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Minimally, “suicide” is intentional self-murder. The concept derives from the Latin sui (“of oneself”) and cide (“a killing”). In German, suicide is literally self-murder (selbstmord). Suicide is usually distinguished from homicide (which is contraintentioned), natural death (which is unintentioned) and accident (which may be subintentioned), making up the so-called “NASH” classification of manners of death on death certificates (sometimes a fifth manner of “undetermined” or “pending” death is added).
II. Types of Suicide
III. Prevalence and Epidemiology
A. Depression, Hopelessness, and Mental Disorders
B. Alcoholism and Drug Abuse
C. Age, Sex, and Race
D. Prior Suicide Attempts, Ideation, and Suicide Talk
E. Lethal Methods
F. Social Isolation and Negative Interaction
G. Suicide in Families and Imitation
H. Stress and Negative Life Events
I. Anger, Irritation, and Dissatisfaction
J. Physical Illness
V. Biological Factors
A more elaborate definition of suicide by the French Sociologist Emile Dirkheim is any death that is the direct or indirect result of a positive or negative act accomplished by the victim him(her) self, which he(she) knows or believes will produce this result. Several important consequences follow from this definition. First, suicide must be a death. Nonfatal suicide attempts, self-destructive thoughts or gestures, partial suicides, and so on, strictly speaking are not suicides. Second, suicides must be self-inflicted. The agent (“efficient” or “proximate” cause) must not be another person (murder), atrophy or disease of the human body (natural death), or an external, impersonal agent encountered capriciously (accidental death). Third, risk-taking that leads to death, if the indirect causal sequence can be specified and was intentional, is suicide. Indirect suicide is a common but neglected form of suicide.
Fourth, not doing something, as well as positive action, can be suicidal. Obvious examples include not taking life-preserving medication or not moving from the path of an approaching vehicle (ceteris paribus). Fifth, suicide is an intentional death. If someone swallows fifty Seconal capsules and dies, but did not believe or know (e.g., was a child) they were lethal enough to kill, then the death was an accident. Problems of measurement of intentionality (especially after death) have led some investigators to focus on lethal behaviors and to ignore intentionality altogether. This approach is unacceptable, since many lethal behaviors result in accidental deaths or even in murders. Finally, death must be certain or thought to be certain. The essential point here is negative. If someone does something (e.g., jumps out of a second-story apartment window) and does not believe that it will kill, but it does, then the outcome is an accidental death. In 1995 the National Institute of Mental Health held a conference to address issues of suicide nomenclature, which resulted in a publication entitled “Beyond the Tower of Babel–A Nomenclature for Suicidology.”
Suicide can be thought of as resulting from the inability or refusal to accept the terms of the human condition. As such, suicide is problem-solving behavior. In fact, suicide is a drastic solution to the problem of life itself, as well as to many other specific life problems. Edwin Shneidman describes suicide as “a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution.” Of course, suicide is often, even usually, not the preferred resolution to one’s life problems.
“Rational” suicides are usually committed by older adults, who are nonpsychotic, who wait until their depression remits, have a consistent wish-to-die over time, consider deleterious consequences for significant others (even involve them in the decision, particularly their children), explore nonsuicidal alternatives thoroughly, are often in hopeless, irreversible physical conditions, sometimes with unrelenting pain or discomfort, and have made all necessary preparations for death. Under these conditions and perhaps a few others, some (not many) suicides can be said to be rational. One of the problems with the spate of assisted suicides by Dr. Jack Kevorkian is that it is not clear that his clients were assessed or treated first for clinical depression.
Although the types of suicides vary, there probably are some common traits of most suicides. In addition to being seen as problem-solving, according to Shneidman, many suicides:
- wish to produce cessation of consciousness;
- wish to reduce intolerable psychological pain;
- have frustrated psychological needs;
- feel helpless and/or hopeless;
- are ambivalent about dying;
- are perceptually constricted;
- feel a need for egression or fugue;
- interpersonally communicate their suicide ideas;
- use self-destruction as life-long coping.
