Suicide Notes

Suicide

Introduction

  • Suicide is a major global health concern.
  • It is among the leading causes of death worldwide.
  • Approximately 1 million people die by suicide each year.
  • In the United States, over 42,000 suicides occur annually.
  • Some individuals engage in parasuicides, which are unsuccessful suicide attempts.
  • Suicide is not officially classified as a mental disorder in DSM-5.
  • Suicidal behavior disorder has been proposed for the next DSM revision.
  • Suicide has been recorded throughout history, involving figures like King Shaul, Ernest Hemingway, and Robin Williams.

What Is Suicide?

  • Suicide: A self-inflicted death in which one makes an intentional, direct, and conscious effort to end one’s life.
  • Intentional Death (Shneidman): Categorizes individuals based on their intent.
    • Death Seeker: Clearly intends to end their life.
    • Death Initiator: Intends to end their life because they believe the process of death is already underway.
    • Death Ignorer: Does not believe that their self-inflicted death will mean the end of their existence; believes they are trading their present lives for a happier existence.
    • Death Darer: Has ambivalent feelings about death and shows this in the act itself (e.g., Russian roulette).
  • Subintentional Death: Indirect, covert, partial, or unconscious self-destructive behavior.
    • Self-injury or self-mutilation, such as cutting, burning, or banging one’s head.
    • 17% of teens engage in self-injurious behavior, particularly skin cutting, which is often connected to chronic feelings of emptiness.
  • How Suicide Is Studied:
    • Retrospective analysis (psychological autopsy): Examination of suicide through suicide notes or statements from people who knew the deceased.
    • Studying people who survive their suicide attempts: There are 12 nonfatal suicide attempts for every fatal suicide.

Internet and Suicide

  • Pro-Suicide Websites: These sites have tripled over the past seven years.
    • Some provide advice or information about how to die by suicide to 7.5% of teenagers.
  • Live-Streaming Suicides: Social networking efforts are being used to identify people at risk and provide aid and information.

Patterns and Statistics

  • Suicide rates vary by:
    • Country
    • Gender and marital status
    • Race and ethnicity
    • Social environment
    • Religious devoutness (not exclusively affiliation)
  • Underreporting of suicide may exist.

Triggers of Suicide

  • Common triggers and possibilities:
    • Stressful events: Loss of a loved one, divorce or rejection, loss of a job, financial loss, natural disasters.
    • Long-term stress: Social isolation, serious illness.
    • Mood and thought changes: Feelings of pessimism.
    • Dichotomous thinking: Viewing problems and solutions in rigid, black-and-white terms.
    • Alcohol and other drug use.
    • Mental disorders.
    • Modeling.
  • Stressful Events and Situations:
    • Immediate Stressors: Loss of loved one, job loss, financial loss, natural disasters.
    • Long-Term Stressors: Social isolation, serious illness, abusive environments, occupational stress.
  • Mood and Thought Changes:
    • Changes in mood and shifts in thinking patterns often precede suicide attempts.
    • Hopelessness, sadness, anxiety, tension, frustration, shame.
    • Dichotomous thinking.
  • Alcohol and Other Drug Use:
    • 70% of suicide attempters drink alcohol just before the act.
    • One-fourth of these people are legally intoxicated.
    • Other drugs may have similar ties to suicide, especially in teens and young adults.
  • Mental Disorders:
    • The majority of suicide attempters have a psychological disorder.
    • Unipolar or bipolar depression (70%).
    • Chronic alcoholism (20%).
    • Schizophrenia (10%).
    • Risk increases with multiple disorders.
    • Other psychological disorders: PTSD, panic disorder, substance use disorder.
    • Often in conjunction with schizophrenia or borderline personality disorder.
  • Modeling: Contagion of Suicide:
    • A suicidal act can serve as a model for others, particularly among teens.
    • Common models: Family members, friends, celebrities, highly publicized cases, coworkers, and colleagues.

