just observed in some cases with no clear inference about intent, validating 1 as a concept. In fairness to Laura, I can also attest that it is often difficult to make an inference about intent in both categories, but when possible to do so these could be useful and usable concepts.
Just riffing on that theme... it seems possible to distinguish 3, 4 and 5 as separate concepts along the same lines of reasoning, i.e. based on explicit disclosure from the patient. In theory, someone could admit to deliberate self- harm without disclosing a motive or end goal (3), or could add information that allows inferring (4) or (5).
Now, about clinical terms... I have seen deliberate self- harm, whether or not there is intent to die, called "self- harm," "self- injurious behaviour," and "parasuicide." The last term (parasuicide) is tricky- some clinicians have used it to mean basically (5), but when I looked up some references to refresh my knowledge current usage entails any deliberate self- harm regardless of intent, e.g. https://dictionary.apa.org/parasuicide
I'm curious about your thoughts on how to approach descriptions (synonyms) for the concepts.
Defining the concept and coming up with a clear FSN seems much more straightforward than making decisions about which terms are appropriate SYN for which concepts. Do you assign a the term as a synonym if there is evidence that any group of clinicians use the term when expressing the idea, or does it need to be some sufficiently large number of groups?
It starts to feel like an overwhelming task with the mental health concepts. There are so many different training programs and types of degrees in this field. Each "camp" develops its own term for the same idea, and uses the same term to express multiple ideas (per our discussion about mood, emotion and affect).
I think all of these (except 1) would be a subset of self-injurious behavior.
With Self-abusive and self-mutilatory behavior, I'm not sure that the person is necessarily aware enough to have intent (e.g., self-mutilation with Lesch-Nyhan syndrome.)
With 5, the person clearly does not intend to die.
Deliberate self-harm is not used typically in the US in my experience. So someone from the UK should weigh in on the typical clinical meaning. I believe the term parasuicide has been used as well, though am not sure if that's current or more in the past.
My understanding of suicidal behavior is broader and can encompass a range of behaviors associated with suicide or suicide attempts.
Also, within suicide attempts there are aborted and interrupted attempts.
The problem, at least in my mind with including a significant focus on intent in the categorization is that intent is often difficult to infer, even after the fact. (It's even harder to get a handle on prior to an attempt.) Many people are ambivalent, can't really recall what they were thinking (especially if they were intoxicated at the time or were unconscious for awhile after a serious attempt). Many people have difficulty conceptualizing intent and/or answering questions about intent clearly. This is one (of many) major problems that I see with the C-SSRS in that one question refers to some intent whereas another refers to intent. This distinction has always seemed challenging (if not impossible) to make and it's asking compound questions on top of that.
In the 2015 psychiatric evaluation practice guideline, we used the following definitions:
Suicidal ideas Thoughts of serving as the agent of one’s own death.
Suicide attempt A nonfatal, self-directed, potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury (Crosby et al. 2011). It may be aborted by the individual or interrupted by another individual.
Suicide intent Subjective expectation and desire for a self-injurious act to end in death.
Suicide means The instrument or object used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide method The mechanism used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide plan Delineation of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide Death caused by self-directed injurious behavior with any intent to die as a result of the behavior (Crosby et al. 2011).
Note that this definition of plan is what we got consensus on based on typical clinical use of the terms, but the C-SSRS defines method and plan as distinct.
CrosbyAE,OrtegaL,MelansonC: Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, February2011. Available at: http://www.cdc.gov/violenceprevention/pdf/self-directed-violence-a.pdf. Accessed May 25, 2015.
Laura Fochtmann thanks for the detailed response. This is really helpful.
Here's a picture of how we might be able to express the things you describe as being important for describing self harming and suicidal behavior.
(graphic updated with corrections; not loving any of this, but hoping these brainstorming ideas can help get us thinking about how we might fully define behavior concepts)
The picture below shows ideas for (observable entity) concepts we could request. These would allow us to express the aspects of behavior you describe above. Since we can't easily change the defining attributes of clinical findings, creating observable entities would allow us to use the "interprets" and "has interpretation" defining attributes of findings to express these meanings.
11/18/2021 2pm, Note: I played with some finding concepts and outcome of behavior doesn't seem useful at all; probably something better captured in the information model v. concept model??
Updated claims matrix - includes ideas and terms expressed in post and documents from Laura Fochtmann.
An example of using descripition logic (and new observable entities) to distinguish between head banging with unknown intent (e.g, in severe developmen disorders) and head banging as a self-injurious behavor:
6 Comments
Piper Allyn Ranallo
Michael First, Laura Fochtmann, Uma Vaidyanathan, Scott Bradley Prior, Janna Hastings
Can you take a look at the following and weigh in on which of the following ideas are used clinically, and what terms are associated with them?
In all cases
Specific questions:
Scott Bradley Prior
Hi Piper and all!
My thoughts on the questions you posed...