The concept of suicide also needs to be differentiated carefully from attempted suicide. “Attempted suicide” usually implies a conscious intent to kill oneself. However, most suicide attempters never die suicidal deaths (perhaps 85 to 90% die nonsuicidal deaths) and some of them also wish to live (i.e., they are ambivalent). This fact seems to escape many physicians, clinical psychologists, and research psychiatrists who claim they are studying suicide but whose only samples are patients who have made nonfatal suicide attempts. To help resolve such conceptual problems Norman Kreitman recommends the term “parasuicide,” that is, nonfatal acts of deliberate self-injury (ignoring one’s intent to die).
Probably the most numerous of all self-destructive behaviors are those that are indirect. It will be recalled from Durkheim’s definition that under carefully specifled conditions indirect self-destructive behaviors are in fact suicides. Since the 1930s and the work of Karl Menninger, the following behaviors have sometimes been regarded as partially or chronically suicidal:
- alcoholism and drug abuse;
- chronic overeating and obesity;
- smoking to excess;
- reckless driving and accident proneness;
- sexual promiscuity and prostitution;
- ignoring needed medications (like insulin);
- risky sports;
- certain crimes.
Of course, not all behaviors that are self-destructive are suicidal. Some partial self-destruction is absolutely necessary for growth to occur. In fact the educational process itself requires giving up prior ideas and conditioning in the interest of intellectual growth. The word “pseudocide” could be coined to describe adaptive behaviors that are partially self-destructive. It has long been recognized that many nonfatal suicide attempts are cries for help or appeal behaviors. Some parasuicidal behaviors are attempts at self-transformation and not at all intended to end one’s life.
It must also be noted that not all suicides are individual suicides, nor do all individual suicides have purely individual causes. In 1978, 911 fundamentalist followers of Jim Jones committed suicide (some were murdered) in Guyana. In AD 72-73, 960 Jews suicided at Masada, rather than become captives of the Romans. More recently, there were 48 Swiss suicides/murders of the Order of the Solar Tradition (October 1994) and 39 suicides by members of the “Heaven’s Gate” cult in California (March, 1997). It is not too far-fetched to consider even industrial pollution or nuclear war as social suicides. There are clearly social-structural factors in what seem to be only personal motivations. One thinks of the economic anomie of the stock market crash in 1929 in the United States or the role of competition in some Japanese suicides. There can be mixtures of suicide and nonsuicides as well, such as mass murder followed by suicide.
The concept of suicide is not new. Art and history reveal numerous suicides resulting from defeat in battle, dishonor, shame, social obligation, and depressive illness. Probably the first visual reference to suicide is Ajax falling on his sword in a painting done about 540 BC. We also think of Socrates (399 BC), Samson and Judas in the Judeo-Christian scriptures, Dido, Lucretia, Thomas Chatterton, and more recently Yukio Mishima and Marilyn Monroe. The Asian ritual of seppuku and the Indian custom of suttee should be noted as well.
II. Types of Suicide
Suicide is not one kind of behavior. Thus, the explanation of suicide cannot be by a single factor or the province solely of one professional discipline. Suicidology cannot be reduced to biology, genetics, psychology, or sociology. Suicidology is doomed to be an inexact science unless it carefully specifies and delineates its dependent variable. Predictor variables must be tailored to the type of suicide to be investigated, understood, and controlled. For example, some suicides have clear biological markers (especially low brain serotonin levels), whereas other suicides have few or none. Some suicides are interpersonal, but some others are largely intrapersonal. Every individual suicide or type of suicide shares some common predictors with most other suicides, but also has some relatively unique predictors of its own.
Theoretically there can be as many or as few types of suicide as one wishes to specify. Most suicidologists define three or four basic suicide types and one to three subtypes for each basic type. When a suicide researcher goes beyond four to twelve suicide types, he or she runs the risk of having too small a sample to analyze meaningfully (which includes the statistical problem of low power), since suicide is a rare behavior (namely, 1 to 3 per 10,000 in the general U.S. population). For present purposes, the suicidal typologies of Durkheim, Freud and Menninger, Baechler, and Maris will be reviewed briefly. Biological types are sufficiently important to be examined separately. It should be remembered that here we are focusing on completed suicides. Another important continuum of self-destructive types is suicide ideas, gestures, nonfatal suicide attempts, and suicide completions.
