Forty percent of people with alcohol-related disorders checking into rehabilitation profile clinics admit at least one suicide attempt(1). The suicide rate in patients addicted to alcohol is high and varies from 7% to 15%(2). The general population with a clinical diagnosis of alcohol addiction is 10 times more likely to die by suicide(3). Therefore, suicidal behavior in patients with alcohol-related disorders is frequent and clinically relevant, hence the need to better assess and identify risk factors, in order to better address them.
Suicide in general theory
Many theorists have sought to explain suicide, in order to elucidate what drives a common individual to combat maybe the most primal and intensive instinct, that of self-preservation. What compels an individual to take his own life?
For example, Shneidman(4,5) explained suicide as a response to crushing pain, Durkheim (1951)(6) highlighted the role of social isolation, and Abramson (2000)(7) emphasized the role of hopelessness. In 2005, Thomas Joiner(8) introduced his “interpersonal theory of suicide”, a framework by which suicidal ideation and the progression from ideation to attempts were treated as separate processes that come with separate sets of explanations and risk factors. Joiner theorized a specific application of the framework: perceptions of low belongingness and high onerousness combine to generate longing for suicide, whereas high capability for suicide helps possibly lethal suicide attempts.
The one theory that stands out, however, and which can also easily be applied to people battling alcohol addiction, is the one by Baumeister (1990)(9), who describes suicide as an escape from an aversive state of mind, or as an escape from self. In short, Baumeister describes that following a severe experience, an aversive state of self-awareness begins to develop, the individual starting to see himself as inadequate, incompetent, unattractive or guilty. Once the individual will begin to experience negative affect, he will try to escape, unsuccessfully, from meaningful thoughts into a relatively numb state of cognitive deconstruction (constricted temporal focus, concrete, rigid thinking, immediate or proximal goals, rejection of meaning). This deconstruction state brings forward irrationality and disinhibition, making severe measures seem acceptable. With reduced inhibition, suicide can be seen as the ultimate step in an effort to escape from self and world.
Models of the relationship between alcohol addiction and suicide
Risk factors involved in suicide (George E. Murphy, 1992)
In this model, Murphy(10) assessed certain factors that determined people addicted to alcohol to take their lives by comparing data from two studies, spanning two decades in-between, one from 1959 and the other one from 1979, trying to identify if those risk factors stand still in current times.
Therefore, he identified a series of risk factors, as follows: 1) recent heavy drinking; 2) talk/threat of suicide; 3) comorbidity (major affective disorder/other); 4) little or no social support; 5) unemployment; 6) serious medical problems, and 7) living alone. With the exception of comorbidity (major affective disorder – e.g., major depression episode) which can be attributed to different diagnostic criteria, all other risk factors are exactly the same, similar in percentages, despite the number of subjects.
Based on these findings, several models of the relationship between alcoholism and suicide were theorized, as follows.
Cusp catastrophe model (Hufford, 2001)
Considering that traditional linear models are unable to predict the occurrence and timing of suicidal behavior, Hufford(11) proposes an alternative approach, a nonlinear one, cusp catastrophe model, derived from chaos theory. Recently, behavioral sciences are starting to incorporate chaos theory into the analysis of complex behavioral systems(12). Its application has changed perception of linear models to predict human behavior(13).
Chaotic processes have been able to predict the development of adolescent alcohol use. One facet of the chaos theory is catastrophe theory. Consisting in a set of mathematical models used to describe discontinuous change, and originally developed by Rene Thom (1975)(14), the catastrophic model states that a minor change in one variable can provoke an abrupt or “catastrophic change” in another variable (e.g., drinking/acute intoxication leads to suicide).
One particular type of the catastrophic change is the cusp catastrophe and it has been very successfully applied to behavioral sciences(15). This cusp catastrophe model consists of five qualities, as follows: 1) bimodality – predicted behavior has an either/or; 2) sudden transitions – changes in behavior manifest suddenly; 3) hysteresis – these changes or transitions do not occur at the same time; 4) inaccessibility – having the input parameters, certain behaviors are extremely unlikely, and 5) divergence – a small change of these input parameters can drastically affect the behavior.
Therefore, Hufford argues that the relationship between alcohol and suicide behavior may represent a cusp catastrophe, by respecting these five qualities. Firstly, alcohol intoxication can either propel suicidal ideation into suicidal behavior or can provoke a temporary affective improvement during this intoxication. Secondly, sudden transitions are common (during intoxication, suicide risk can change drastically). Thirdly, hysteresis is present, in the sense that transition from suicidal ideation to active suicide occurs suddenly, whereas transition to mood improvement necessitates more effort. Furthermore, intense suicidal ideation coupled with alcohol intoxication forces behavior to either suicide or temporary active affective improvement.
Although describing itself as a nonlinear model, this theory focuses still on proximal risk factors and distal risk factors, and mainly focuses on active acute intoxication. In this theory, proximal risk factors determine the moment on suicide, when the patients are intoxicated. Therefore, active acute intoxication can determine a series of risk factors, including psychological pressions/distress (thoughts of despair, solitude, depression). Also, acute intoxication increases aggressivity, therefore the patient is more willing to engage in more aggressive suicidal attempts.
