Suicide behavior disorder – clinical highlights

Early definitions of suicide

Encyclopedia Britannica hosts the definition of suicide given by E. Shneidmanin 1973, which views suicide as an intentional action performed by the person with the purpose of ending one’s existence⁽¹⁾. The World Health Organization (WHO) defines suicide as an action performed with the deliberate intent of killing oneself. The National Institutes of Health (NIH) define suicide as death caused by a self-harming behavior that is intended to generate death⁽²⁾.

Shneidman outlined the ten elements all suicidal persons have in common. He emphasized that the suicidal persons actually aim to find a solution to their problem, and they intend to stop being aware of their experiences (not necessarily to die per se, but to end the lived anguish). Their trigger is psychological pain that suddenly or in time becomes unbearable, inhumane, and they experience a lot on unmet needs, from the basic survival and safety ones to the one of feeling loved, seen, accepted, included and acknowledged. Also, the suicidal persons feel helpless and hopeless; thus, on an affective level, they feel that salvation is impossible for them. On a cognitive level, the suicidal persons are ambivalent, continuously towing the line in their mind between death to stop the anguish and continuing to live but differently, with less pain if possible. From the outside, this is a contradiction, a situation where either one, or the other is true. Nevertheless, these cognitive states coexist simultaneously in the suicidal person’s mind, and for their situation on the edge of life and death, this ambivalence makes sense. Furthermore, the perception of the suicidal person is constricted, rendering the cognitive processes of the suicidal person ineffective. The suicidal person’s cognition is unable to process details and options. Regardless of the information input, the affected cognitive system of the person only takes into account the two extreme outputs of life with suffering or death by suicide, and renders life with suffering as invalid. Also, the actions of the suicidal person constitute a form of escape from the prison of suffering. Escape in this situation has no moral right or wrong implications: it is an extreme escape from the fire by jumping into the frying pan. Shneidman also posited that all suicidal persons communicate about it, give clear accounts about their intention or repeatedly hint about it. Lastly but not of less importance, the manner in which the suicidal persons have tackled previous troubles is also used in tackling the struggle with suicidality – in death, the person is as he/she is in life⁽³⁾.

Figure 1 shows an overview of Shneidman’s ten commandments of suicide⁽³⁾.

Suicidologists warn against the use of certain words in association with suicide, because of the inappropriate meaning of their association. For example, to commit suicide wrongfully implies commitment to die by suicide. Also, failed suicide attempt wrongfully associates failure to the outcome of the person’s survival after the suicide attempt and, implicitly, wrongfully links success to dying by suicide⁽⁴⁾.

Various terms have been associated to suicide attempts. Kreitman coined the term parasuicide and defines it as non-fatal lesion or ingestion of excess substances, acute alcohol poisoning being excluded. Thus, the breadth of the suicide attempt definition narrows down drastically, to only include extremely rare circumstances⁽⁵⁾. Kessel proposes the terms deliberate self-poisoning for suicide attempts with medication or chemicals and deliberate self-injury for self-mutilation behaviors lacking the intent to die by suicide⁽⁶⁾. Morgan, in 1979, proposed the term deliberate self-harm that would reunite both types of circumstances described by Kessel’s terms⁽⁷⁾.

O’Carroll brought new insight in 1996 on what he called a tower of Babel of terms used so differently by different mental health specialists that it leads to misunderstandings and labelling. Thus, he described the spectrum of suicidality, with a decreasing degree of risk and severity, from death by suicide, suicide attempt with physical injury, suicide attempt, behaviors instrumentally connected with suicide, behaviors connected with suicide, threats of suicide, and suicidal ideation⁽⁸⁾. Silverman and De Leo added in 2016 that suicidal ideation also has degrees of severity, increasing from the suicidal ideation without suicidal intent, to unclear or undetermined degrees of suicide intent, to occasional, passive (thinking about life ending without one’s active contribution to bring about this outcome), active (thinking about potential actions to bring about one’s death) and persistent⁽⁹⁾.