Emile Durkheim was one of the founders of the scientific study of suicide and published a hallmark study in 1897. Durkheim believed that there were four basic types of suicidal behavior (with seven subtypes and six mixed types). The four basic (pure or ideal) types of suicide are:
Egoistic and altruistic suicides are polar types, as are anomic and fatalistic suicides. It must be remembered that Durkheim was interested in broad social conditions of suicide, not in the attributes of individual suicides, and that his pure types of suicide are in fact mixed in real life.
Durkheim argued that suicide rates varied inversely with the degree of integration of the social groups of which the individual forms a part. For example, egoistic suicide results from excessive individuation or lack of social integration. Other things being equal, Protestants (who tend to advocate a “priesthood of all believers”) should have higher suicide rates than Catholics or Jews (who are more socially homogeneous and bound by tradition, catechisms, the Torah, etc.). On an individual level, male skid-row outcasts would be close to the egoistic suicide type. Apathy characterizes egoistic suicides.
Altruistic suicide, on the other hand, results from insufficient individuation and is characterized by energy or activity, rather than apathy. The altruistic suicide type typically finds the basis for existence beyond earthly life, as with religious martyrs (like the Jonestown, Waco, and Swiss cults), soldiers who die for their country (like the Japanese kamikaze pilots in World War II), or Indian widows who were sacrificed on their husband’s funeral pyre (suttee).
If egoistic and altruistic suicides refer to social participation or involvement, anomic and fatalistic suicides concern social deregulation or hyperregulation. In a sense then, ego-altruistic suicides operate on the level of horizontal or social restraint, whereas anomicfatalistic suicides result from vertical or normative restraint. In French, anomie literally means without norms and anomic suicide results from a temporary but abrupt disruption of normative restraint. Suicides following stock market crashes or high rates of divorce could be considered anomic.
Fatalistic suicide (which Durkheim considers only in a footnote) refers to suicides generated by excessive regulation. One thinks of jail or prison suicides or suicides of very young married couples. Most real-world suicides have both anomic and egoistic traits (and to a lesser degree altruistic and fatalistic traits). Note, too, that suicide varies only negatively with social integration, if the society’s or group’s norms are against suicide. For example, in Jonestown, Guyana, or the Heaven’s Gate cult suicide and social integration were positively related. Durkheim maintained that altruistic and fatalistic suicidal types were relatively rare.
Psychiatric and psychological types of suicides were developed by the celebrated Viennese physician Sigmund Freud and the American psychiatrist Karl Menninger. For Freud and Menninger, suicides had three fundamental dimensions, namely, hate, depression (melancholia), and guilt. It followed that all suicides were of three interrelated types:
- revenge (a “wish-to-kill”)
- depressed (a “wish-to-die”)
- guilty (a “wish-to-be-killed”).
Freud thought that the loss of an important love object(s) (such as the death of one’s father; see the example of American poet Sylvia Plath) who had been internalized as part of one’s own ego (“introjection”) often resulted in adult melancholia (depression). Freud claimed that all suicides concerned hostility or a death wish originally directed at an external object (father, lover, etc.). Accordingly, one component of (and one type of) suicide comprised anger, rage, hatred, revenge, or a “wish-to-kill.” Menninger called such suicide “murder-in-the-180th degree” or retroflexed anger.
Psychologically trying to kill an introjected object results in ego-splitting and regression. The suicide also feels guilty for harboring murderous wishes toward love objects. Thus, suicides are not only a “wish-to-kill” but also a “wish-to-be-killed” or punished for one’s murderous feelings. Finally, suicides are depressed, hopeless, and cognitively constricted. As one’s ego is destroyed by self-hatred and guilt, a “wish-to-die” arises. Freud further thought that processes of civilization required collected repression of sexuality and aggression, which in turn were channeled into a group superego, fragmenting and diminishing healthy egos even more. In a sense, higher suicide rates were one cost of civilization.
