SUICIDESUICIDE

Prof. Doina Cozman, MD, PhDProf. Doina Cozman, MD, PhD

DefinitionsDefinitions Any case of death directly or indirectly Any case of death directly or indirectly

resulting from a positive or negative act, resulting from a positive or negative act, performed by the victim, knowing the result of performed by the victim, knowing the result of his/her his/her act act (Durkheim, 1980).(Durkheim, 1980). This definition underlines 3 key elements:This definition underlines 3 key elements:

The act is fatalThe act is fatal The act is performed by the victim on The act is performed by the victim on

herself/himselfherself/himself The victim is aware of the The victim is aware of the lethalitylethality of of

the actthe act Douglas ads 2 more elements:Douglas ads 2 more elements:

The subject’s intent to dieThe subject’s intent to die The motivation to dieThe motivation to die

DefinitionsDefinitions

Suicide is the intentional act, Suicide is the intentional act, performed by the human being, in performed by the human being, in order to cease to exist (Shneidman, order to cease to exist (Shneidman, 1973).1973).

Suicide is the act through which an Suicide is the act through which an individual seeks to physically self-individual seeks to physically self-destruct, with destruct, with aa more or less more or less genuinegenuine intention to intention to endend her/his life, her/his life, being more or less being more or less awareaware of her/his of her/his reasons (WHO).reasons (WHO).

ConceptConcept

SuicideSuicide CompletedCompleted

Results in the death of the individualResults in the death of the individual Called simply: Called simply: suicidesuicide

Not completed – suicide attemptNot completed – suicide attempt Failure Failure to complete the fatal gestureto complete the fatal gesture Called: Called: suicide attemptsuicide attempt (Durkheim) (Durkheim)

ConceptConcept

Is suicide a fatal act that Is suicide a fatal act that undoubtedly belongs to a mental undoubtedly belongs to a mental illness or can it be an act of a illness or can it be an act of a normal person?normal person?

Rational vs. pathological suicideRational vs. pathological suicide

ConceptConcept

SuicideSuicide PathologicalPathological

In a mentally ill personIn a mentally ill person Non-pathologicalNon-pathological

RationalRational In persons without mental illnessIn persons without mental illness Seems Seems ““perfectly perfectly explainableexplainable””

Suicidal behaviorSuicidal behavior

Differences between suicide and Differences between suicide and attempted suicide (attempted suicide (StengelStengel):): Gender distributionGender distribution

Suicide: M/F = 3/1Suicide: M/F = 3/1 Attempted suicide: M/F = 4/1Attempted suicide: M/F = 4/1

AgeAge Suicide maximal incidence > 65Suicide maximal incidence > 65 Attempted suicide maximal incidence 18 – Attempted suicide maximal incidence 18 –

3030 Currently – important increase of suicide Currently – important increase of suicide

rates in 18 – 24 !!!rates in 18 – 24 !!!

Suicidal behaviorSuicidal behavior

Differences between suicide and Differences between suicide and attempted suicide (attempted suicide (StengelStengel):): Social statusSocial status

Suicide more frequent in higher social status Suicide more frequent in higher social status personspersons

Attempted suicide more frequent in lower Attempted suicide more frequent in lower social status personssocial status persons

Overall incidence over the last 100 Overall incidence over the last 100 yearsyears

Suicide – constantSuicide – constant Attempted suicide – over 3 fold increaseAttempted suicide – over 3 fold increase

Suicidal behaviorSuicidal behavior

Mental health indicatorMental health indicator Global problem after 9/11Global problem after 9/11 Suicide rate:Suicide rate:

Suicide No in a year/100000 Suicide No in a year/100000 inhabitantsinhabitants

Suicidal behaviorSuicidal behavior

WHOWHO Sri Lanka – 114 /100000Sri Lanka – 114 /100000 Lithuania, Estonia, Latvia – 48 /100000Lithuania, Estonia, Latvia – 48 /100000 Hungary – 40 /100000Hungary – 40 /100000 Russian Federation – 35-38 /100000Russian Federation – 35-38 /100000 Romania 12-14 /100000Romania 12-14 /100000

Sălaj – 30 /100000Sălaj – 30 /100000 Braşov, Sibiu – 25-30 /100000Braşov, Sibiu – 25-30 /100000 Cluj – 10-25 /100000Cluj – 10-25 /100000 Mehedinţi – 5 /100000Mehedinţi – 5 /100000

Suicidal behaviorSuicidal behavior

Deliberate self-harmDeliberate self-harm Any non-fatal act in which the Any non-fatal act in which the

subject causes a lesion on subject causes a lesion on herself/himself or self-administers herself/himself or self-administers a substance a substance (overdose),(overdose), situations situations that might that might more or lessmore or less endanger endanger her/his existence. her/his existence.

