Over the ages, people have tried to exercise their "right" to life or death as regards their own existence. During various historical eras, in various geographic areas, conceptions on suicide have been influenced by cultural, spiritual, and psychological factors.
In primitive societies, even in our times, sacrificing the life of those members of the tribe who could become a burden for the rest of the community, due to illness or old age, was welcome. Such examples were cited in connection with Eskimo tribes, Samoan tribes, as well as the Indians of North America and Canada. This type of behaviour was subject to terminological clarification in the work of Durkheim (1897), who classified it as altruistic suicide.
Suicide--a recurring event through the ages
An overview of the most important moments in the millennial history of suicide highlights changes in the attitude towards this type of death in various cultures and in different periods of civilization. World-renowned suicidologists and thanatologists (Farberow 1975; Schneidman 1985; Van Hoof 1990; Stillion 1996) gathered the most significant data about autolysis in the history of civilization. This self-destructive behaviour can be studied based on the examples of suicide offered by the Old Testament, suicide in ancient Greece and Rome, suicide in the early Christian era, suicide in secular society, and suicide in countries belonging to Eastern civilizations (Toynbee 1934).
In ancient times, Jews condemned suicide, hence in the Bible, the Old Testament recounts only four cases of suicide, committed in circumstances related more or less to war situations (Samson, King Saul and his servant, Achitophel). The only reported case of suicide in the New Testament is that of Judas Iscariot. The verbal expression for the suicide victim in Hebrew is "the one who knowingly destroys himself."
In Greece, in ancient times, suicide was forbidden. The corpse of the suicide victim was deprived of the funeral rites and his/her right hand was cut off and buried separately. Nevertheless, the Stoics were declared partisans of suicide.
In ancient Rome, only during the Decadence did suicide become more frequent, perhaps also due to Seneca's influence: "to think about death is to think about freedom." This behaviour was forbidden to slaves or Roman soldiers, whose life belonged to the state.
In India, since antiquity, under the considerable influence of Brahmanism, people often committed suicide during certain religious holidays. In Asia, in China for example, by suicide one aimed at perfection or demonstrated attachment to an idea or a master. For example, 500 of Confucius' disciples threw themselves into the sea in protest against the destruction of his books. Japan has cultivated for centuries a special code of honour, which has been perpetuated into our own time, containing, among other things, a particular technique of suicide in the ritual of sepukku (hara-kiri).
In Gaul and Germany, the tradition of suicide was closely related to the faith of entry into Valhalla. Widows sacrificed themselves on the grave of the husbands who died in combat (Makinen 1997).
The Dacian cult of Zalmoxis involved the consensual sacrifice ritual of the most valiant warriors.
Christianity categorically forbade suicide up to refusing the burial of those who transgressed this interdiction (Tyrode 1998).
In the fifth century, St. Augustine condemned suicide, considering this act more sinful than murderous, because he who commits suicide condemns his soul to the eternal torments of hell.
Thomas Aquinas (1225-1274) presented in his monumental work Summa Theologica three arguments against suicide. First, suicide is unnatural, violating the physical and biological laws governing the structure of human beings by the will of the Creator. The second reason relates to the losses suicide victims cause to the society to which they belong by avoiding civic duties and tasks, on the one hand, and, on the other hand, by setting a bad example for other people. The third reason derives from the suicide victims' failure to show respect and gratitude to God by refusing the most precious gift they received from the Creator, namely their own life. Based on these arguments against suicide, one can deduce further theological consequences with regard to the impossibility of the sinner to confess the sin and repent under the circumstances of having committed a fatal and definitive act. However, Thomas Aquinas offered an excuse for those who are not "in their right mind," meaning that a mad man who kills himself can be exonerated, which anticipates, by many centuries, the introduction of the notion of "pathological suicide" (Moron 1987).
In the 12th and 13th centuries, the Cathar heresy, among others, incited "the Perfects" to commit "sacred suicide." The repression was violent: their bodies were exposed to public opprobrium in markets and at the crossroads.
During the Renaissance new defenders of suicide appear in the name of individual freedom.