In an interdisciplinary synthesis published in 1979, French social philosopher Jean Baechler contended that there were eleven types of suicide (including non-fatal suicide attempts) fitting into four broad categories:
With all escape suicides the central meaning is to take flight. There are three subtypes: flight (to avoid an intolerable situation), grief (to deal with a loss), and punishment (to atone for a fault). Aggressive suicides are directed against another person or persons and consist of four subtypes: vengeance (revenge suicides), crime (murder-suicides), blackmail (putting pressure on another person), and appeal (a cry for help or alarm signal).
Oblative suicides are reminiscent of Durkheim’s altruistic suicides. There are two subtypes: sacrificial (to gain a value greater than one’s own life) or transfiguration (to obtain a state, like religious martyrdom). Finally, ludic suicides are either of the ordeal type (to prove something) or the game type (to play with or risk one’s life). Except for the ludic suicidal types, Baechler’s types are mainly an amalgam of Durkheim and Freud’s types. It is a conceptual flaw that Baechler includes nonfatal suicide attempters in his typology of suicides.
In my own view, most suicides (about 75 %) are of the escape or fugue variety. Usually suicides are trying to escape from pain, aging, shame, unhappiness, failure, loneliness, or fatigue. As such, suicide is problemsolving behavior. As much as we do not like to admit it, the only real solution to some life problems is to die. Hopelessness and repeated depressive illness figure prominently into escape suicides. Most other suicides (roughly 20% of all suicides and many nonfatal suicide attempts) are revenge or aggressive suicides. Such suicides have strong interpersonal components and include motivations of anger, retribution, or manipulation. A few suicides are self-sacrificing or self changing. Such suicides typically give their lives for others or for a higher cause. Lastly, a small number of suicides (and many nonfatal suicide attempters) are risk-related. These suicides lose their lives in attempts to live on the edge of life or to enhance the quality of their life. Most risk-taking suicides are willing to die but death is not their primary objective. Of course, there are subtypes to these four basic suicide types and actual suicides are a mixture of these ideal types.
III. Prevalence and Epidemiology of Suicide
Suicide is and always has been a relatively rare behavior. In general population, one to three persons per 10,000 takes their lives each year. In 1991 in the United states (the latest year for which official statistics were available at this printing), there were 30,810 suicides. This amounts to a rate of suicide of 12.2 per 100,000 population. Suicide is now the ninth leading cause of death in America, ranking ahead of cirrhosis of the liver (tenth) and just behind AIDS (eighth) and pneumonia-flu (sixth). Among adolescents, suicide is the third leading cause of death after accidents and homicides (of course, most adolescents do not die at all). For the last several years, suicide has accounted for about 1.5% of all deaths in any given year.
National suicide rates tend to drop in war times (especially during major wars) and rise in economic crises (such as the 1929 great depression in the United States). Suicide rates are highest in western mountain states, like Nevada, Arizona, New Mexico, Montana, and Alaska. Although heart diseases and cancers are still the leading causes of death in most age categories, until late middle-age (i.e., 35-44), three of the five leading causes of death are violent. Accidents, suicides, and homicides rank as the third, fourth, and fifth leading causes of death, respectively, among the middle-aged.
Suicide rates also vary considerably by age, sex, race, marital status, and occupation. Generally, suicide rates increase gradually with age until about age 85, after which they drop off slightly. The increase in suicide rates by age is mainly a male trend. Typically, female suicide rates peak in midlife (about ages 45 to 54), then plateau or decline slightly. Overall, the ratio of male to female suicide rates is three or four to one. The highest suicide rates are consistently observed among white males, followed in declining order by black males, white females, and black females. In 1989, 72% of all suicides were by white males and 18 % were by white females (note that 90% of all suicides in the United States are committed by whites). It is estimated that there are eight to twenty nonfatal suicide attempts for every completed suicide. Thus, there could be as many as 600,000 suicide attempts in the United States each year (not all attempts, as opposed to the legal requirement to report all deaths, are reported to emergency rooms). The ratio of nonfatal suicide attempts to suicide completion is thought to be especially high among young people. Between 1960 and about 1977 (the peak year for which teen suicide rate increased), the suicide rate among 15- to 24-year-olds (largely males) rose dramatically (roughly 230 to 250%).
