Life after near death: What interventions work for a suicide survivor?
Motives and methods of self-harm may suggest an individual's risk for future attempts
Table 1
8 categories or narratives of suicidal behavior
| Motive | Characteristics |
|---|---|
| True suicidal act | Release from intense baseline despair/hopelessness; self-nihilism as a permanent end to internal pain (entails highest intent to die and highest risk of completed suicide) |
| Self-mutilation | Relieving dysphoria or dissociation/depersonalization; acts of DSH designed to self-regulate or distract from emotional pain or other overwhelming affects |
| Retributive rage | Revenge; impulsiveness, vengefulness, and reduced capacity to conceive of other immediate options |
| Parasuicidal gesturing | Communication designed to extract a response from a significant other; often repetitive acts of DSH, strong dependency needs |
| Acute shame | Penance designed to escape from or to atone for a shameful act; often occurs within a short time after act is committed |
| Altruism | Relief of real or imagined burden on others; often occurs in setting of medical illness or substantial financial concerns |
| Command hallucinations | Acting in compliance with a command hallucination; often in setting of schizophrenia or depression with psychotic features |
| Panic | Driven by agitation, psychic anxiety, and/or panic attack; action intended as escape from real or imagined factor provoking agitation |
| DSH: deliberate self-harm | |
| Source: References 1-3 | |
CASE REPORT: Caught in the act
Mrs. L, age 35, works at a nail salon and took $12 from the cash register to buy gas so she could visit her husband in the next town. She’d never done anything like that before. She planned to return the money the next day, but her act was captured by a security camera and reported before she had a chance. Her boss said she had to go to the police.
Mrs. L was so ashamed that she decided she wanted to die. She drove her car to a remote hunting area where she tried to shoot herself in the head. The gun bucked, however, and shot her in the shoulder instead. She climbed into the front seat and drove herself to the hospital.
Method of self-harm
Survival of a suicide attempt depends in part on the lethality of the suicide method. Although she survived, Mrs. L’s attempt was intended to be quite lethal and illustrates shame as a motive.
The method’s lethality does not always correlate with the intent to die.9 Attempters with the highest suicidal intent do not reliably choose the most lethal method, either because they overestimate the lethality of methods such as cutting or overdose or because less lethal methods were most accessible.
Firearms, which are both accessible and lethal, remain the most common and deadly method in the United States, with more suicides from gunshot than all other methods combined.13 Cultural factors also are involved, such as in India where poisoning (especially with readily available organophosphates) is more common than gunshot.14 Suicidality screening in psychiatric practice and in the emergency department should always include questioning about convenient access to lethal means, especially those commonly used among the local population.
Clinical management
Treatment goals for patients who have demonstrated suicidal behavior may include decreasing the occurrence of suicidal thoughts, plans, gestures, or attempts. At a population level, accepted management strategies include:
- psychotherapy (cognitive-behavioral therapy [CBT], dialectical behavioral therapy)
- contracts for safety (widely employed but lacking evidence of efficacy)
- medications that target underlying disorders (antidepressants, mood stabilizers, antipsychotics).
Ineffective interventions? A study examining suicide trends since 1990 in the United States18 found disheartening evidence that although treatment dramatically increased, the incidence of suicidal thoughts, plans, gestures, or attempts did not significantly decrease ( Box 1 ).18–26 Based on a systematic review of 15 randomized controlled trials, Arensman et al19 offered 2 explanations for why studies of various psychosocial and pharmacologic interventions showed no significant effect on suicidality compared with usual care:
- the intervention had a negligible effect on patient outcomes
- the sample size was too small to detect clinically important differences in reattempt rates.