Furthermore, it facilitates the transition from ideation to action by expectation of consumption (the patient can drink as a coping mechanism, hoping to alleviate its negative feelings, but when that expectation is not met, he appeals to suicide). Lastly, acute intoxication can constrict cognition and coping mechanisms, further strengthening this transition to suicide.
Distal risk factors represent a statistical potential for suicide, and mainly consist in alcohol dependence, comorbidities (e.g., major depression), negative life events or relapses.
The surface of the cusp catastrophe model is defined by two parameters, the normal and the splitting factor. When the splitting factor passes a certain threshold, then a bifurcation in behavior commences. When predicting suicidal behavior in alcoholics, the normal factor is represented by the distal risk factors and the splitting factor by the proximal ones, provoked by the acute intoxication. Proximal risk factors that come with acute intoxication can either transform ideation into behavior or can improve – even though temporarily – the negative affect. So, having the distal risk factors as a background, proximal risk factors determined by acute intoxication can bifurcate this outcome, suicide or not.
Conner’s diathesis-stress model (2004)
Still focusing on proximal and distal factors, Conner(16) proposes two different types of risk factors, talking about predisposing and precipitating factors. Predisposing factors refer to long-lasting vulnerabilities that strengthen the relationship between alcoholism and suicide. Precipitating factors occur within weeks or months of suicide and represent events or status changes (major depression) that are presumed to increase suicide risk. Secondly, he introduces another two processes into this conceptual framework, making a clear distinction between mediation and moderation. A mediator(17) acts on the causal pathway between a predisposing factor and an outcome (e.g., suicidal act), acting as a precipitant (generative mechanisms) in which the risk influences the outcome.
As an example, we have relationship disruptions, which mediate the relationship between aggressivity/impulsivity and suicidal behavior (that is, higher trait of aggression and impulsivity in a relationship are prone to lead to a break-up, which may greatly influence one’s decision to take his own life or not). Moderators(18) tend to be less mutable than mediators and alter the association between a risk factor and an outcome. Common examples include age and sex (for example, depression leads to more acts of suicide as the patient grows older, as opposed to younger individuals)(19).
Unlike Hufford, who focuses greatly on acute intoxication, Conner’s center of attention lies more on the chronic effects of alcoholism on the individual, taking into account some of his personality traits, such as aggression/impulsivity (externalizing constructs), or negative affect/feelings of hopelessness (internalizing constructs), that either constitute the basis of addiction, or derive from it.
Therefore, predisposing factors supposed to increase (moderate) the risk for suicide in people with alcohol use disorders are represented by aggression/impulsivity and alcohol severity and negative affect/hopelessness. Interpersonal disruptions and major depressive episodes are seen as precipitating factors.
Patients with higher traits of aggression and impulsivity are predisposed to having interpersonal difficulties, including relationship disruptions, that is a common precursor to completed suicide. Individuals who are more susceptible to negative effect and hopelessness are more likely to endure emotional difficulties in the context of break-ups, therefore it is presumed that negative affect and hopelessness increases (moderates) the risk for suicidal acts when such hardships are met.
Major depressive episodes lie as a precursor to suicidal acts and may be primarily a consequence of negative affect and hopelessness, hence major depression mediates the relationship between negative affect and suicide. Another mediation is facilitated by major depressive episodes, where people who suffer from interpersonal loss tend to get depressive feelings, which in turn increase the possibility for suicide.
Lamis and Malone’s updated diathesis-stress model (2012)
Lamis and Malone(20), inspired by Connor’s model, take the model a step further, and while they integrate previous concepts like predisposing and precipitation factors, moderators and mediators, they include additional variables, thought to play a vital role in the link of alcohol dependence and suicidality. Supplementary, novel risk factors include social support (more exactly, the lack of it), depressive symptoms (making the distinction to major depressive episode), and alcohol-related problems (or life strains) that derive from a harmful alcohol use (disrupted interpersonal relationships, financial concerns or legal difficulties). Moreover, this conceptual framework takes into consideration alcohol use at different levels (e.g., moderate drinkers, social drinkers, episodic drinkers – dipsomaniac use, or chronic abusers). Furthermore, the present model praises itself to include suicidal ideation or attempts, not just completed suicide, as in previous theories. Lastly, this framework presents novel mediating and moderating effects among variables relating to suicidal behaviors outside those incorporated in the current literature, its main focus concentrating on the lack of social support, which can constitute a large coping mechanism in patients battling addiction and its inadequate effects (a large sum of life strains that derive from this alcohol harmful use).
Alcohol consumption-related factors with suicide
When studying the link between aggression and impulsivity, on the one hand, and alcohol use disorder and suicidality, on the other hand, studies tend to link these personality traits into an integrated concept, aggression/impulsivity, because they go hand in hand when it comes to developing addiction, which in turn leads to suicide(21).