In the 17th century, John Donne, English clergyman, considering that the arguments of the Church against suicide are too rigid, secretly wrote a book, Biathanatos, which he did not publish during his lifetime. The divergence between his opinion and that of the Church focuses on the inclusion or non-inclusion of suicide in the category of mortal sin. Donne is the first author to suggest that in the human nature, alongside the life instinct that contributes to survival, there is also the death instinct. Thus, he is the first who, long before Freud, developed the concept of thanatos as a natural human desire to die, as an attraction to death equally strong as that to life. To this end, he brings as argument the example of group suicides in different parts of the world (centurions in India, North American Indians, Jews of Massada).
With the beginning of the Reformation, Protestantism ruled against the legitimacy of suicide. Martin Luther links committing suicide to the violation of the 5th Commandment: "We will not shorten or injure our lives, but we will consider it as a gift from God and we will use it for the glory of God."
Enlightenment shifts the conception on suicide from a religious and moral perspective to a pathological one, highlighting the presence of spiritual or mental disorder as the cause of self-aggression.
The spirit of the Encyclopaedia troubles once again the conceptions on suicide. Thus, for d'Alembert or even Diderot, suicide becomes a kind of pledge of individual freedom and the publication in 1774 of Goethe's novel, The Sorrows of Young Werther triggered an actual trend of suicides in young people, not only in Germany, but also in other parts of Europe.
The influence of Enlightenment philosophers was felt in the change of attitude to the autolytic behaviour, with the legislator gradually abandoning the practice of bringing criminal charges against such conduct. "The decriminalisation" of suicide in Europe began in 1786 in Tuscany, continuing in France (1791) and Prussia. The Napoleonic Wars then spread this decriminalization throughout Europe, in the Netherlands, Norway (1842) and Germany. The countries in Eastern and Southern Europe and the UK only changed their laws in this field in the twentieth century.
In the 19th century, the number of suicides increases significantly due to social, cultural, economic, demographic factors. Both in England and in America suicide is organized in clubs that spread concepts which are not far from such initiatives that, today, campaign for euthanasia.
Collective suicide has always been an event difficult to interpret, sometimes regarded by contemporaries as an act of heroism or, conversely, of cowardice. One such event happened at Masada, in the year 73, when 960 Jews, besieged by the Romans, took their own lives. The plea of the leader, Eleazar, is eloquent: "The greatest desire of our enemies is to get us alive. We know that, no matter how great is our resistance, we can not avoid being taken by assault tomorrow; but they can not prevent us from gaining on them through a noble death and end our days together with our loved ones ... Who can be such an enemy of his country and so cowardly as to not see it as a great misfortune to be still alive and not want the happiness of the dead before watching this holy city all in ruins and our sacred temple completely destroyed by the profanatory blaze?" (apud Minois 1995).
Important events in the universal history of suicide (according to Stillion & McDowell 1996) The event and the Historical description approximate date 1000 BC Death of Samson and Saul Reported without comment. Possible causes: self-punishment, justification of faith and God, reaction to the death of children, despair, fulfilling the prophecy. 399 BC Death of Socrates Honourable death: rational control over death. 350 BC Proclamation of Aristotle Suicide is established as illegal. 300 BC-300 AD Development of Developing the concept Greek and Roman Stoicism of rational suicide. 33 AD Death of Judas Iscariot Reported without comment. Possible causes: guilt, remorse, self-punishment, fulfilling the prophecy. 65 AD Death of Seneca and Reference to the concept his wife Paulina of rational suicide. The quality of life matters more than its duration. 73 AD The mass suicide at Masada 960 defenders of Masada chose to commit suicide rather than surrender. 300-400 AD Martyrdom became a purpose for fervent Christians. 400 AD St. Augustine Censorship of martyrdom condemns autolysis to secure the future of Christianity. 533 AD Council of Orleans Denies the burial ritual for suicide victims, who were considered criminals. 563 AD Council of Braga Denies the burial ritual for all suicide victims. 590 AD Council of Antisidor Adds a punishment system for suicide victims. 693 AD Council of Toledo Adoption of the excommunication penalty for those who commit or attempt to commit suicide. 1265-1272AD Thomas Aquinas Presents arguments against published Summa Theologica suicide, which is considered a sin. 1284 AD Synod of Nimes Denies Christian burial for suicide victims. 1647 AD John Donne published Raises the question of whether Biathanatos killing oneself is always a sin. 1670 AD Secular laws were Suicide was considered a triple promulgated against suicide crime: murder, high treason and heresy. 1763 AD Meridan published a Introduces the concept medical book on suicide of suicide as disease. 1838 AD Esquirol published a Adds arguments to the chapter describing suicide as interpretation of suicide a symptom of mental illness as disease. 1897 AD Durkheim published Starts studying suicide as Le Suicide a social phenomenon. 1800-1900 AD The emergence of Posits the freedom and Existentialism responsibility of the individual (Kierkegaard, Nietzsche, etc.) for the suicidal act. Suicide is seen as just another decision for the individual to take in life. 1917 AD Freud published Mourning Establishes the modern concept and melancholia according to which suicide is seen as evidence of mental illness. 1958 AD The first suicide Based on the idea that suicidal prevention centre in Los Angeles thoughts are fleeting and crisis intervention is curative.
Collective suicide may also occur through manipulation (Sorrow & Lester 1993). A revealing example of mental contagion occurred in 1978, in Guyana, where hundreds of people from a religious cult led by Jim Jones committed suicide by a ritual of collective poisoning with cyanide on the orders of their leader. The manipulation of hundreds of people was exercised by this highly influential leader who actually did not commit suicide, but had the power to induce firm convictions to the group of people who had followed him from the U.S., individuals who lost their own personality and allowed themselves to be led by the delusions of their leader. Suicide was ordered by a specific signal, parents had to first kill their own children, and then to take their own dose of poison.
History of suicidology as a science
First to study the issue of suicide were the French authors Esquirol, Achille-Delmas, Deshaies.
The French Psychiatric School, whose first representative was Esquirol, describes suicide from the point of view of "the alienist," maintaining that those who commit this act suffer from a mental illness (Scheps 1998). Esquirol: "Suicide is a phenomenon resulting from a number of different causes; this phenomenon is not characteristic of a disease." Brierre de Boismond: "If there is a madness suicide, it can only be a monomania." The general conclusion of these alienists is that suicide is not a distinct type of insanity.
The most important study of the nineteenth century is undoubtedly Emile Durkheim's Le suicide. Etude sociologique, published in Paris in 1897. Durkheim showed that there is no correlation between the frequency of psychopathological states and suicide. To support his assertion, he quotes the famous psychiatrists of his time, namely, Falret, Esquirol, and Brierre of Boismond.
As a sociologist, Durkheim wanted to show that autolysis is an indicator of the relation between society and social consciousness and also that society is external and restrictive in relation to the individual. His work, Le Suicide, is divided into three parts:
* Book One: Extra-social factors;
* Book Two: Causes and social types;
* Book Three: About suicide as a social phenomenon in general.
In the study of social factors, Durkheim classified autolytic behaviour into three distinct categories:
* Egoistic suicide due to the hypo-integration of the individual in the community or society. The author emphasizes in this context that the suicide rate is higher in Protestant countries compared to the Catholic ones, explaining this phenomenon by the dissolution of the religious community. As far as the family life is concerned, there is a lower suicide rate for married couples compared to singles. Therefore, the frequency of suicide varies inversely to the degree of integration (family, religious, political) of the social groups to which the individual belongs.
* Altruistic suicide derives from the fact that the individual is hyper-integrated in society. Death is seen as a duty. Cited here are the cases of the North American Indians, the Japanese, the Gauls, the Celts, and some populations of Tibet and Siam. There is also a type of altruistic suicide in military communities.
* Anomic suicide characterizes modern societies, where economic, political, religious, and, ultimately, moral imbalance favours the propensity to autolysis. Durkheim exemplified with economic crises that lead to a state of material instability, as well as a state of family instability, hence the impressive increase in the number of divorces under the circumstances of a decline in the economic status of the family. The deviant states of bourgeois society--crisis and opulence--are considered by Durkheim the main causes of suicides. The overstraining of individuals by exaggerating the competitiveness of social relations, and not only, causes restlessness that leads to suicide.
Addressing suicide incidence according to race, the author also mentions, tangentially, certain traditional methods of autolysis in the Japanese and Eskimos, which are related more to their practicing groups than to racial differences. With regard to heredity, considered as a predisposing factor for autolytic behaviour, Durkheim states that in the families in which there is a higher incidence of autolytic behaviour, the main cause is related more to the mental contagion factor, rather than heredity.
Durkheim's hypothesis on society's involvement in determining the autolysis has not been refuted yet, as the author claims that the suicide rate depends on three factors:
* the nature of the individuals that make up society;
* the nature of social organization;
* the events that disturb the function of collective life (anomic states).
In other words, "at any given moment the moral structure of society establishes the contingent of voluntary deaths."
In France, in the twentieth century, Maurice Porot took over Durkheim's research and introduced psychological tests (TAT, Rorschach) in the study in order to identify the specific traits of the suicidal personality.
Freud published two important works for understanding suicide as a mental illness. The first is Mourning and Melancholia (1917), and the second, The Ego and the Id (1923). Freud develops not only the concept of aggression towards the Ego, but also the concept of Thanatos to describe the death instinct.
After the Second World War, suicidology emerged as a discipline in its own right within the field of thanatology. The most prominent personality in the field is Schneidman, thanatology professor at the University of California, who, in 1958, founded the first suicide prevention centre in the U.S.--Los Angeles Suicide Prevention Centre.
In Europe suicide prevention centres were already operating in countries such as Austria, Great Britain, and France, but the American method of intervention in crisis soon became a model for addressing suicidal behaviour in the wider context of existential crisis.
On the nature and cause of the suicidal process
The causes of suicide are, even nowadays, an important point of debate in various theoretical attempts to explain the psychopathological or psychological phenomena that lead the person towards the fatal or nonfatal action of deliberate self-harm.
The medical model seeks a linear, cause-effect explanation between the various psychopathological disorders, their degree of severity, and the occurrence of suicidal behaviour.
The psychological model seeks explanation in the type of interpersonal relationships, with emphasis on early relationships (of attachment, especially with the mother and, subsequently, with the whole family) (Ainsworth 1969; Bowlby 1998) and on the pathological relational mechanisms that do not allow for the satisfaction of the basic psychological needs and which will translate into delays in the psycho-emotional maturation of the individual, involving dysfunctions in the manifestation of impulses and instincts.
The biopsychosocial model seeks to explain psychiatric disorders based on genetic predispositions, which add factors of psychological and social vulnerability.
From semantic clarifications to clinical definitions
Definition of suicide
Suicide means the person's desire not to live tomorrow. How can such an aspiration or idea occur in the mind and soul of a human being meant for life, with an instinct of self-preservation capable to make it face the greatest dangers?
The importance of suicide as a public health issue is persistently underestimated, although in most European countries death by suicide is among the top 10 causes of death.
Suicide, as the main auto-aggressive behaviour, was defined by many authors along time (Ionescu 1973). Among the most famous definitions, let us quote that offered by the French sociologist Emile Durkheim (1858-1917): "The term suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows that will produce this result."
A genuine exegesis on definitions given to suicide was provided by Douglas, in The Social Meanings of Suicide, which reveals the presence of six criteria in properly defining suicide, namely:
1. Initiating the act;
2. The act itself, that causes death;
3. The desire or intention of self-destruction;
4. The loss of will;
5. The motivation to die;
6. The awareness of the fatal potential of the act.
A simple and concise definition is given in the 1973 edition of the Encyclopaedia Britannica (article by Schneidman): "Suicide is the human act of self-inflicted, self-intentioned cessation."
The definition adopted by WHO reads: "Suicide is the act by which an individual seeks to physically destroy itself, with the intention more or less genuine of losing their life, being aware, more or less, of its reasons."
Suicide itself remains an act of conduct difficult to identify within the auto-aggressive behaviour, especially in children and teenagers. Its success may not be the authentic expression of suicide, just as a failed suicide may be quite different in meaning from attempted suicide.
Definition of parasuicide
The first problem arising in the discussion of nonfatal auto-aggressive behaviour is that of terminology. Traditionally, the term "attempted suicide" was used for decades and gave rise to confusions. As early as 1897, Durkheim discussed attempted suicide as follows: "Attempted suicide can only be defined as a failure to achieve actual death."
In Shneidman's view (1985), attempted suicide is a term that should be reserved only for those rare cases of lethal intent in which the individual survives despite all circumstances. In fact, until 1950, few authors made a clear distinction between "successful suicide" and failed attempt. In 1952 Stengel identified epidemiological differences between the two groups and, to better distinguish between the two forms of behaviour, he proposed using the term "attempted suicide."
After 1960, it was put forward that suicidal intent should not be regarded as essential. Kessel proposed using the terms deliberate self-poisoning and deliberate self-injury instead of attempted suicide.