As a caveat to all health professionals, suicide (i.e., death by suicide) differs from suicide attempt (i.e., actions undertaken by the person with the intent of ending one’s life). Also, suicide differs from death resulting from medical complications or physical injuries sustained in the most severe type of suicide attempts, where the direct result of the person’s actions was not death initially, and the subsequent death is sometimes generated by initial injuries or their complications, but sometimes other unrelated factors unexpectedly complicate the medical outcome. Moreover, the terminology used by mental health professionals for suicide-related terms differs from country to country⁽¹⁰⁾. The Centers for Suicide Prevention proposes in 2016 the two criteria – the degree of injury, from no injury to death, and the degree of intent to end one’s life, from low to high – that would broadly divide the spectrum of suicidal behaviors in four categories. The death with low intent to die comprises the category of accidental suicide, while the death with high intent to die is the intentional death by suicide. Low intent to die with low degree injuries comprises the self-harm category, while the high intent with low degree injuries represents the suicide attempt category⁽¹¹⁾.

The proper alignment of terms related to the definition of suicide requires clear criteria for each of the main components of suicide. These main components are: result = the person’s death; intent = a degree of intent, explicit or even ambiguous and unclear, as long as it involves the risk of death; awareness = the action is undertaken with the awareness of potential lethality; action = the person initiates, implements and finalizes the action⁽¹²⁾.

Epidemiological data regarding suicide underscore that, in the past decade, the global number of yearly suicides decreased from 800,000 to 710,000. However, suicide is and remains a major global public health issue due to several reasons. Firstly, the global goal of 30% decrease of deaths by suicide will not be met with the current albeit decreasing trends. Furthermore, almost 25% of the burden of suicide is carried globally by low- and medium-income countries (LMICs), which are less equipped for prevention and management. Also, suicide is the third most important cause of death in persons aged 15 to 29 years old^(13,14). Suicide requires global and national prevention strategies; some countries have national suicide prevention strategies, but most countries do not. Suicide affects more and more certain population groups, such as indigenous persons, minorities of all types, young persons, economically or socially marginalized populations that are mostly out of the reach of prevention programs, if they exist⁽¹⁴⁾.

The suicide rates in Romania have decreased in the past 15 years, from 13 per 100,000 to 5-10 per 100,000 population. However, the trends of constant or higher suicide rates in specific counties, age groups and economic regions combine with the lack of a national prevention strategy and ineffective mental health services. Epidemiological data regarding suicide in Romania in the pre-pandemic and pandemic period are scarce, yet available⁽¹⁵⁾.

Assessment of suicide risk

Suicide risk assessment comprises clinical, psychometric evaluations, and biological tests.

Clinical scales for the assessment of suicide risk

Short clinical scales for the evaluation of suicidal emergencies

Mini-International Neuropsychiatric Interview – MINI (American Psychiatric Association, 1990), translated into 72 languages, was developed for the use of psychiatrists. It is a structured clinical interview based on the DSM-IV criteria and adapted to the DSM-5 and ICD-11 criteria. It takes 15-20 minutes to apply and includes six items that assess suicidal ideation, plans and attempts, assigning the person to a low, moderate or severe suicide risk⁽¹⁶⁾.

Clinical scales for the evaluation of planning and lethality of the suicide attempts

Columbia Suicide Severity Scale (C-CSRS) is a semi-structured interview that assesses the history of suicide attempts, with respect to method used, lethality, context and precipitating factors. The suicide attempts are thus separated into actual, ambiguous, aborted (stopped in its tracks by the person) and interrupted (stopped from outside circumstances or persons)⁽¹⁷⁾.

Clinical scales for the evaluation of suicide risk in emergency situations

Paykel scale is a short scale, easily applied in emergency rooms and urgent situations. It contains five items: 1) Have you felt that life is not worth living? 2) Have you wished to be dead, for example to never wake up from sleep? 3) Have you thought about ending your life, even if you did not act upon this thought? 4) Have you ever seriously considered or planned to enact suicide? 5) Have you ever attempted suicide?⁽¹⁸⁾

Patient assignation to a suicide risk category

Patients are assigned to risk categories according to the degree of suicide risk: high, moderate or minimal; the stage of the suicide process they are currently in: suicide crisis represents the imminent risk, and long-term risk also needs to be considered; and available resources, respectively: access to care (medical or other), family and social support⁽¹⁹⁾.