Typically, marriage (and having children) protects one against suicide, especially among whites. Suicide rates are higher for the widowed, followed by the divorced and the never-married or single. Studies of the relationships of occupations, social class, and suicide rates have been equivocal. Some (Durkheim) have found suicide rates to be highest in the upper social classes and in the professional and managerial occupations. Others (Warren Breed and Ronald Maris) have found just the opposite. It is now apparent that within each broad census occupational category there are job types with both high and low suicide rates. For example, among physicians, psychiatrists tend to have the highest suicide rates, whereas surgeons and pediatricians typically have low suicide rates. The predomin a n t method of suicide for both males and females is firearms. Suicide rates are slightly higher in the months of March through May and on Mondays. There has been a spate of recent books focusing on suicide and the life span. Suicide varies by each major age or developmental group. Suicide is a special and somewhat different problem for children, adolescents, young adults, the middle-aged, the young – old , and the old-old.
IV. Predictors of Suicide
Prediction of suicide is such a complicated process that some scholars believe that accurate identification of suicidal individuals before the fact is impossible. As with many rare events, the major problem is one of too many false positives, that is, identifying someone as a suicide when they are in fact a nonsuicide. Correctly identifying true suicides (positive cases) is referred to as “sensitivity” and correctly identifying true nonsuicides (negative cases) is called “specificity.” In one study of 4800 psychiatric patients, Alex Pokorny was able to predict 15 of 67 completed suicides. However, he also got 279 false positives.
Ten major sets of predictors of suicide will now be examined. However, the reader should be cautioned that single-variable predictors seldom explain suicides or suicide rates well. Most suicides exhibit comorbidity (i.e., have multiple psychiatric diagnoses) or polymorbidity. There are in fact several different key predictors involved in most suicides. Often predictors interact with each other and vary in relative importance or weight depending on the type of suicide one is attempting to predict. Most prediction of suicide takes the form of specific scales.
A. Depression, Hopelessness, and Mental Disorders
It should be self-evident that very few happy people take their own lives. We now know that about 15% of those with primary depressive illness will eventually suicide, at a rate of roughly 1% per year. Notice, however, that it follows that 85% of depressives will die a nonsuicidal death. There are also many specific types of depressive illnesses (probably the most common suicide-related diagnosis is major depressive episode). George Murphy and Eli Robins state that 47% of completed suicides in their St. Louis sample were manic-depressives. In another study in England, Brian Barraclough found that 64% of completed suicides had a primary depressive illness. Schizophrenics are also overrepresented among suicides, especially among hospital suicides. Still, the suicide rate among schizophrenics is relatively low compared to that of depressives. Ronald Maris found that several specific depression items were particularly related to completed suicide. These predictors included sleep disturbances, feelings of hopelessness, dissatisfaction, wanting to die, and loss of interest in other people. Aaron T. Beck claims that hopelessness is a better predictor of current suicidal intent than depression.
B. Alcoholism and Drug Abuse
George Murphy and Eli Robins state that 72% of all completed suicides are depressed (47%) and/or alcoholic (25%). No other single variable was present in even 5% of their St. Louis suicide completers. In a thorough review of many research studies on suicide and alcoholism, Alec Roy and Markku Linnoila concluded that, on average, 18% of all alcoholics will eventually die a suicidal death. Curiously, alcohol abuse may actually protect against suicide early on (perhaps in part by transiently raising hydroxyindoleacetic acid levels). Alcoholic suicides tend to be older males who have been alcoholic for 5 years. Some alcoholics may be using alcohol as self-treatment of depressive illness. Alcoholism aggravates other predictors of suicide as well. For example, alcoholism usually leads to loss of important social relationships. One study of adolescent suicide attempters discovered that 43% had serious drug problems.
C. Age, Sex, and Race
It is important to remember that the typical suicide tends to be an older white male. Some biological researchers have argued that maleness is more lethal than femaleness at all ages (even in utero). Males are more likely to die from most causes (except from obvious sex-linked illnesses and injuries, such as reproductive problems) than females are. Males usually make more violent suicide attempt than females. Perhaps part of these differences is related to male hormones and chromosomal differences. Although the patterns of suicide over the life span are changing, it is still true that suicides tend to develop slowly over a period of years. Everywhere in the world the lowest suicide rates are among the young. Suicides have developmental careers that peak around the ages 40 to 50 in most groups.
