Download theories of attempted suicide

Clinical Neuropsychiatry (2009) 6, 4, 188-191
THEORIES OF ATTEMPTED SUICIDE:
SHOULD THEY DIFFER FROM THEORIES OF COMPLETED SUICIDE?
David Lester
Abstract
This paper explores whether theories of completed suicide are applicable to attempted suicide. It is concluded
that theories are needed which apply specifically to attempted suicide, and suggestions are made for sociological and
psychological theories of attempted suicide.
Key Words: completed suicide, attempted suicide
Declaration of interest: none
David Lester, Ph.D.
Psychology Program
The Richard Stockton College of New Jersey
Jimmie Leeds Road
Pomona
NJ, 08240-0195, USA
[email protected]
The study of suicide (more precisely called
completed suicide) spans many centuries, unlike
attempted suicide which has been of interest for less
than half a century. Although sociological studies of
suicide are relatively easy to carry out, the psychological
study of suicide is hindered by the fact, of course, that
suicides are dead and cannot be interviewed or given
psychological tests. As a result, psychologists have
studied of attempted suicides in order to learn about
completed suicides, the method of substitute subjects
(Neuringer 1962). This raises the issue of whether
attempted suicides resemble completed suicides or are
they different populations?
There have been several approaches to answering
this question.
Follow-up studies of attempted suicide
What percentage of attempted suicides eventually
die from suicide? Dorpat and Ripley (1967) reviewed
prior research and estimated that this percentage is
somewhere in the range of 10% to 20%.
Retrospective studies of completed suicides
A second approach is to see how many completed
suicides have previously attempted suicide. Dorpat and
Ripley in their review of prior research estimated that
this percentage is somewhere in the range of 9% to 62%,
indicating a large degree of inconsistency between the
different studies.
Differences and similarities between attempted
and completed suicides
Research that indicates that attempted and
completed suicides are similar is used to argue for the
use of substitute subjects, whereas research that
indicates that the two groups differ is used to criticize
the use of substitute subjects. In an early review of the
research, Davis (1967) found similarities on five of the
variables that he studied and difference on the other
twelve. For example, it is well documented that, in
general, men complete suicide more than women,
whereas women attempt suicide more than men.
However, all this means from a methodological
viewpoint is that sex must be controlled for in studies
of attempted suicide that aim to increase our
understanding of completed suicide. The same may be
true for other differences between attempted and
completed suicides.
Maris (1971) compared women who had attempted
suicide with women who had completed suicide and
found different patterns of symptoms and experiences.
He concluded that the two groups were very different.
Research such as Maris’s argues against the validity of
the method of substitute subjects.
SUBMITTED MAY 2009, ACCEPTED SEPTEMBER 2009
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© 2009 Giovanni Fioriti Editore s.r.l.
Theories of attempted suicide
The lethality of successive suicide attempts
One interesting question is whether the lethality
of the suicidal behavior in those who attempt suicide
on one or more occasions before eventually completing
suicide increases monotonically in severity. The results
of early research differed, with Eisenthal, et al. (1967)
finding no changes and Cutter, et al. (1969) reporting
an increase in lethality. More recently, Pallis and
Barraclough (1977-1978) found that attempted suicides
who later completed suicide used more lethal methods
in their initial attempt.
Extrapolating from attempted to completed
suicides
The terminology for attempted suicide has been
controversial. Some researchers have argued that many
“attempted suicides” were not in fact trying to die. Their
motivation in some cases is to change their social
environment (the reactions of others toward themselves)
and survive. This led to suggestions that some attempted
suicides be labeled as parasuicides (Kreitman 1977),
self-injurers (Prinstein 2008) or as engaging in deliberate self-harm (Hawton & Harris 2008). Although
attempts have been made to proposed a standardized
nomenclature (Silverman, et al. 2007), researchers continue to use their preferred label.
Those who attempt suicide engage in acts that are
trivial (such as swallowing a few aspirin) to highly lethal
(such as shooting themselves but surviving). Lester, et
al. (1975) suggested that classifying attempts on their
basis of their intent to die could be useful for learning
about completed suicides. In their study, they classified
attempted suicides into high, moderate and low intent
to die based on their answer to questions (yes, uncertain
and no) or on an objective suicidal intent score (Beck,
et al. 1974a). They found that the scores of these
attempted suicides on Beck’s Depression Inventory
(Beck, et al. 1961) and Beck’s Hopelessness Scale
(Beck, et al. 1974b) increased monotonically from low
suicidal intent to high suicidal intent. They argued that,
therefore, extrapolation to the most lethal group of all
(completed suicides) would indicate that completed
suicides would have even higher depression and
hopelessness scores. Lester, et al. (1979) followed up
their sample of attempted suicides and looked at the
scores at intake (at their initial testing) of those who
subsequently completed suicide. Indeed, they did have
very high depression and hopelessness scores at intake.