Table 1 presents the Columbia Classification Algorithm of Suicide Assessment (C-CASA)⁽¹⁹⁾.

Diagnosing the suicidal behavior

Diagnosis of suicidal behavior according to ICD-10

ICD-10 includes intentional self-harm in the X60-X84 codes = 988 three-digit code. X60-X64 involve drowning and self-poisoning with psychotropic medication, narcotics etc., X65 represents alcohol intentional self-poisoning, X68 entails intentional self-poisoning with pesticides, X74.2 involves firearms, X78.8 involves sharp objects, and X80 involves jumping from heights⁽²⁰⁾.

Suicidal behavior in DSM-5-TR

DSM-5 acknowledges the clinical diagnoses of suicidal behavior associated with other mental disorders, and suicidal behavior disorder (SBD), respectively. SBD is listed together with the non-suicidal self-injury (NSSI) disorder in Section 3 of proposed criteria that require further studying. The criteria for SBD are as follows^(21,22):

Criterion A means personal history (past 24 months) of suicide attempt = sequence of behaviors self-initiated by the person with the expectation of producing one’s own death in the moment when the behaviors started.

Criterion B means that the criteria of non-suicidal self-injury are not met.

Criterion C means that the behaviors listed in criterion A are not applied to suicide ideation or preparations for suicide.

Criterion D excludes behaviors that occur during delirium or confusion.

Criterion E excludes actions with an exclusively religious or political motivation.

Current suicidal behavior disorder means that the suicide attempt happened in the past 12 months, while suicidal behavior disorder in early remission means a suicide attempt in the past 12-24 months before the assessment^(21,22).

The validation evidence that supports the SBD diagnosis^(22,23) entails: personal and family history, current context and predictability.

Personal and family history factors include: the family aggregation/co-aggregation of suicidal behavior, heritability of suicidal behavior ascertained via twin, adoption and family studies, sociodemographic factors, such as 3.5 times more suicides in men than in women, more nonfatal suicide attempts in women than in men, suicide and suicide attempt rates widely differing according to race and ethnicity in USA, history of physical or sexual abuse, recent stressors – financial in men, marital in women, illnesses in elderly, negative psychological contagion in adolescents, and psychiatric history – the prior history of suicide attempts increases the odds of future suicide attempts three to six times^(22,23).

The current context-related validity evidence includes the association with cognitive, emotional, temperament and personality factors unrelated to SBD proposed criteria, such as severe stress, impaired decision-making, learning and problem solving, distorted social cognitions. Also, genetic, molecular and neural factors are ascertained: serotoninergic and hypothalamic-pituitary-adrenal axis dysfunction, neuroinflammation, genome – wide association studies have found many genes associated with suicidal behavior that carry a small individual effect, but their cumulated effect is 10%. Furthermore, there are comorbidity patterns of SBD and several psychiatric disorders such as bipolar affective disorder, major depressive disorder, schizophrenia, anxiety, eating disorder, personality disorders, especially borderline and antisocial, and addictions^(22,23).

Last but not least, the predictability evidence regarding SBD entails diagnostic stability – i.e., clear criteria that differ from the non-suicidal self-injury criteria – and persistence/repetition of the suicidal behavior in a two-year window before and after a suicide attempt. Also, the pattern of evolution is relevant. A suicide attempt predicts subsequent suicide attempts, regardless of the time passed from the suicide attempt. The risk of repetition is highest immediately after an attempt or after discharge for a suicide attempt related hospitalization, and continues to remain particularly high for two years. The variability of evolution post-suicide attempt is also noticed in other psychiatric disorders in DSM-5, which makes the evolution evidence not unique to SBD. Also, the therapeutic response is diagnostic evidence. In specific population groups, studies ascertained the decrease of suicidal behaviors after treatment with clozapine, lithium, psychotherapies such as dialectical behavioral therapy and cognitive behavioral therapy, and also electroconvulsive therapy in patients with severe depression and a high risk of suicide^(22,23).