Currently – Currently – deliberate self harm deliberate self harm is is the term used instead of the former the term used instead of the former notion of parasuicide notion of parasuicide

Pathological suicidePathological suicide

PsychosisPsychosis Bipolar affective disorderBipolar affective disorder SchizophreniaSchizophrenia Major depressive disorder (MDD)Major depressive disorder (MDD)

Male – 10-15%Male – 10-15% Female – 3-5%Female – 3-5%

Personality disorders (PD)Personality disorders (PD) Borderline PDBorderline PD Antisocial PDAntisocial PD

Substance dependence (alcohol / other)Substance dependence (alcohol / other) NeurosisNeurosis

Especially if comorbid with depressionEspecially if comorbid with depression Modern life characteristics: anomie, depersonalization, Modern life characteristics: anomie, depersonalization,

burnoutburnout, noise, neglecting spiritual life, , noise, neglecting spiritual life, loss of loss of spiritual and moral valuesspiritual and moral values, lead to agitation and panic , lead to agitation and panic reactions which, by increasing the affective tension, reactions which, by increasing the affective tension, cannot be controlled any longer, and suicide appears as cannot be controlled any longer, and suicide appears as the only way out of the stressful situation.the only way out of the stressful situation.

Phases of suicidePhases of suicide

First phase:First phase: Incubation phaseIncubation phase The subject thinks about dying The subject thinks about dying

and the necessity of deathand the necessity of death It can be It can be triggeredtriggered by a number by a number

of causes:of causes: social social adjustmentadjustment difficulties difficulties degree of social group cohesiondegree of social group cohesion EtcEtc

Phases of suicidePhases of suicide

Second phaseSecond phase Transition from abstract, Transition from abstract, ambivalentambivalent

images to images to actual actual preparations by preparations by searching the searching the meansmeans and method of self- and method of self-destruction.destruction.

This phase is characterized by a marked This phase is characterized by a marked increase of the intra-psychic tension that increase of the intra-psychic tension that reaches paroxysm and explodes in a reaches paroxysm and explodes in a psychogenic reaction. In this moment the psychogenic reaction. In this moment the individual individual reachesreaches the decision to act. the decision to act.

This is the moment of the This is the moment of the ““self-destructive self-destructive acting-outacting-out””

Phases of suicidePhases of suicide

Third phaseThird phase The phase when the individual The phase when the individual

puts into practiceputs into practice the pre- the pre-planned self-destructive planned self-destructive behaviors, followed or not by the behaviors, followed or not by the desired outcome – DEATH.desired outcome – DEATH.

The most important things in this The most important things in this phase are:phase are: The methods usedThe methods used The effects of the methodsThe effects of the methods

Methods used in suicidal Methods used in suicidal behaviorbehavior TraumaticTraumatic

““WhiteWhite”” weapons (knives, blades) weapons (knives, blades) FirearmsFirearms JumpingJumping Crushing (train, car)Crushing (train, car) BurningBurning CorrosivesCorrosives

AsphyxiationAsphyxiation HangingHanging StrangulationStrangulation SuffocationSuffocation DrowningDrowning Carbon vaporsCarbon vapors GasGas ElectrocutionElectrocution

ToxicToxic Poisons (Poisons (arsenicarsenic salts, strychnine, cyanides, belladonna) salts, strychnine, cyanides, belladonna)

Methods used in suicidal Methods used in suicidal behaviorbehavior Cultural differencesCultural differences

FranceFrance 33% - hanging 33% - hanging 25% - drowning 25% - drowning 20% - firearms20% - firearms

Sweden, Norway, Denmark – drowning Sweden, Norway, Denmark – drowning is rareis rare

China – China – most frequent self-poisoningsmost frequent self-poisonings with opium and with opium and arsenicarsenic salts salts

Japan Japan Hara kiriHara kiri FirearmsFirearms

Suicide preventionSuicide prevention

PrimaryPrimary SecondarySecondary TertiaryTertiary

Policies, organizations, Policies, organizations, programsprograms

www.iasp.info

- The International Association for - The International Association for Suicide Prevention – also Suicide Prevention – also available on Twitter and available on Twitter and FacebookFacebook

www.antisuicid.com

Shneidmann: 10 Shneidmann: 10 commonalities of suicidecommonalities of suicide

The common The common purpose purpose of suicide is of suicide is to to seek a solutionseek a solution

The common The common goal goal of suicide is of suicide is cessation of consciousnesscessation of consciousness

The common The common stimulus stimulus of suicide is of suicide is psychological painpsychological pain

The common The common stressor stressor in suicide is in suicide is frustrated psychological needsfrustrated psychological needs

The common The common emotion emotion in suicide is in suicide is hopelessness-helplessnesshopelessness-helplessness

Shneidmann: 10 Shneidmann: 10 commonalities of suicidecommonalities of suicide

The common The common cognitive state cognitive state of suicide of suicide is is ambivalenceambivalence

The common The common perceptual state perceptual state in suicide in suicide is is constrictionconstriction

The common The common action action in suicide is in suicide is escapeescape The common The common interpersonal act interpersonal act in in

suicide is suicide is communication of intentioncommunication of intention The common The common pattern pattern in suicide is in suicide is

consistent with life-long styles of consistent with life-long styles of copingcoping