Suicide risk mitigation

Suicide is a behaviour, and the causes are multifactorial and interrelated. There are several theoretical models of suicide and the main ones include the interpersonal theory,[30] the three-step theory,[31] and the integrated motivational-volitional model.[32]

Suicide is associated with a constellation of psychological, biological, genetic, social, and environmental factors, but whether these factors are causative remains uncertain.

The exact pathophysiology of suicide is poorly understood and currently offers little assistance in clinical practice. Genetic, social, personal, behavioural, situational, and environmental factors are involved in increasing a person’s suicide risk.[33] A complex relationship exists between self-harm, suicidal thoughts, suicidal behaviours, and suicide.[34]

Genetic and neuroendocrine studies suggest that factors involved in serotonin pathways may be implicated in self-harm.[35] This seems to be independent of the serotonin abnormalities found in depression. Other possible factors include involvement of the noradrenergic, dopaminergic, and hypothalamic-pituitary-adrenal axis stress response function.[36] Structural findings in the brain are associated with self-harm, including reduced grey matter in the cortex (orbitofrontal, dorsolateral prefrontal, and anterior cingulate), the insula, the superior temporal gyrus, and the basal ganglia, and increased volume of the amygdala.[37][38][39][40] These findings point to impaired functioning of the amygdala-orbitofrontal-cingulate network, (i.e., an underactive prefrontal cortex cannot respond appropriately to non-emotional stimuli, and a hyperactive prefrontal cortex cannot inhibit the emotional/threat-driven limbic system).[37][41]

Suicidality

Generally refers to any thoughts or actions associated with an implicit or explicit intent to die, but is of limited value because it covers a wide range of concepts (including self-harm) and the authors of this topic recommend that it not be used.

Suicidal ideation

Includes thoughts, feelings, ruminations or preoccupations with death, in general, and suicide in particular. The risk of suicide is influenced by many factors including the magnitude, clarity, and persistence of suicidal thoughts; psychological pain; and associated negative thinking such as hopelessness, helplessness, guilt, entrapment, burdensomeness, and shame.

Suicidal intent

The wish to die and expectation of death by suicide. Suicidal intent includes both objective and subjective perspectives. The risk for death by suicide is usually related to the strength of the suicidal intent, which may be reflected more by the person’s belief in the lethality of the chosen method of suicide than the actual lethality of the chosen method.

Suicide planning and preparation

Refers to specific ideas about an impending suicide attempt. May include choice of method, plans to access the method, belief about the lethality of the method, a time or setting for the event, writing a suicide note, preparing a will, giving away pets, and giving away personal belongings or property. In general, suicide plans that are premeditated, unlikely to be discovered, and involve the choice of a highly lethal method (e.g., firearm or hanging) usually indicate a plan with a greater or more imminent suicide risk. Some people may rehearse aspects of suicide attempt and this needs to be taken extremely seriously.

Suicide attempt

Any purposeful action that is associated with an implicit or explicit intent to die, regardless of the objective lethality of the method. History of a previous suicide attempt increases risk for death by suicide.[4] The term parasuicide is ambiguous and the authors of this topic recommend that it not be used.

Self-harm

Intentional physical harm by self-injury or self-poisoning, regardless of motivation.[5]

Non-suicidal self-injury (NSSI)

Some people manage distress by self-harming, especially self-cutting, and report that their actions do not have suicidal intent.[6][7] However, reported intent of previous episodes of self-harm does not appear to correlate with future self-harm or suicide.[4][8][9][10] This may relate to conscious or subconscious under-reporting by the individual, or it may be because the pathophysiology of self-harm is the same, regardless of previous conscious intent. Furthermore, self-harm method switching also occurs routinely, and while it may not be the original motivation, suicide intent can develop over time.[11]

Pathophysiology

Classification