Lecture 9 Mood Disorders: Suicide Lecture Outline I. Introduction II. Who Commits Suicide? A. Age B. Race C. Sex D. Marital Status E. Occupational and Educational Status F. Psychiatric History G. Culture III.Why Do People Commit Suicide? A. Cognitions B. Loss C. Communication D. Current State E. Social Factors IV. Prevention [Film/Guest Speaker] ------------------------------------------- I. Introduction The effects of Mood Disorder on an individual's life can be profound and devastating. The DSM-III-R list of symptoms make this clear: behavioral, cognitive, physiological, and emotional consequences are all an aspect of the Mood Disorders. In addition, there are often relationship difficulties, occupational problems, and substance abuse. The potential and most tragic consequence is self-destruction. (Depression is certainly not the only cause of suicide - Suicide is also clearly associated with Schizophrenia, substance abuse, and some of the personality disorders, for example). Some estimates (Carson, et al., 1988; Klerman, 1982; Wekstein, 1979): Suicide is one of the leading causes of death in Western countries, and rates are on the rise in the U.S. In the U.S.: 200,000 persons attempt suicide each year 27,000 successful each year (about one every 20 minutes) A major cause of death for adolescents and young adults (10,000 or more college students every year attempt suicide) [These numbers are undoubtedly underestimates - suicide is often kept secret by family and even by professionals] II. Who commits suicide? Depression is clearly associated with suicide: perhaps more than half are depressed (Barraclough, Bunch, Nelson, et al., 1974; Murphy, 1983). The lifetime risk of suicide for people with Mood Disorders has been estimated to be anywhere from 15% to 50% to even 90% (Murphy, 1983). Note: Much of what we know about the characteristics of suicide is based on "psychological autopsies": interviews with close friends, relatives, doctors, etc. conducted shortly after the death. Problems with this approach include things like memory biases, intentional distortions. Other characteristics of people who commit suicide: A. Age: Suicides are attempted by preteens to the elderly, but rates are highest for people between the ages of 45 - 60 (Davison & Neale, 1986). B. Race: Suicide rates are greater for whites than nonwhites (Firestone, 1986; Seiden, 1984). C. Sex: Three times as many men as women succeed at killing themselves (Davison & Neale, 1986; Firestone, 1986). But three times as many women as men attempt suicide (Davison & Neale, 1986). This is because women tend to act impulsively, are relatively public about their attempts, and tend to use relatively less serious means. Men, in contrast, tend to give prior warning signs of their intentions (indicating that the act was not purely impulsive, but thought out in advance), and they use highly effective methods (eg: a gun, jumping from a high place) (Clayton, 1983). D. Marital Status: People who are single, divorced or widowed are 2-3 times as likely to commit suicide as married people, especially among men (Clayton, 1983; Murphy, 1983). For married women (esp. ages 20 to 30), there is some evidence that they are more likely to attempt suicide than single women (Shneidman & Farberow, 1970). E. Occupational and Educational Status: White collar workers are more likely to commit suicide than blue collar workers (Firestone, 1986). At particular risk are white males with affluent backgrounds (Seiden, 1984), for example: psychiatrists, psychologists, physicians and lawyers (Davison & Neale, 1986). In addition, college students who excel in academics are more likely to commit suicide, perhaps because they tend to be the most self- critical (Seiden, 1966; Firestone, 1986). F. Psychiatric History: Individuals who have mental health problems and individuals who have been hospitalized because of such problems are at greater risk for suicide (Clayton, 1983; Murphy, 1983; Motto, 1979). Especially at risk are those with MAjor Depression, Bipolar Disorder, or chronic alcoholism. G. Culture: Suicide rates vary from one culture to another. For example, here are some suicide rates (per 100,000) for a number of different cultures (DeCatanzaro, 1981; Kidson & Jones, 1968; Wekstein, 1979): Aborigines of Australia............0.0 Greece..................less than 9.0 United States...........12.2 Sweden..................20.8 Czechoslovakia..........22.4 Hungary.................40.7 H. Handout 9-1 includes some of these factors, as well as other factors, which distinguish between high-risk and low-risk groups. III. Why do people commit suicide? There are numerous attempts to explain why someone would want to kill themselves. Yet, even with these theories, it is notoriously difficult to predict who will actually attempt suicide (Murphy, 1983). We will review some of the theories that have been suggested by investigators. Each of these theories undoubtedly captures only certain aspects of this very complex phenomena. Perhaps the most fruitful approach will thus be a theory that combines variables from these various approaches. A. Cognitions: Various theories have been developed that place cognitions (beliefs, imagery, thought processes, etc.) in a central causal role for psychological disorders (eg: Beck & Emery, 1985; Ellis & Harper, 1976). A person contemplating suicide may do so