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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 Mariss argues against the validity of the method of substitute subjects. SUBMITTED MAY 2009, ACCEPTED SEPTEMBER 2009 188 © 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 Becks Depression Inventory (Beck, et al. 1961) and Becks 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, Durkheims (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 189 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 Taylors typology includes both completed and attempted suicide, unlike Durkheims 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 persons 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 Durkheims 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 Lesters 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. References Beck AT, Schuyler D, & Herman I (1974a). Development of suicidal intent scales. 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