As I ponder it, there is a difference between 1 and 3 for the reasons you suggest. Some developmental disorders do indeed entail self- harming behaviour and although this type of behaviour seems intentional, as people with this disorder tend to self- harm more when stressed, there is no clearly or explicitly articulated intent to self harm. Compare this to some personality disordered patients, some of whom have told me they intentionally self- harm to relieve stress, deal with anger, etc.- but the take home point is that under some circumstances it can be inferred (from explicit patient disclosure) that self- harming is intentional (validating 3 as a concept) whereas self- harming behaviour is just observed in some cases with no clear inference about intent, validating 1 as a concept. In fairness to Laura, I can also attest that it is often difficult to make an inference about intent in both categories, but when possible to do so these could be useful and usable concepts.
Just riffing on that theme... it seems possible to distinguish 3, 4 and 5 as separate concepts along the same lines of reasoning, i.e. based on explicit disclosure from the patient. In theory, someone could admit to deliberate self- harm without disclosing a motive or end goal (3), or could add information that allows inferring (4) or (5).
Now, about clinical terms... I have seen deliberate self- harm, whether or not there is intent to die, called "self- harm," "self- injurious behaviour," and "parasuicide." The last term (parasuicide) is tricky- some clinicians have used it to mean basically (5), but when I looked up some references to refresh my knowledge current usage entails any deliberate self- harm regardless of intent, e.g. https://dictionary.apa.org/parasuicide
Hope this helps!
talk soon
Scott
Piper Allyn Ranallo
Thanks for posting this Scott Bradley Prior.
I'm curious about your thoughts on how to approach descriptions (synonyms) for the concepts.
Defining the concept and coming up with a clear FSN seems much more straightforward than making decisions about which terms are appropriate SYN for which concepts. Do you assign a the term as a synonym if there is evidence that any group of clinicians use the term when expressing the idea, or does it need to be some sufficiently large number of groups?
It starts to feel like an overwhelming task with the mental health concepts. There are so many different training programs and types of degrees in this field. Each "camp" develops its own term for the same idea, and uses the same term to express multiple ideas (per our discussion about mood, emotion and affect).
Piper
Laura Fochtmann
I think all of these (except 1) would be a subset of self-injurious behavior.
With Self-abusive and self-mutilatory behavior, I'm not sure that the person is necessarily aware enough to have intent (e.g., self-mutilation with Lesch-Nyhan syndrome.)
With 5, the person clearly does not intend to die.
Deliberate self-harm is not used typically in the US in my experience. So someone from the UK should weigh in on the typical clinical meaning. I believe the term parasuicide has been used as well, though am not sure if that's current or more in the past.
My understanding of suicidal behavior is broader and can encompass a range of behaviors associated with suicide or suicide attempts.
Also, within suicide attempts there are aborted and interrupted attempts.
The problem, at least in my mind with including a significant focus on intent in the categorization is that intent is often difficult to infer, even after the fact. (It's even harder to get a handle on prior to an attempt.) Many people are ambivalent, can't really recall what they were thinking (especially if they were intoxicated at the time or were unconscious for awhile after a serious attempt). Many people have difficulty conceptualizing intent and/or answering questions about intent clearly. This is one (of many) major problems that I see with the C-SSRS in that one question refers to some intent whereas another refers to intent. This distinction has always seemed challenging (if not impossible) to make and it's asking compound questions on top of that.
In the 2015 psychiatric evaluation practice guideline, we used the following definitions:
Suicidal ideas Thoughts of serving as the agent of one’s own death.
Suicide attempt A nonfatal, self-directed, potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury (Crosby et al. 2011). It may be aborted by the individual or interrupted by another individual.
Suicide intent Subjective expectation and desire for a self-injurious act to end in death.
Suicide means The instrument or object used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide method The mechanism used to engage in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide plan Delineation of the method, means, time, place, or other details for engaging in self-inflicted injurious behavior with any intent to die as a result of the behavior.
Suicide Death caused by self-directed injurious behavior with any intent to die as a result of the behavior (Crosby et al. 2011).
Note that this definition of plan is what we got consensus on based on typical clinical use of the terms, but the C-SSRS defines method and plan as distinct.
Crosby AE, Ortega L, Melanson C: Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, February 2011. Available at: http://www.cdc.gov/violenceprevention/pdf/self-directed-violence-a.pdf. Accessed May 25, 2015.
The current link is:
https://www.cdc.gov/suicide/pdf/self-directed-violence-a.pdf
Piper Allyn Ranallo
Laura Fochtmann thanks for the detailed response. This is really helpful.
Here's a picture of how we might be able to express the things you describe as being important for describing self harming and suicidal behavior.
(graphic updated with corrections; not loving any of this, but hoping these brainstorming ideas can help get us thinking about how we might fully define behavior concepts)
The picture below shows ideas for (observable entity) concepts we could request. These would allow us to express the aspects of behavior you describe above. Since we can't easily change the defining attributes of clinical findings, creating observable entities would allow us to use the "interprets" and "has interpretation" defining attributes of findings to express these meanings.
11/18/2021 2pm, Note: I played with some finding concepts and outcome of behavior doesn't seem useful at all; probably something better captured in the information model v. concept model??
Piper Allyn Ranallo
Updated claims matrix - includes ideas and terms expressed in post and documents from Laura Fochtmann.
An example of using descripition logic (and new observable entities) to distinguish between head banging with unknown intent (e.g, in severe developmen disorders) and head banging as a self-injurious behavor: