article on suicide and BPD

[Guest guest]

Copyright 2003 Gale Group, Inc.

IAC (SM) Newsletter Database

Copyright 2003 Copyright by President and Fellows of Harvard College. All

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Harvard Mental Health Letter

May 1, 2003

SECTION: No. 11, Vol. 19; Pg. 0 ; ISSN: 1057-5022

IAC-ACC-NO: 99410755

LENGTH: 2431 words

HEADLINE: Confronting suicide Part I - Vulnerable people and perilous

circumstances.

AUTHOR-ABSTRACT:

THIS IS THE FULL TEXT: COPYRIGHT 2003 President and Fellows of Harvard

College on behalf of Harvard Health Publications (Harvard)/Staywell. Inc.

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Suicide has been treated as a moral and legal dilemma and a topic of

philosophical contemplation. It has been exalted as martyrdom, condemned as a

sin, and proclaimed the ultimate existential choice. It is the climax of many

great works of drama and fiction. But in everyday life, suicide is rarely

material for art or philosophy. The mental health system is the institution

and mental health professionals are the people most often called on to

respond to suicidal thoughts, threats, and behavior. It is the most serious

psychiatric emergency and one of the most difficult problems encountered in

the treatment of mental illness and emotional disorders.

Demography of suicide

Reliable statistics on suicide are not easy to compile because reporting and

records are neither thorough nor candid. Family members and others have many

reasons - emotional, financial, and legal - for denying that a death is

suicide. Official sources are not always able to distinguish suicides from

accidents in cases like drunk driving and drug overdoses. And cultural stigma

can prevent any acknowledgment of suicide. The reported suicide rates in many

Latin American and Muslim countries are extremely low, but few believe they

are accurate. Worldwide, official numbers may be 50% lower than the true

figures.

Even given these limitations, we know that suicide is surprisingly common. It

is, according to the World Health Organization, the world's 13th leading

cause of death. In the United States, there were nearly 30,000 suicides in

2000. Suicide was the 11th most common cause of death, accounting for 1.2% of

all deaths. The 2000 suicide rate of 10.6/100,000 represented a fall of 10%

since 1995. For comparison, the homicide rate was about half that, and the

accidental death rate was three times as high.

In this country, more than 80% of suicides are men. Whites are twice as prone

to suicide as blacks and Hispanics, and single men twice as suicide-prone as

married men. Single women are more likely to commit suicide than married

women only up to age 45. Divorced and widowed men have high suicide rates at

all ages. Divorced women also have high rates at all ages, but only young

widows are more vulnerable than average.

The risk of suicide rises with age, and that rise is due to one group - white

men over 50, who are 10% of the population but account for 30% of suicides.

The suicide rate in white women and in African Americans of both sexes

remains steady or falls with age. The age distribution is changing, though.

People ages 15-24, who once accounted for 5% of suicides, now account for

14%. It is the third leading cause of death among American adolescents.

Men who report sexual relations with men have very high suicide rates when

young, but the significance of that fact is difficult to interpret. The true

number of gay men is not known, and not all men who have sexual relations

with men describe their orientation as homosexual.

In the United States, although not in other countries, most suicides (an

estimated 60%) are by gunshot. The suicide rate is correlated with the

proportion of households owning firearms - highest in Nevada and Montana,

lowest in New York and New Jersey.

Risk factors

Epidemiologists study large numbers of people who commit suicide to discover

common risk factors - characteristics of the physical or social environment,

behavior, or genetic traits that are statistically associated with a higher

than average rate of suicide. By acting to reduce some of these risks, we can

lower the number of suicides in the population as a whole.

To uncover the patterns of thought, feeling, and behavior that distinguish

people who commit suicide, researchers also use a method called psychological

autopsy, which involves examining medical and psychiatric records and

interviewing relatives and friends of the deceased. They usually find an

underlying long-term vulnerability and an immediate source of stress.

Psychological autopsies - and interviews with people who attempt suicide -

indicate unmistakably that psychiatric disorders are the most common form of

vulnerability. Ninety percent of people who commit suicide have a psychiatric

disorder. Mood disorders are the most common; up to 60% of people who commit

suicide have major depression or bipolar disorder. The falling rate of

suicide in the 1990s may be due to improved understanding of depression and

its treatment.

Other psychiatric disorders associated with suicide are alcoholism and other

addictions (40% of suicides), schizophrenia (6%), and anxiety disorders

(10%). Nearly 50% of people who commit suicide also have a personality

disorder. In borderline personality disorder, suicidal thoughts, threats, and

attempts are among the defining symptoms, along with instability in moods and

personal relationships, irrational anger, and impulsive behavior.

Genetics, serotonin, and suicide

A family history of suicide and suicide attempts greatly raises the risk of

suicide. The child of a person who attempts suicide has six times the average

risk of committing suicide. According to one estimate, 13% of people with an

identical twin who commits suicide take their own lives, compared to less

than 1% of fraternal twins. The adopted-away children of a biological parent

who commits suicide have a far higher suicide rate than their adoptive

brothers and sisters.

This apparent hereditary vulnerability, which is partly independent of

hereditary vulnerability to psychiatric disorders, may be the product of

genes that regulate the synthesis, release, and breakdown of the mood- and

impulse-regulating neurotransmitter serotonin. Low serotonin is associated

with a tendency toward rage and impulsive behavior. One study found that

among people hospitalized for suicide attempts, those with low levels of the

breakdown product of serotonin in their spinal fluid were 10 times more

likely to kill themselves within a year. People who carry a certain variant

of the gene that encodes the production of one type of receptor for serotonin

have twice the average rate of suicide. Another gene that has been associated

with suicide regulates the production of the enzyme that degrades serotonin.

There is some evidence that the most deadly suicide attempts are made by

people with low serotonin activity in the prefrontal cortex - the seat of

planning, judgment, and inhibition. One study found that in the brains of

depressed suicidal patients, this region contained an unusually high number

of receptors for serotonin, as though they were trying to compensate for a

shortage of the neurotransmitter. Another study found that impulsively

aggressive persons with personality disorders do not activate the normal

inhibitory regions of the prefrontal cortex in response to serotonin.

The gene studies are preliminary, and serotonin levels are not simply

hereditary but vary with a person's state of mind. Although we are not soon

going to have genetic or blood tests for suicidal tendencies, such research

does provide evidence for biological origins of suicide.

A combination of two psychiatric disorders - especially alcoholism or drug

addiction along with a personality disorder or schizophrenia - raises the

risk for suicide by more than the added effects of the two disorders.

Suicidal situations

Losses, failures, and disappointments of many kinds, real or imagined -

bereavement, divorce, unemployment, and severe episodes of depression,

anxiety, or psychosis - lead vulnerable people to perform desperate

self-destructive acts. Social disruption increases vulnerability, so victims

of violence and people who have been imprisoned or jailed have higher suicide

rates. Isolation is also a danger, especially in older white men. Suicide

rates tend to fall during natural disasters and other crises that evoke a

community spirit.

Intoxication is an important cause of suicide even in people who are not

alcoholics or addicts. Alcohol relieves anxiety, impairs judgment, and

loosens inhibitions. In one study of 50 people who attempted suicide, 14 had

blood alcohol levels suggesting intoxication. In a study of completed

suicides, one-third had high blood alcohol levels. Several studies have found

that the suicide rate in 18- to 21-year-olds rises when the legal drinking

age is lowered. Cocaine and amphetamines can create another formula for

suicide - paranoia and heightened energy. Heroin addicts may take overdoses

with suicidal intent.

In depressed people, suicide is associated with severe anxiety, insomnia, and

rapidly cycling bipolar (manic-depressive) disorder. It's most common in the

first episode of severe depression. Soldiers with post-traumatic stress

disorder are most likely to commit suicide if they feel guilty about their

actions during combat.

About 10% of schizophrenic patients commit suicide, mainly in the early

stages of the illness or the first weeks after discharge from a psychiatric

hospital - especially if they have high intelligence and high expectations.

It is not clear whether the act is provoked more often by hallucinations and

delusions or by despair over the illness.

Alcoholics are especially likely to kill themselves in a crisis - for

example, an arrest or the loss of a husband, wife, or job. One study found

that 50% of alcoholics but only 15% of depressed patients who committed

suicide had lost a husband or wife to death or divorce in the year before

they died.

Resources

American Association of Suicidology

4201 Connecticut Ave. N.W.

Suite 408

Washington, DC 20008

www.suicidology.org

Promotes research, public awareness, and education for professionals and

volunteers. Publishes a quarterly journal and newsletters.

American Foundation for Suicide Prevention

120 Wall St., 22nd Floor

New York, NY 10005

www.afsp.org

A nonprofit organization that supports research and treatment programs.

