Completed suicide provokes a multitude of questions: What motivated it? What interventions could have diverted it? Could anyone or anything have prevented it? The question of who dies by suicide often overshadows the question of what lessons suicide attempt (SA) survivors can teach us. Their story does not end with the attempt episode. For these patients, we have ongoing opportunities for interventions to make a difference.
A history of SA strongly predicts eventual completion, so we must try to identify which survivors will reattempt and complete suicide. This article addresses what is known about the psychiatry of suicide survivors—suicide motives and methods, clinical management, and short- and long-term outcomes—from the perspective that suicidality in this population may be a trait, with SA or deliberate self-harm (DSH) as its state-driven manifestations. When viewed in this manner, it is not just a question of who survives a suicide attempt, but who survives suicidality.
CASE REPORT: End of the game
Ms. T, age 39, was admitted to the intensive care unit after an aspirin overdose. She had been living with a man in a southern state for 8 years since the demise of her first marriage, but kept deferring remarriage. She returned to Minnesota with her teenage daughter to visit her family and stayed 6 months. Her partner phoned Ms. T every day, telling her he wanted her to come back. One day he tired of the game and said, “Fine, don’t come back.” She immediately overdosed, then called him to tell him what she’d done. He called her daughter, telling her to go check on her mother and to call 911. When later asked why she did it, Ms. T said, “So he would know how much he loved me.”
Motive for self-harm
Ms. T’s suicide attempt was nonlethal, and she reported it immediately—characteristics of parasuicidal gesturing as a motive. A useful categorization of suicidal behavior divides it into discrete categories or narratives. Gardner and Cowdry describe 4: true suicidal acts, parasuicidal gesturing, self-mutilation, and retributive rage.1 We modify this schema with 4 additional categories: altruism, acute shame, command hallucinations, and panic ( Table 1 ).1-3 Categories are differentiated by affective state, motivation, and goal of behavior, but all involve situations in which the individual feels a lack of other options and resorts to maladaptive strategies.
Although this classification scheme helps clinicians understand a patient’s mindset, the specific motive underpinning DSH or SA is not consistently linked to its lethality. True suicidal acts frequently are marked by careful planning and high-lethality methods that increase the risk of completed suicide, but any motive can lead to a lethal act, whether or not death was intended.2,3
Factors that increase the risk of SA and completed suicide include male gender, age (adolescent or age >60), low socioeconomic status, and alcohol or drug abuse.4 An underlying mood disorder accounts for 73% of attributable risk of suicide or medically serious SA in older adults.5 This connection between mood and suicidality highlights the concept that emotional pain can cause so much suffering that patients seek release from distress by ending their lives.
A useful model by Shneidman6 casts psychological pain as 1 dimension in a 3-dimensional system that includes press and perturbation. In this model:
- Pain refers to psychological pain (from little or no pain to intolerable agony).
- Press means actual or imagined events in the inner or outer world that cause a person to react. It ranges from positive press (good fortune, happy events, protective factors) to negative press (stressors, failures, losses, persecution), which in turn decrease or increase the likelihood of suicide.
- Perturbation refers to the state of being disturbed or upset.
Certain risk factors make SA simultaneously more likely to occur but less likely to be lethal. For example, parental discord, nonheterosexual orientation, and female gender have been found to increase non-fatal attempts among adolescents.7 Borderline personality disorder increases the reattempt rate out of proportion to completion among adults.8 One might interpret a pattern of repeated nonlethal attempts to mean the patient has no real intent to die, but this is not always the case.