In 1970, in the monograph entitled Parasuicide, Norman Kreitman introduced the term parasuicide. A comparative study of the defining characteristics of suicide and parasuicide, conducted by Kreitman, is presented in the following table:
Characteristics of suicide and parasuicide (apud Kreitman 1970): CHARACTERISTICS PARASUICIDE SUICIDE Incidence 20-30 times rate Relatively increase in the stable rates last 20 years Seasonal Inconclusive High rates in April, variations May Age Young > old Old > young Gender Women > men Men > women Social class Lower > middle Upper > middle > upper > lower Marital status Frequent in divorced Frequent in divorced, and singles widowed and singles Isolation Not associated Associated Urban/rural Frequent in urban Frequent in urban environment areas; associated areas; associated with poverty with social anomie Methods Peaceful: BZD, Violent methods, analgesics poisons, barbiturates Mental illness Loose correlation Tight correlation with depression with depression Alcohol dependence Associated Associated Personality Sociopathy Sociopathy, cyclotymia
Parasuicide in Kreitman's description comes to be understood as any case of nonfatal injury or overdose. Acute alcohol poisoning is excluded from its scope. The introduction of the term "parasuicide" radically restricts the area of the term "attempted suicide," which remains limited to extremely rare cases. A suicidal episode highlights the precariousness of the inhibitory mechanisms against aggression of an individual who gives in to any self-harming suggestions. It is also known that parasuicide victims who come to commit suicide are generally people who accumulated a large number of parasuicidal episodes before their death, although only occasionally do they have a clear evolution of increasing severity.
In 1979, Morgan suggested the introduction of the term deliberate self-harm to designate both attempted suicide by poisoning with drugs or chemical substances (deliberate self-poisoning) and self-injury (deliberate self-injury).
Non-pathological suicide versus pathological suicide
The interest shown by WHO in the issue of suicide was shown in the increasing number of congresses and conferences for prevention, as well as in setting up a new direction in medical research, suicidology, which includes not only psychiatrists, but also physicians, medical examiners, psychologists, sociologists, and lawyers.
The many contemporary lines of research conclude that there are two fundamental types of suicide, differing in motivation: nonpathological suicide and pathological suicide.
Rational suicide. Non-pathological suicide
Suicide falls under the category of rational suicide when the act seeks to avoid suffering, or if the act is consistent with the beliefs of the society to which the person belongs, or is an expression of remorse, as in expressive suicide.
The first category, that is, avoiding suffering and loss of human dignity by living moments of atrocious suffering and decrepitude, is found in relation to the avoidance of pain caused by terminal stages of cancer, AIDS, paralysis. Studies in cancer patients have demonstrated that most people who committed suicide have shown low tolerance for pain and the discomfort of cancer therapy. At the same time, they have a desire to control events until the end and prefer, by choosing voluntary death, to avoid situations of degradation or unconsciousness (Farberow 1961).
There is also the case of rational suicide in people deeply involved in the couple relationship, who decide not to survive the death of their spouse (see, in Romania, the death of the artist Irinel Liciu). This suicide out of love, following the example of Romeo and Juliet, is quite common in Japan.
The first category also includes "euthanasia" suicide or suicide in severe sociogenic situations comprising not only severe incurable diseases, but also mutilations, abandonment of the elderly, inadequacy, or emigration. It is also found in other situations such as: loss of parents or children, or in professional or emotional failures, unrecoverable material losses.
The second category of non-pathological suicide refers to the presence of strong beliefs in certain geographical areas (see Scandinavian mythology concerning the entry into Valhalla or the Dacian belief in the cult of Zalmoxis), which would be consistent with the collective unconscious the suicide victim shares.
Siegel states that rational suicide is the act fulfilled by a perfectly lucid person, master of all his or her mental faculties, that is, in absence of mental illness or severe stressful conditions.
Non-pathological suicide is based on the premise of freedom to choose a solution from among several, including the choice of voluntary death as a solution to one's personal destiny. The choice is free, conscious, and rationally motivated. This rationale of getting out of a certain extreme situation is difficult to understand for an outside observer.
There is also the "sacrifice" or "protest" suicide motivated by moral, religious, political beliefs, and "the cultural shock" of people living in an atmosphere of sensory, cognitive, or decisionmaking overload, which contributes to the feeling of isolation and frustration.
According to Resnik (1980), rational suicide is included within the broader notion of crisis, a condition in which a person is forced to confront situations of distress, not being able, at that time, to avoid or to solve the problem by their means and capabilities.
