234 CHAPTER 6
taking pills or cutting a vein. In the latter situations, the individual
often has at least a few minutes to seek help after having acted. Some
people may be very ambivalent about suicide and so may attempt
suicide with a less lethal method or try to ensure that they are found
by others before any lasting damage is done. Unfortunately, these sui-
cide attempts may still end in death because the help the individuals
had anticipated did not materialize. Other people who attempt sui-
cide do not appear to be ambivalent; they may or may not display
warning signs, but will follow through unless someone or something
intervenes (Maris, 2002). One suggestion for DSM-V is that a sixth
axis be added for the evaluation of a patient’s suicidal risk, just as
clinicians and researchers evaluate a patient’s level of functioning on
Axis V (see Chapter 3) (Oquendo et al., 2008).
Not all acts associated with suicide—such as certain types of skin
cutting —are, in fact, suicide attempts. Such deliberate self-harming
is usually potentially less lethal and is sometimes referred to as para-
suicidal behavior. People may harm themselves without any suicidal
impulse because they feel numb, or because such self-harming behav-
iors allow them to “feel something” (Linehan, 1981). Alternatively,
some people deliberately harm themselves to elicit particular reac-
tions from others. Parasuicidal behavior is discussed in more detail inCHAPTER
Risk and Protective Factors for Suicide
The risk of suicide is higher for people who have a psychological dis-
order—whether offi cially diagnosed or not—than for those who do
not have a disorder. The three most common types of disorders among
those who commit suicide are (Brown et al., 2000; Duberstein & Con-
well, 1997; Isometsä, 2000; Moscicki, 2001):- major depressive disorder (50%),
- personality disorders (40%), and
- substance-related disorders (up to 50% of those who commit sui-
cide are intoxicated by alcohol at the time of their death).
People who commit suicide may have more than one of these disorders.
Substance use or abuse plays a pivotal role in many suicide attempts because
drugs and alcohol can cloud an individual’s judgment and ability to reason. Also,
as we’ll see in Chapter 9, some substances, such as alcohol, are depressants: They
depress the central nervous system and can lead to depressed mood (Rosenbaum et
al., 2005). If someone is already depressed and drinks to “take away the pain,” he
or she may momentarily feel somewhat better when the blood alcohol level reaches
a certain point, but soon thereafter his or her mood will be even worse than before
drinking.
A history of being impulsive is another signifi cant risk factor for suicide (Sanchez,
2001). Impulsive people may not exhibit warning signs of serious suicidal intent.
Beyond the presence of specifi c psychological disorders or impulsivity, another
strong predictor of completed suicide is a history of past suicide attempts (Elliott
et al., 1996; Moscicki, 1997; Oquendo et al., 2007). Specifi cally, people who have
made serious attempts are more likely subsequently to die by suicide than are those
who have made less serious attempts (Ivarsson et al., 1998; Krupinski et al., 1998;
Stephens, Richard, & McHugh, 1999). Additional risk factors are listed in Table
6.12. Those at risk may benefi t from early evaluation and treatment.
One group at higher risk for suicide is gays and lesbians, particularly during
adolescence (Ramafedi, 1999). The increased risk, however, stems primarily from
the social exclusion and discrimination experienced by these individuals (Igartua,
Gill, & Montoro, 2003). Among homosexuals, suicide is most likely during theA body of research examines suicide notes to
evaluate what leads some people to try to kill
themselves. Any conclusions drawn from such
data, however, are limited. Fewer than 40% of the
people who commit suicide leave notes, and there
may be important differences between those who
leave notes and those who don’t (Leenaars, 1988;
O’Connor, Sheeby & O’Connor, 1999). Moreover,
suicide notes are subject to various self-report
biases, including the desire to leave a particular
impression and to elicit a particular reaction from
the readers (Leenaars, 2003).Omaha Police Department via Getty Images