Suicidal Behavior Disorder

  

Dr. Neil Fernando & Dr Ruwan M Jayatunge

Suicide is a psychiatric emergency and needs immediate intervention. It has been recognized as a major health problem and a leading cause of death worldwide. Suicide does not occur in a vacuum; it’s a fatal outcry and a highly complex and multifaceted phenomenon.

Suicide is the most severe and final manifestation of psychological pain (Rahman et al., 2010). Suicide is a social malady with far-reaching impact. Suicide is defined as an act of intentionally terminating one’s own life (Nock et al., 2008). The National Institute of Mental Health defines suicide as a death caused by self-directed injurious behavior with intent to die as a result of the behavior. Suicides result from the complex interaction of many factors (O’Connor et al., 2014).

Suicidal behavior has a unique trajectory and the behavior pattern is clearly in the medical domain. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed suicide. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. Many mental health clinicians recognize suicidal behavior as an independent construct.

According to the French sociologist Emile Durkheim, the term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result. For Emile Durkheim suicide is not a personal act. He believed that the more socially integrated and connected a person is, the less likely he or she is to commit suicide. Durkheim identifies four different types of suicide which are egoistic suicide, altruistic suicide, anomic suicide and fatalistic suicide.

Psychodynamics of the pathway to suicide is complex. According to Menninger (1938) suicide is caused by unconscious drives. Depression, psychic pain, impulsiveness, anger, anxiety, despair, loneliness, panic, violence, revenge, and a host of other factors are acting in a complex and almost infinite combination to produce the catastrophic behavior and it leads to suicide (Gibbons, 2024).  Some experts propose the relationship between attachment styles and suicide ideation. Silva Filho and team (2023) highlight that disruptive attachments are related to emotional dysregulation and mental disorders throughout life.  

Suicide and suicidal behavior have become a public health concern in Sri Lanka. The suicide rate in Sri Lanka in 2022 was 27 per 100 000 and 5 per 100 000, in males and females, respectively, with an overall suicide rate of 15 per 100 000 populations. However, incidence of suicide is underreported in Sri Lanka due to legal and stigma-associated factors. According to the World Health Organization-based statistics, suicide occurs in approximately 16.7 per 100,000 persons per year and is the 14th-leading cause of death worldwide.

For the development of suicide risk, biological, psychological, social, and environmental factors have been identified (Turecki, et al., 2019). The link between suicide and mental disorders is well established. There is a correlation between suicidality and psychopathology (Gvion &Apter, 2011). Psychopathology, biological vulnerability, family characteristics, and stressful life events play a key role in suicidal behaviors.  The most common psychiatric conditions associated with suicide or serious suicide attempts are mood disorders, but personality disorders, alcohol and substance abuse, anxiety disorders, and schizophrenia are also frequently associated with suicidal behavior. (Sher,2004). Other risk factors such as unemployment, marital disruptions and financial crises also play a crucial role.

Suicides have a rippling effect. As described by Pirkis and Nordentoft (2011), media reporting of suicide can influence suicide rates. According to the social learning theory one person's suicide can influence another's suicidal behavior. The aftermath of suicide touches the lives of family and friends of the victim. The ripple effect can impact individuals and their families and friends. The ripple effect can extend to something known as "vicarious suicidality”. The evidence suggests that suicidal behavior is “contagious” (Gould & Lake 2013).

Suicide is preventable and preventing requires strategies at all levels of society with a comprehensive public health approach. Promoting mental health education and de-stigmatisation efforts are highly essential. Suicide prevention is an emotive, complex goal for clinicians and health systems (Larkin et al., 2023).

Clinical suicidology” emphasizing suicide risk assessment, treatment, training, and the management of suicide-related liability. For there to be suicidal behavior there needs to be an established intent to die and a measurable medical lethality associated with the behavior (Silverman,2006). Clinical suicidology identifies suicide an act with a fatal outcome which the deceased, knowing or expecting a potentially fatal outcome, has initiated and carried out with the purpose of bringing about wanted changes (DeLeo et al., 2004).

Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behavior (Turecki et al., 2016). antidepressants are widely used in suicide prevention pharmacotherapy. For psychotherapeutic methods mental health clinicians recommend dialectical behavior therapy, cognitive therapy prolonged grief therapy and attachment based family therapy.

Implementing effective public health programs, promote wellness and removing stigma around suicide related behaviors can reduce the risk of suicide contagion. Furthermore, identifying risk factors and recognizing the warning signs for suicide can help prevent suicide. Media reporting on suicide can affect suicidal behavior and responsible reporting help prevent the suicide contagion effect. There should be a comprehensive national strategy to prevent suicide.

(Dr. Neil Fernando is a consultant Psychiatrist and   Dr. Ruwan M Jayatunge is a Clinical Psychologist)

References

 

De Leo, D., & Spathonis, K. (2004). Suicide and Suicidal Behaviour in Late Life.  Suicidal Behaviour: Theories and Research Findings.

Gibbons, R. (2024). Understanding the psychodynamics of the pathway to suicide. International Review of Psychiatry, 36(4-5), 508–516.

Gould, M., & Lake, A. M. (2013). The contagion of suicide behavior: Impact of media reporting on suicide. Forum on Global Violence Prevention: Based on Global Health Institute of Medicine, National Research Council: Washington DC: ational Academics Press.

Gvion Y, Apter A. Aggression, impulsivity and suicide behavior: a review of the literature. Suicide Life Threat Behav. 2011;15:93-112.

Larkin C, Arensman E, Boudreaux ED. Preventing Suicide in Health Systems: How Can Implementation Science Help? Arch Suicide Res. 2023 Oct-Dec;27(4):1147-1162. doi: 10.1080/13811118.2022.2131490. Epub 2022 Oct 20. PMID: 36267036

Nock MK, Borges G, Bromet EJ, Alonso J, Angermeyer M, Beautrais A, et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry. 2008;192:98-105.

O'Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry. 2014 Jun;1(1):73-85. doi: 10.1016/S2215-0366(14)70222-6. Epub 2014 Jun 4. PMID: 26360404.

Pirkis J, Nordentoft M. Media influences on suicide and attempted suicide. In: O’Connor RC, Platt S, Gordon J, editors. International handbook of suicide prevention: research, policy and practice. Chichester; Malden, MA: John Wiley & Sons; 2011. pp. 531–44.

 Rahman B.,   Shirin V ., Mitra. N (2010). The relationship between attachment styles and suicide ideation: the study of Turkmen students, Iran, Procedia - Social and Behavioral Sciences, Volume 5,   Pages 1190-1194, ISSN 1877-0428,

Sher,L.(2004). Preventing suicide, QJM: An International Journal of Medicine, Volume 97, Issue 10  Pages 677–680, https://doi.org/10.1093/qjmed/hch106

Silva Filho OCD, Avanci JQ, Pires TO, de Vasconcellos Carvalhaes Oliveira R, Assis SG. Attachment, suicidal behavior, and self-harm in childhood and adolescence: a study of a cohort of Brazilian schoolchildren. BMC Pediatr. 2023 Aug 17;23(1):403. doi: 10.1186/s12887-023-04215-7. PMID: 37592202; PMCID: PMC10433545.

Silverman. M.M.  (2006). The Language of Suicidology.Suicide Life Threat Behav. 2006 Oct;36(5):519-32.

Turecki, G., Brent, D.A., Gunnell, D. et al. Suicide and suicide risk. Nat Rev Dis Primers 5, 74 (2019). https://doi.org/10.1038/s41572-019-0121-0

Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet. 2016 Mar 19;387(10024):1227-39. doi: 10.1016/S0140-6736(15)00234-2. Epub 2015 Sep 15. PMID: 26385066; PMCID: PMC5319859.