because he or she wishes to make amends for some act committed, or rid him/herself of unacceptable thoughts, or because of other thoughts or cognitions he/she has (Mintz, 1968). Freud believed suicide was a result of aggression turned inward - we're angry at mom, but that's unacceptable, so we turn it in on ourself. Excessive self-criticism and self-aggression are also often posited as the reason for suicide. Example: The "Inner Voice" (Firestone, 1986) - Some people have a system of hostile thoughts and attitudes that constantly nag, judge, attack and punish oneself. This inner voice is part of one's "internal dialogue" (the thoughts that run through our heads all the time). For example: "You clumsy fool! Look at what you did!" "Can't you do anything right?" "Oh no. I know I'll make a fool of myself." "I can't do that, I'm too stupid." The "voice" operates on a continuum: We have all experienced it to some extent. When it becomes vicious and predominant, self-destruction may result (eg: substance abuse, psycho- somatic illness, suicide). The voice is learned: Typically arising because of overly punitive and critical parents (or other important persons) during one's childhood. This attitude then became internaliz- ed. Although it is likely that innate factors such as temperament may set the stage for one's inner voice. B. Loss: The loss of a loved person may result in great despair and hopelessness. Even Freud experienced the effects of lost love: At 29, he wrote a note to his fiancee: "I have long since resolved on a decision (suicide), the thought of which is in no ways painful, in the event of losing you" (Jones, 1963, p.85)/ C. Communication: Two-thirds of all suicide attempts are estimated to be actually attempts to communicate something to others (Carson, et al., 1988). For example: the need for love, the desire for others to feel guilty, unmet needs in general. Thus, the method used in the attempt is typically nonlethal, and it is done when and where others are likely to discover the person and intervene. D. Current State: The intention to kill oneself is not a constant condition for the individual. It comes and goes. This suggests that the intention to commit suicide is "state-dependent": the intent only arises when the person is in an appropriate state (cognitive state, mood state...). For example, there is some evidence that indicates suicide rarely occurs in a person who is not currently going through a depressive episode (Murphy, 1983). It should be noted, however, that other evidence suggests that it is when the depressed person is beginning to feel better that suicide risk is highest (Beck, 1967). E. Social Factors: Emile Durkheim, a famous Sociologist of the 1800's, identified three types of suicide. According to Durkheim (1951), the motivation to commit suicide is largely a social phenomenon. Durkheim's three types of suicide: 1. Altruistic Suicide - A person who highly identifies with a social groups' morals, interests, and norms will be willing to sacrifice his/her life for the goals of the group. Or, the sacrifice may arise because the group requires a his/her death, or in other cases because he/she violated certain group norms. What ever the case, the person willingly commits suicide because of his/her high integration with the group. Examples: a) Jonestown mass suicide: more than 900 followers of the religious leader Jim Jones committed suicide in 1978 in an isolated commune in Guyana b) Martyrs c) Kamakazie pilots of the Japanese WWII airforce 2. Egoistic Suicide - In this case, the individual is weakly integrated into the group. Durkheim described these people as self-centered, with no emotional attachments to others or to the group. Thus, he/she loses social restraints, he/she has no sense of commitment, and so judges that suicide will not effect anyone but him/herself. 3. Anomic Suicide - Durkheim described a state of being called "anomie": a sense of normlessness that one experiences when one has no clear idea of what the expectations of the group are in terms of moral and appropriate behavior. He or she is left in a state of limbo and disorientation. Anomie occurs during times of rapid social changes, when one's relation to the group changes in sudden and unanticipated ways. The rapid social changes Durkheim discussed were 1) industrialization, 2) urbanization (the growth of and move to cities), 3) modernization. These changes are still occurring. The world of your parents childhood was very different from yours. How do you learn the rules? What are the rules? Such uncertainty may increase the risk for suicide. IV. Prevention [Film or Guest Speaker] Suggestions for films: 1. Depression and suicide: You can turn bad feelings into good ones. 26 minutes, Pennsylvania State Univ: Psychological Cinema Register. Explores some of the causes of depression in teenagers and ways to prevent such feelings of loneliness or sadness from becoming overwhelming. 2. The suicide clinic. 28 minutes, University Extension, Indiana Univ: Audio Visual Center. Illustrates work of suicide clinic, and discusses psychological characteristics of suicides. Links most suicides with long-term depression. Suggestions for Guest Speakers: 1. Paul Joffe, and/or Judy Ellickson (University of Illinois Counseling Center's "suicide team") 2. Grant Willis or Dave Crowley (CCMHC crisis services, including crisis line)