Underlying Causes of Suicide

  • Psychodynamic View:
    • Suicide results from depression and anger at others that is redirected toward self (Stekel).
    • An introjecting lost person (Freud; Abraham): Anger over a lost loved one turns to self-hatred and then depression.
    • Later suicidal behaviors are related to childhood losses (Freud).
    • Death instincts/Thanatos (Freud).
  • Durkheim’s Sociocultural View (1897): Suicide probability is determined by attachment to social groups.
    • Suicide Categories:
      • Egoistic: Isolated, alienated, nonreligious people.
      • Altruistic: Socially well-integrated people.
      • Anomic: Inhabitants of personally unstable social environments.
  • Interpersonal View:
    • Interpersonal-psychological theory (Thomas Joiner et al.).
    • Perceptions related to desire for suicide:
      • Perceived burdensomeness.
      • Thwarted belongingness.
    • Psychological ability to carry out suicide.
    • Important to examine variables collectively.
  • Biological View:
    • Genetics: Early twin studies point to genetic links to suicide.
    • Brain development: Low serotonin activity and abnormalities in depression-related brain circuits contribute to suicide.
    • Both aid in the production of aggressive feelings and impulsive behavior.
    • Key psychosocial factors.

Suicide and Age

  • Children:
    • Suicide is infrequent among children.
    • Suicide by the very young is often preceded by behavioral struggles.
    • Many child suicides appear to be based on a clear understanding of death and a clear wish to die.
  • Adolescents:
    • Suicidal actions become much more common after the age of 13.
    • About 8 of every 100,000 U.S. teenagers commit suicide yearly.
    • 12% have persistent suicidal thoughts.
    • 4-8% make suicide attempts.
    • Teenage Suicide Links:
      • Developmental stress of adolescence.
      • Long- and short-term stressors, especially among LGBTQ teens.
      • Clinical depression, low self-esteem, hopelessness.
      • Anger, impulsiveness, alcohol or drug problems.
      • Internet and in-person modeling.
    • Far more teens attempt suicide than succeed.
    • Ratio may be as high as 200:1.
    • Factors linked to suicide attempts:
      • Competition for jobs, college positions, academic and athletic honors.
      • Weakening family ties.
      • Availability of alcohol/drugs.
      • Mass media.
    • U.S. teen suicide rates vary by ethnicity.
    • Young white Americans are more suicide-prone than African Americans or Hispanic Americans at this age.
    • Highest suicide rates are displayed by American Indians.
    • Incidence rates are closing among all groups.
  • The Elderly:
    • U.S. elderly are most likely to commit suicide and are most successful.
    • Contributory factors:
      • Illness.
      • Loss of close friends and relatives.
      • Loss of control over one's life.
      • Loss of social status.
      • Ethnicity.

Treatment and Suicide

  • Treatments After Suicide Attempts:
    • Medical care.
    • Appropriate follow-up with psychotherapy or drug therapy.
    • Therapies: Psychodynamic therapy, drug therapy, group and family therapies, cognitive-behavioral therapy (Beck), mindfulness-based, dialectical behavior therapy.
  • Therapy Goals:
    • Keep the patient alive.
    • Reduce psychological pain.
    • Achievement of a nonsuicidal state of mind and a sense of hope.
    • Development of better ways of stress management.
  • Suicide Prevention:
    • Prevention programs and crisis hotlines.
    • Staffed by professionals or paraprofessionals.
    • Offered through various modalities.
  • Suicide Prevention Goals for Initial Contact:
    • Establishing a positive relationship.
    • Understanding and clarifying the problem.
    • Assessing suicide potential.
    • Assessing and mobilizing the caller's resources.
    • Formulating a plan.
    • Longer-term prevention: Referral, therapy, reduction of access to common suicide means.
  • Do Suicide Prevention Programs Work?:
    • Assessment of program effectiveness is difficult.
    • Variety of program types, variables, and confounds.
    • Mixed results.
    • Accurate suicide risk assessment is elusive.
    • Newer assessment approaches: Nonverbal behaviors, psychophysiological measures, brain scans, Self-Injury Implicit Association Test (Nock).
  • Psychological and Biological Insights Lag Behind:
    • Suicide has received much more examination from the sociocultural model than from any other.
    • Sociocultural factors shed light on the general background and triggers of suicide but typically leave us unable to predict that a given person will attempt suicide.
    • Clinicians do not yet fully understand why some people kill themselves while others in similar circumstances manage to find better ways of addressing their problems.