Therefore, in order to use samples of attempted
suicides to learn about completed suicide, the attempted
suicides must be categorized by their intent to die and
monotonic trends in variables identified. Nonmonotonic trends do not permit extrapolation.
Can there be theories of attempted suicide?
One critical question here is whether the theories
that have been proposed for completed suicide apply
to attempted suicide (and vice versa). For example,
Durkheim’s (1897) theory of completed suicide
proposed that the levels of social integration and social
Clinical Neuropsychiatry (2009) 6, 4
regulation in societies predict the societal suicide rate
(with extreme levels of both variables [very high and
very low] resulting in high rates of completed suicide).
Does this theory apply equally well to societal rates of
attempted suicide? No research has been done to explore
this.
It might be argued that ecological (regional) and
time-series rates of attempted suicide do not exist,
making such studies impossible. Although rare, such
rates are occasionally reported. For example, Lester
(1990) used published rates of attempted suicide over
the electoral wards of Edinburgh (Scotland) and found
that the rate of attempted suicide was associated with
child abuse/neglect, age structure and housing patterns.
It is clear, therefore, that sociological studies of
attempted suicide are possible.
Joiner (2005) has proposed that those who complete suicide have the desire to die by suicide and the ability
to do so. He also proposed two proximal causal factors
for completed suicide: thwarted needs to belong to a
group and the perception that one is a burden to others.
Does this psychological theory apply to attempted
suicides? Interestingly, Joiner has tested his theory of
completed suicide using psychiatric patients who have
attempted suicide (Van Orden, et al. 2008), although he
has also tested parts of the theory using suicide notes
from completed suicides (Joiner, et al. 2002).
The critical issue is, therefore, whether theories
of attempted suicide can be formulated.
Possible sociological theories of attempted
suicide subheading
Steven Taylor
Taylor (1982) argued that the sociological study
of only completed suicide was incomplete and that
sociologists must study attempted suicide. Taylor agreed
with Douglas (1967) that a meaningful sociological
approach to the study of suicide identifies the meanings
of suicidal behavior. Taylor proposed two dimensions
underlying suicidal behavior, which results in four
types. The first dimension was uncertainty versus
certainty. In uncertainty, individuals feel ignorant about
what is important; in certainty, individuals know
everything they want to know. In the context of suicide, I view these two extremes as entailing anxiety
(uncertainty) versus depression/hopelessness (certainty).
The second dimension was ectopic versus
symphysic. Ectopia is where individuals feel detached
from others, especially the opinions and evaluations of
others. In symphysia, individuals have an overriding
sense of attachment to others, and they are dependent
upon the opinions and evaluations of others. This gives
us four meanings for the suicidal act.
(1) Ectopia/certainty leads to submissive suicides
who feel defeated, resigned and without hope. A suicidal
person with a terminal illness illustrates this type.
(2) Ectopia/uncertainty results in thanatation
suicides in which individuals are uncertain about their
own identity and the meaning of their existence.
Binswanger (1958) described the case of Ellen West
who spent her life fighting her desire for food and her
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David Lester
fear of gaining weight. Only through her suicide did
Binswanger feel that she had achieved a meaningful
existence. In her diaries, Ellen West described how she
felt excluded from all real life and she was withdrawing
from people. “I am quite isolated. I sit in a glass ball.”
This is ectopia.
(3) Symphisia/certainty results in sacrificial suicide. Taylor presented the case of a husband whose wife
greeted him on returning home after his third suicide
attempt with, “….here comes your father; he has never
done anything well, even taking his own life.” He killed
himself by hanging soon afterwards. These people,
therefore, are killing themselves because others want
them to (Meerloo [1962] called this phenomenon
psychic homicide) or because they perceive that their
suicide will change the opinions of other about them.
(4) Symphisia/uncertainty results in appeal
suicides in which individuals are desperately
communicating distress to others and trying to
manipulate the behavior of others.
Many attempted suicides fit into this last category,
and so Taylor’s typology includes both completed and
attempted suicide, unlike Durkheim’s four types which
were all types of completed suicide.
Stephen Platt
Platt (1985) examined the stable yet different rates
of attempted suicide in the wards of Edinburgh
(Scotland) and proposed a subcultural theory to explain
them. Kreitman, et al. (1970) suggested that many
attempted suicides view self-aggression as an
acceptable means of communicating to others.