D. Prior Suicide Attempts, Ideation, and Suicide Talk
Obviously one has to make a suicide attempt in order to complete suicide. Roughly 15 % of all nonfatal suicide attempters go on to complete suicide sometime in their lives. However, most (85 to 90%) older males (over 45 years) make only one fatal suicide attempt. Thus, a suicide attempt can be used to predict suicide in such cases but not to prevent suicide. Younger women are more likely than other groups to make repeated suicide attempts, but even they seldom make more than five nonfatal attempts before completing suicide. Only about 15 to 25% of suicides leave suicide notes. In the general population (such as random surveys taken in shopping malls), as many as 20% have considered suicide at some time in their lives. Most suicides do talk about suicide and death before their suicides, if you listen carefully. Of course, the trick is to know which of these suicide comments to take seriously. It is very useful to ask directly if an individual is suicidal, although often the individual will deny suicidal intent. If one should get a positive response to such questions, it is wise to follow-up with questions about the individual’s specific plan, method, timing, and other detailed preparations for death. A skilled clinician can also consider a patient’s dreams and, use projective tests or even hypnosis to get at suicidal ideation.
E. Lethal Methods
Often a life or death outcome in a suicidal crisis is largely predicted by the availability of a lethal method. Indeed, “suicide proofing” in hospitals, jails, and prisons focuses on removing sharp or protruding objects, clothing and bedsheets that could be torn and made into nooses, and large supplies of medicines that could be used to overdose. In Great Britain, toxic gas supplies to homes were a primary method of suicide. When home gas was detoxified, the suicide rate went down. Potential suicides did not just switch to another method, like hanging or shooting themselves. Although in 1970 in the United States, poisons were the leading method for female completed suicides, by 1987 firearms were the single most common suicide method for both men (64-75%) and women (40%). Many observers have concluded that suicide control in effect amounts mainly to gun control. Hanging is the second most common suicide method (14-15%) for males (especially in jails and hospitals) and poisoning is the second most common method for females (25 %).
F. Social Isolation and Negative Interaction
Numerous experiments (e.g., with mice or in confined human sea travel) have demonstrated that prolonged social isolation raises levels of irritability, hostility, and aggression. In Ronald Maris’s Chicago research about 50% of completed suicides reported having no close friends at all. Whereas 71% of natural deaths had been “very or fairly close” to their parents, only 41% of nonfatal suicide attempters and 29% of suicide completers were close to their parents. Completed suicides were also much more likely than natural deaths (even though the natural deaths on average were 20 years older) to be unemployed at the time of their deaths (33 % versus 16 %). In another study, 42% of suicidal depressives lived alone compared to only 7% of nonsuicidal depressives. However, social involvement can increase suicide potential if one’s social relations are negative and disruptive (as in many revenge suicides). How one came to be alone is probably just as important as the simple fact of social isolation.
G. Suicide in Families and Imitation
It is well known that suicides tend to run in families. Maris discovered that 11% of Chicago suicides had other antecedent first-degree relatives who suicided, whereas none of the natural death controls had suicides in their families. This pattern could be the result of genetic factors or of modeling. For example, the Journal of the American Medical Association (1985) investigated suicide and manic-depressive illness in Amish families and claimed that both outcomes were related to a defect in a narrow portion of chromosome 11. Contagion influences on suicide seem to be greatest among the young. The New England Journal of Medicine reported in 1986 that the adolescent suicide rate rose about 7% in New York City roughly up to a week after the broadcasting of television network films on adolescent suicide. In the same time frame, adult suicide rates rose only 0.5 %.