Depression and Bipolar Support Alliance

730 North lin St., Suite 501

Chicago, IL 60610

www.dbsalliance.org

Provides advocacy, support, and information for people at risk and their

families and friends.

National Hopeline Network

(SUICIDE)

www.hopeline.com

A 24-hour crisis hotline; also publishes the journal Preventing Suicide.

National Institute of Mental Health Suicide Research Consortium

6001 Executive Blvd.

Room 8184, MSC 9663

Bethesda, MD 20892

www.nimh.nih.gov/research/suicide.cfm

Administers research grants and disseminates information about suicide.

In the elderly, suicide is associated with physical illness, family conflict,

financial troubles, and recent bereavement. In youth, it is associated with

drug and alcohol intoxication, recent deaths in the family, trouble in school

or with the law, and very often, the breakup of a romance. A psychological

autopsy comparing 120 adolescents who committed suicide with matched controls

found that nearly half of the suicides had suffered a recent personal loss,

humiliation, or rejection. For boys (although not girls), the most common

incident was the end of a love affair.

Contagious suicide?

The media sometimes give intense publicity to " suicide clusters " - a series

of suicides that occur, mainly among young people, in a small area within a

short period of time. Sometimes the media themselves are blamed for

glamorizing suicide and provoking imitation. Others think that the contagion

comes from relatives, neighbors, schoolmates, and friends. This is a

controversial question. Copycat suicide does not fit the formula of

underlying vulnerability plus severe stress, and many experts believe that it

is rare. Some recent research (see Harvard Mental Health Letter, March 2002)

suggests that the suicides of relatives and acquaintances are not a model

and, if anything, are more likely to serve as a deterrent.

Thoughts, threats, and attempts

Eight out of 10 people who commit suicide give some sign of their intentions

- suicidal ideation (expressing a wish for death, talking about suicide,

openly planning suicide), suicide threats, and suicide attempts. About

two-thirds discuss the matter with someone in the last few months before

their death. In the National Comorbidity Survey, conducted in the early

1990s, 13% of 6,000 people responding had had thoughts of suicide, 4% had

made a suicide plan, and 5% had made a suicide attempt.

Figures on attempted suicide are obviously less reliable than those on

completed suicide. Even the definition of a suicide attempt is not always

clear. We don't know how many people who swallow a bottle of aspirin or

Tylenol - probably the most common kind of failed suicide attempt - really

expect to die. Still, a suicide attempt is by far the best available

indicator of increased suicide risk. An estimated 20%-60% of people who kill

themselves (the range is wide because the data are so poor) have made a

previous attempt, and about 10% of people who attempt suicide will commit

suicide within 10 years.

Although men are far more likely than women to kill themselves, women appear

to attempt suicide much more often. One explanation is that men, especially

older men, act with more deliberation, use more reliable means - gunshots as

opposed to wrist-cutting or drug overdoses - and are more likely to be

isolated, making rescue impossible. Another possibility is that often no one

learns about a man's failed suicide attempt. Men usually have more difficulty

than women talking about feelings or accepting help. They are less likely to

admit to a suicide attempt or to seek treatment afterward.

To be continued

References

American Academy of Child and Adolescent Psychiatry, " Practice Parameter for

the Assessment and Treatment of Children and Adolescents with Suicidal

Behavior, " Journal of the American Academy of Child and Adolescent

Psychiatry. (July 2001): Vol. 40, No. 7, Supp., pp. 24S-51S.

Institute of Medicine. Reducing Suicide: A National Imperative. Washington,

D.C.: National Academies Press, 2002. www.nap.edu/catalog/10398.html

s DG, ed. The Harvard Medical School Guide to Suicide Assessment and

Intervention. San Francisco: Jossey-Bass,1999.

Jamison KR. Night Falls Fast: Understanding Suicide. New York: Knopf, 1999.

For a more complete list of references, see www.health.harvard.edu/mental

IAC-CREATE-DATE: March 31, 2003

LOAD-DATE: April 02, 2003

[Guest guest]

One thing I have seen in statistics, but no explanation is given for

it, is that France as a much higher suicide rate than the USA, but a

much lower murder rate. The sum of the murder and suicide rates is

comparable for the two countries.

The difference is so great that if the USA had France's murder rate

they would say they had solved the murder problem, and vice versa.

I suspect that a big factor is cultural: in France people are more

introverted, less outgoing. I don't think this represents

personality differences, just different norms of expressing oneself.

Anyway, with such an enormous difference, some research on this could

be very enlightening.

- Dan