Attempted suicide is viewed as understandable and
appropriate in some circumstances. Platt proposed a
more formal hypothesis: there is a subculture in
contemporary society in which the communication
functions of attempted suicide are particularly wellunderstood (Platt 1985, p. 258).
In order to explore this idea empirically, Platt
interviewed people in four areas, one with a high rate
of attempted suicide (566 per 100,000 per year) and
three with low rates of attempted suicide (ranging from
125 to 205). He interviewed both attempted suicides
and a random sample of residents in the areas.
As expected, people in the area with a high rate of
attempted suicide were less educated, more often from
the lower social classes, and more likely to be renting
housing than owning it. Platt found some differences
in subcultural values on the psychological tests that he
administered. Those living in the region with the high
rate of attempted suicide felt that people were likely to
have sex before marriage, attempt suicide and (for men)
fight in public. However, people in all the regions
strongly condemned attempted suicide.
Although Platt admitted that he had failed to
establish a clear difference between the regions that
would provide evidence for a subcultural theory of suicide, he argued that future research might do so.
David Lester
Lester (1988) suggested the form that a Durkhei-
190
mian theory of attempted suicide might take. Attempted
suicide is not an attempt to kill oneself in most cases.
Rather, it is a communication to significant others in
the person’s life – a cry for help (Farberow &
Shneidman 1961). People do not attempt suicide if they
are isolated, and so attempted suicide should be more
common in those who are socially integrated.
Rates of attempted suicide are higher in females
than in males, the young and those from the lower
social classes. These groups share the quality of being
relatively oppressed. There are greater external
constraints on them and, therefore, they are more
socially regulated. We can propose that completed suicide will be more common in those who are not
strongly regulated and integrated socially, whereas
attempted suicide will be more common in those who
are strongly regulated and integrated socially. In
addition, the social relationships of attempted suicides
will be characterized by conflict and fail to provide
much gratification.
The validity of this proposal is supported by the
fact that modern sociologists have simplified
Durkheim’s theory of completed suicide, arguing that
completed suicide is more common only in societies
with low social regulation and integration (Johnson
1965). This is consistent with Lester’s proposed theory.
Possible psychological theories of attempted
suicide
Attempted suicides differ from completed suicides
on many variables, but many of these differences do
not suggest theories. For example, the fact that women
attempted suicide more than men and completed suicide less than men does not suggest a theory. However,
attempted and completed suicides do differ in
psychiatric diagnoses, and these differences may
stimulate a unique theory of attempted suicide.
Tanney (2000) summarized the results of research
on the psychiatric features of completed and attempted
suicides (p. 334). He reported that completed suicide
was relatively more common in schizophrenics whereas
attempted suicide was relatively more common in those
with antisocial and borderline personality disorders. In
addition, whereas completed suicide was rare in those
with dissociative disorders, these individuals do attempt
suicide.
Borderline personality disorder is characterized by
impulsivity, unstable and intense interpersonal
relationships, inappropriate and intense anger, affective
instability, identity disturbances, and a chronic sense
of emptiness (Maris, et al. 2000). In contrast, completed
suicide, except perhaps in adolescents, is characterized
by long-term, chronic disturbance, and the suicidal act
is carried out with deliberateness and planning. This
distinction resembles the state verses trait distinction
in psychology, where states are chronic conditions and
states are temporary conditions. Consistent with the
psychiatric differences between completed and
attempted suicide, Orbach, et al. (1997) reported that
adolescents who attempted suicide were characterized
by high pain tolerance (for stimuli such as electric
shock) and dissociation, in addition to hopelessness and
depression.
Clinical Neuropsychiatry (2009) 6, 4
Theories of attempted suicide
The severity of the psychiatric disturbance also
appears to be associated with whether the suicidal act
is fatal or not. Attempted suicides appear, in general, to
have less severe psychopathology than do completed
suicides.
It may be, therefore, that theories of personality
disorders, especially borderline and antisocial
personality disorders, may provide heuristic theories
for attempted suicide.
Discussion
In this paper, it has been argued that suicidologists
should stop assuming that the method of substitute
subjects in the study of completed suicide is valid.
Although there may be an overlap between the
populations of completed and attempted suicides, we
need to propose unique theories for attempted suicide.
Furthermore, it should be remembered that health care
professionals come into contact only with the more
severe attempted suicides. Those who make gestures,
such as swallowing a few aspirin or acetaminophen pills
recover at home, are not examined by health care
professionals. Thus, the samples of attempted suicides
that researchers study are biased toward the more lethal
attempters – the “tip of the iceberg”.
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