H. Stress and Negative Life Events
Most suicides are chronic and develop over a period of 40 to 50 years, but against this backdrop acute stress or negative life events can “trigger” a suicide. This is especially the case if stressors have been repeated, as in the third or fourth hospitalization for depressive illness. It must be remembered that stress operates in concert with other predictive factors (i.e., there are interactive effects). Shneidman (in reviewing the Stanford Terman data) found that suicide was especially probable if a key supporting person (a “significant other”) was lost, such as a midlife male losing a wife through death or divorce. Other acute negative life events that have shown to exacerbate suicide potential include having to go to prison or jail, shame, major financial failure, and terminal or painful irreversible physical illness.
I. Anger, Irritation, and Dissatisfaction
It must never be forgotten that most suicides are violent aggressive acts. Anger and irritation are frequently the catalytic agents that ignite depression and hopelessness into a suicide attempt. Psychiatrists argue that suicide is in many cases thinly disguised murderous rage that gets turned back upon the eventual suicide. Gerald Brown and Frederick Goodman claim that aggression may in fact be a more basic affectual response to frustration than depression is (since aggression clearly occurs in animals, but depression may not). It is interesting to speculate on the role of lithium carbonate in the treatment of suicidal behavior among manic-depressives. For example, does it treat the depression or the libidinal and aggressive energy? Anger is particularly suicidogenic when coupled with conceptual rigidity. Shneidman says the “four letter word” in suicidology is “only,” as in “suicide was the only thing I could do.” Suicide has a purging or cathartic effect. Survivors of serious suicide attempts often report feeling in effect that a valve has been opened and their anger or pain level has now been reduced to a tolerable level. There is also an element of atonement or expiation in aggressive self-destructive acting out.
J. Physical Illness
Thirty-five to forty percent of all suicides have significant physical illness. Since most suicides are older males, this is not too surprising. Certainly physical illness in and of itself seldom causes suicide. Maris found that his natural death control group had far more physical illness than his Chicago suicides, but of course none of the natural deaths suicided. Most physically ill individuals (even terminal cancer or AIDS patients) do not suicide. Like other single predictors, physical illness has a complicated relationship to suicide outcomes. Having pronounced these caveats, it does seem that some diseases are more related to suicidal outcomes than others. Suicide is more common among individuals suffering from epilepsy, malignancies, gastroenterological problems, and musculoskeletal disorders (like arthritis or chronic lower back pain).
V. Biological Factors in Suicide
The biology of suicide is primarily a derivative of the phychobiology and psychopharmacology of depression and is clearly still in its infancy, although a promising beginning has been made.
Perhaps the major finding is a disturbance of the metabolism of central monamines in suicides and depressives. Herman Van Praag hypothesizes that disturbances of central serotonergic functions form the root for disturbances of mood and aggressions. Following the work of Marie Asberg et al., van Praag argues that low levels (below 92.5 nmol/liter) of hydroxyindoleacetic acid (5-HIAA; a metabolite of the neurotransmitter serotonin or 5-HT) in cerebrospinal fluid (CSF) are predictive of suicidal acts, especially of violent suicides. The best-fitting Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) diagnoses to low levels of 5-HIAA appears to be “major depressive episode” and “dysthymic disorder.” The correlation between 5-HIAA and suicidal behavior occurs primarily in unipolar depressions. Some of the selective serotonin reuptake inhibitors (SSRIs), like fluoxetine hydrochloride (Prozac), have been thought to paradoxically increase suicide ideation and akathisia in some patients. The dexamethasone suppression test (DST) is probably the best-known biological measure of depression. In nondepressed persons the synthetic steroid dexamethasone will cause suppression of cortisol secretion for about 24 hr, whereas in roughly 50% of primary unipolar depressives the suppression does not occur. This test is most specific for endogenous depression. Typically patients who are depressed hypersecrete cortisol.
In a related set of studies by Brown and Goodwin it is argued that while it is commonly assumed in human self-injury that thought initiates the act, the order in fact may be reversed, with thought being used to elaborate and transform suicidal behaviors rather than to initiate them. Brown and Goodwin claim that aggression is a more primitive response to the environment than depression, since aggression is found at all ages and in all species, but significant depression and suicide are not.