Diagnosis of suicidal behaviors according to ICD-11

In ICD-11, the MB23 category of diagnoses regarding appearance or behavior includes the codes MB23.R and MB23.S. MB23.R ascertains the diagnosis of suicide attempt, meaning a specific episode of self-inflicted harm with the conscious intention to kill oneself. MB23.S ascertains the diagnosis of suicidal behavior, for all actions undertaken by the person with the specific purpose to kill oneself, such as stashing medication, purchasing a firearm or poison, without resulting in current inflicted harm⁽²⁴⁾.

The MB26 diagnostic category, grouping signs or symptoms of thought content, includes the MB26.A diagnosis code of suicidal ideation. This diagnosis refers to all thoughts and ideas of suicide, from thinking that one would be better off dead to the elaborate planning of how to die by suicide⁽²⁴⁾.

DSM-5, suicidal crisis and the newly described suicide-specific syndromes

Suicide-specific syndromes have been described recently: acute suicidal affective disturbance (ASAD) and suicide crisis syndrome (SCS). Their conceptualization bears similarities and differences with the DSM-5 diagnoses and also with the classical concept of suicidal crisis, also known as pre-suicidal syndrome⁽²⁵⁾.

According to Caplan, the key features of crisis are: exposure to an event perceived as highly threatening, inability to change or decrease the impact of the event, high imbalance, high discomfort, high fear, tension and confusion. The suicidal crisis = pre-suicidal syndrome key features, according to Ringel, are constriction, suicide fantasies and aggression that is inhibited and turned against oneself. Additional features of suicide crisis include insomnia, regression, vegetative symptoms and psychomotor changes. The evolution of suicide crisis is fluctuating, in a downward spiral manner^(26,27).

The DSM-5 SBD diagnosis key symptom is suicide attempt in the past 24 months. The suicidal ideation or preparations, the delirium and confusion context and the exclusively political or religious motivation are exclusion features. The evolution may be chronic (planned) or acute (impulsive), with a high risk of repetition for 24 months⁽²¹⁾. The DSM-5-TR proposes separately from the SBD the diagnosis of suicidal behavior associated with mental disorders⁽²⁸⁾.

The acute suicidal affective disturbance key symptom is the severe increase in suicide intent in a matter of hours/days. Additional symptoms are hopelessness, hyperarousal and alienation from self and others. The evolution is spike-like, very fast and also limited in time – i.e., the symptoms become very intense very quickly and wane in a short time⁽²⁵⁾.

The suicide crisis syndrome is characterized by a repeated or prolonged sense of entrapment. Additional symptoms regard cognitive and affective dysregulation (disturbed arousal, loss of cognitive control, impaired affective regulation) and behavioral manifestations such as social withdrawal. The evolution is repetitive or prolonged⁽²⁵⁾.

Prevention of suicide by the introduction
of diagnosis for suicidal crisis

So far, the DSM and ICD classifications have not established a diagnosis for acute situations of psychological distress that trigger increased suicidal behaviors. However, many recent studies prove the existence and validity of the suicide crisis syndrome (SCS). Based on strong empirical evidence in very diverse populations, suicide crisis syndrome requires the criterion of persistent, severe, hopelessness and feeling trapped in a destabilizing, unbearable and unavoidable situation, in addition with one symptom from each of the other four symptom domains: affective dysregulation, loss of cognitive control, hyperarousal and social withdrawal. Interestingly; suicidal ideation does not carry importance for acute situations^(29,30).

The SCS ascertained by the aforementioned criteria was shown as the only relevant predictor of a suicide attempt and also predicts in a valid manner the presence of suicide ideation and behaviors after one month. Therefore, it gives clinicians important data for the management of patients with a high risk of suicide, both in emergency and in outpatient units, by clarifying the formulation of needs for care, strengthening the doctor-patient alliance, and diminishing the medical team’s anxiety about therapeutic decisions and legal ramifications of treatment. Moreover, as global suicide rates are failing to decrease (as projected via the national strategies and cross-national prevention partnerships), the introduction of this diagnosis for specific patterns of acute suicidality may represent the key factor that improves the treatment outcomes and boosts suicide prevention education and research by conceptual reframing^(29,30).   

Corresponding author: Prof. dr. Doina Cozman E-mail: doinacosman@antisuicid.ro

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.