Aggression/impulsivity distinguished patients with history of suicide attempts and remained strongly associated with suicidal behavior even after the remitting of substance use disorders. Similarly, in a study concerning detoxified alcoholics, more lifetime incidents of aggressive behavior and higher scores on impulsivity distinguished those with a history of suicide attempts(22). Goldstein and Volkow (2002)(23) have concluded that acute and chronic alcohol use may produce disinhibitory states, therefore patients manifest impulsive and sensation seeking behavior that they would normally hold back. Krueger et al. (2007)(24) stated that impulsive patients may have problems refraining from alcohol use, even when there is a possibility of encountering negative consequences.
When it comes to aggression separately, aggression-prone individuals can be subdivided into a dichotomic concept, those who display reactive aggression (impulsive – reactive – hostile – affective) and those who display proactive aggression (controlled – proactive – instrumental – predatory). Those who display proactive aggression tend to be perceived as leaders, have higher social skills, are often manipulative, and often face criminal charges. They use a non-emotional aggression in order to obtain certain rewards. However, individuals who express reactive aggression tend to be rejected by their peers, are in constant self-doubt, tend to isolate themselves from society, have low social skills and low self-esteem. They are prone to impulsive, angry responses to aversive events, perceived or actual interpersonal threat(25) and are more prone to interpersonal difficulties, which in turn, leads to suicide. Suicidal planning and impulsivity are not mutually exclusive: “the decision to act following a carefully developed plan can be impulsive”(26).
In conclusion, suicide represents the interaction between impulsivity and the willingness to engage in aggressive behaviors.
Lack of social support
When speaking of social support, we refer to the availability of support from interpersonal relationships with family, friends and/or a significant other, which provide formal and informal sources of help(27). Pauley and Hesse (2009)(28) found that social support from others was negatively related to the quantity of alcohol consumed in a sample of college students. A lack of quality relationships, peer interactions and alienation from others may facilitate drinking(29). Furthermore, in a multi-wave prospective study, Peirce et al. (2000)(30) demonstrated that increased alcohol consumption leads to reduced contact with family, friends and groups. This finding is in line with previous research suggesting that solitary drinkers consume more alcohol and are at an increased risk for developing alcohol problems than individuals who consume alcohol in social situations(31). Similarly, Zalenski et al. (1998)(32) found that participants who perceived less social support from their friends and family reported consuming higher amounts of alcohol than individuals who experienced adequate or elevated levels of social support.
Moreover, Compton et al. (2005)(33) found that the lack of family social support constitutes a predictor of hopelessness feelings, which in turn, tend to lead to depression. Lastly, more importantly than the quantity of social support is the quality of it, suggesting that perceived satisfaction of social support is more important than the amount received(34).
Feelings of hopelessness
Hopelessness is an enduring characteristic(35) associated with stable, negative expectancies and with rigid, dichotomous thinking(36), interpersonal dependency(37), and low positive emotions(38). Hopelessness seems to promote depression, particularly a subtype marked by cognitive (more so than somatic) symptoms(39), which is a direct predictor for suicide.
Commonly labeled neuroticism, negative affect is present in most psychiatric disorders, including mood disorders, anxiety and personality disorders(40). It precedes major depression onset(41), recurrence of depressive episodes and the persistence of these symptoms(42). It prefaces the onset of a group of alcoholics with independent depression(43) (the individuals drink to combat negative affect(44)), these patients, with independent depression, presenting higher odds for suicide attempts, compared to individuals with alcohol-induced depression(45).
This condition also comes with higher risk for either suicide attempts(46) or completed suicide(47). These two conditions are often comorbid, and we can see in literature either increased levels of depression in patients with alcohol dependence(48) or high levels of alcohol consumption in depressed patients(49). The temporal relationship between alcoholism is uncertain, but several studies have shown that, in men, alcoholism can either precede depression(50) or can be derived from it(51). When it comes to women, however, depression tends to precede the onset of alcohol misuse(43). Whatever the temporal relationship may be in literature, we have high percentages of depression in patients who died by suicide (58%(52); more than 70%(50); 45%(53)).
Life strains constitute direct effects of the aggressive/impulsive behavior in patients with alcohol use disorders. People with alcohol dependence are prone to negative events(54). Men with alcohol dependence who have resorted to suicide face financial difficulties(19), unemployment or legal problems(55) compared to those without such attempts.
The interpersonal problems are a common precursor of suicidal acts(56). Interpersonal problems increased four times in the week preceding suicide(57). People with alcohol addiction show the highest values of this parameter compared to any other pathology(58). In adolescents, marital breakups are significantly more associated with suicide in individuals with alcohol abuse than in those with affective or behavioral disorders(51). Physical/verbal aggression at the beginning of the marriage made the difference between married and separated/divorced couples four years apart(59).
Individuals with alcohol use disorders are more likely to resort to suicidal acts. Suicide results from many complex sociocultural factors and occurs especially during periods of socioeconomic, familial factors or personal/existential crises. It is extremely hard to predict the suicide act, hence the need to identify the risk factors in order to prevent it. Almost a century after Karl A. Menninger, in his work, Man against himself (1938), depicted alcohol dependence as a form of chronic suicide, we now have a series of factors involved either directly or indirectly in these suicidal acts, and we can better assess patients who are at risk when dealing with such pathology.
Conflict of interest: none declared
Financial support: none declared
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