Another major biological factor in suicide is clearly alcoholism. As mentioned earlier, Roy and Linnoila surveyed follow-up studies of 27,956 alcoholics, and on the average 18% of all alcoholics in these studies died by suicide. Alcoholic suicides are much more likely to be men rather than women: almost 90% of alcoholic suicide victims are men. The mean age of alcoholic suicides is about 47 years old, with a mean duration of alcoholism of about 25 years. J. B. Ballenger et al. suggest that alcoholics have preexisting low brain serotonin levels that are transiently raised by alcohol consumption, but that in turn eventually lead to further depletion of brain serotonin levels. This may in part account for the paradoxical relation of alcoholism to suicide. That is, alcohol raises low brain 5-HT levels, but in the long run it lowers them. Of course, development of physical problems like cirrhosis of the liver also takes time.
One of the earliest biological markers of suicide risk was developed by W. F. Bunney and Jan Fawcett. They discovered that 3 of their 36 depressed research subjects who committed suicide had very high levels of urinary 17-OHCS (hydroxycorticosterone), namely, 94- mg/24 hr for women and 14 4- mg/24 hr for men. Subsequent efforts to replicate 17-OHCS findings have been frustrated by the need for recording long-term elevated levels and the difficulty of collecting 24-hr urine samples from confused, uncooperative psychiatric patients. As a result, Krieger recommends measuring a precursor of 17-OHCS, namely, plasma cortiso|. In one study, Krieger found that 13 patients who committed suicide had significantly higher serum cortisol levels than did 39 matched patients who did not suicide. In 1983, Agren found that subjects with a history of serious suicide attempts earlier in life had higher plasma cortisol levels.
The sociobiology of suicide suggests that individuals are especially vulnerable to suicide when they experience severe coping impasses related to relationships to the opposite sex, health, and socially productive behavior. These factors are related to diminished capacities to reproduce and/or to produce for the welfare of one’s kin (i.e., to being less biologically fit). Frederick Struve contents that suicide attempts are positively related to paroxysmal electroencephalogram (EEG) dysrhymthmia. Paroxysmal abnormalities are those that occur suddenly and episodically during a tracing. His research shows that both males and females with suicide ideation had more than twice the incidence of paroxysmal EEG dysrhythmias than did control patients, who were free of suicide and assaultive behaviors. The data suggest further that paroxysmal EEGs are associated with suicidal behavior that is impulsive. Cerebral dysrhythmia may impair emotional and behavioral control during periods of high situational stress.
Finally, Bryan Tanney argues that electroconvulsive therapy (ECT) is very effective in the rapid amelioration of depressive disorders of biological origin, especially the delusional depressives or acutely suicidal patients who cannot wait for antidepressant medications to take effect. The side effects and dangers of ECT are minimal. ECT’s action to increase 5-HT2 receptor activity offers support for the diminished 5-HT function in those with suicidal predispositions.
This review of the biology of suicide has left some factors out. Little has been said about genetics, drugs used to suicide or treat suicides, hormones, urinary norepinephrine, CSF magnesium, symptomless autoimmune thyroiditis, and newer diagnostic tools like positron emission tomography (PET), nuclear magnetic resonance (NMR), and other brain imaging. In closing, it should be remembered that suicidal behaviors require a complex multidimensional model (like that in Fig. 3). Biological markers are only one part of this complex etiology. They are not yet specific or predictive of just suicidal behaviors. The accuracy of biological predictors of suicide when used alone is quite weak and, as with other single predictors, produces many false positives.
Suicide is a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution. Suicide is not one behavior but in fact consists of several discrete but overlapping types, each with its own relatively unique etiology and predictors. Some of the basic types of suicide are escape, revenge, altruistic, and risk-taking. These basic types can be further specified by age, sex, race, and a few other variables.
Suicide is a rare behavior, namely, 1 to 3 per 10,000 in the general population. Suicide is a behavior characteristic of older white males, at least in the Western world. Other relevant factors in the prediction of suicide include depressive illness, alcoholism, suicide ideation and nonfatal attempts, lethality of method, social isolation, suicide in the family, stress, anger, and certain types of mental illness (e.g., schizophrenia and borderline personality disorder). The predominant biological market of suicide at this time is low CSF 5-HIAA, a metabolite of serotonin.
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