It is estimated that a crisis may take up to 6-8 weeks, its most vulnerable victims being psychopaths, criminals, psychotics. A state of "permanent crisis" characterises addicts.
Statistically, pathological suicide accounts for the highest number of cases. Colonna argues that "suicide is the only actual risk of mental illness, the context and how it is committed are characteristic to the person and the disease." Pathological suicide is classified into:
--psychotic suicide: first place is occupied by suicide occurring in severe depression (Hamilton 1989) (with a 10-15% rate in men and a 3.5% rate in women);
--suicide in people with personality disorders, common in borderline or antisocial personality disorders;
--suicide in people addicted to alcohol or psychoactive substances;
--suicide in case of neurotic disorders, especially those comorbid with depression.
The characteristics of modern life such as depersonalization, the fast pace of work progress, increased level of noise, neglect of emotional life, and spiritual exhaustion trigger anxiety and panic chain reactions which, increasing emotional tension, cannot be stopped, hence suicide can appear as the only way out of the stressful situation.
Phases of suicide
Suicidology, a branch of forensic medicine, concerns both the medical examiner and the psychiatrist. Its object of study is suicidopathy, considered as a separate entity which evolves in three distinct and necessary phases or stages.
Suicideation is the incubation phase, the mental phase of motivation research during which the subject raises the question of death and need to die. It is triggered by one or more pathological (social adjustment difficulties, decreased or increased social group cohesion) or psychopathological causes. These determine, at any intra-psychic level, the formation of a motivational attitude corresponding to the preparation of the suicidal act, with the ultimate cause being the moment of conflict.
Suicidaction is the transition phase from abstract, conflicting images to the stage of successive, concrete preparations, by searching forms and methods of self-destructive behaviour. This phase is influenced by certain circumstances pertaining to the individual or society. In this sense, the psychopathological circumstances (chronic alcoholism, drug addictions, psychopathies, reactive states), somatogenic circumstances (birth defects, disabilities, severe, incurable somatic diseases) and sociogenic circumstances (proselytism, social and legal conflicts, sociopathies) should be considered. This phase sees a marked and progressive increase in the state of intra-psychic stress up to the paroxysm, when it "explodes" as a psychogenic reaction, at which time the individual adopts "the decision" to commit suicide. It is the time of "self-destructive explosion."
Traumatisation is the phase of implementation of the preconceived self-destructive arrangements or the act itself, whether or not successful, that is, death. Important at this stage of suicidal behaviour are the methods used and their effect. Effects can be psychopathological or specific (completed suicide, attempted suicide, suicidal blackmail) or social and nonspecific (egoistic suicide, altruistic suicide, anomic suicide).
Methods used in suicidal behaviour
In suicide, self-harming methods fall into three categories:
* Traumatic methods: weapons (knives, blades, etc.), firearms (pistol, rifle, explosives), precipitation (defenestration, plunging), vehicular impact (train, car), burning, caustic (caustic soda, acids, etc.);
* Asphyxia methods: hanging, strangulation, suffocation, drowning, carbon vapours, gas, electrocution;
* Toxic methods: poisons (arsenic salts, strychnine, cyanide, belladonna etc.), drug overdose (Bancroft et al 1979).
There are differences between cultural areas in terms of preference when choosing self-harming alternatives. In France, one third of suicides are carried out by hanging, one fourth by drowning and one fifth by firearms. Conversely, in Nordic countries (Sweden, Norway, Denmark) the infrequency of drowning was observed. In China, opium and arsenic salts poisonings dominate. In Japan, the traditional suicide, "hara kiri", tends to be replaced by modern methods, such as firearms. As regards the modern trends of self-destructive behaviour, in relation to increased drug use and abuse, drug addiction can be included in the category of passive self-destructive behaviours.
There are also seasonal variations in the preferential use of a method, as follows: winter poisoning; summer--drowning (Maldonaldo & Kraus 1991). In some countries even regional differences were recorded. Geographical determinism indicates an increased number of suicides in large cities compared to small localities and higher frequency in the lowlands compared to mountain regions (Kessel 1965).
As to the area chosen for committing the destructive act, statistics show that 44% of suicides are carried out at home, followed, in order, by frequented public places, rarely a hotel or at work etc. Literature emphasized the complex role of political, social and economic events in the aetiology of the phenomenon. Sometimes suicide victims suffering from a somatic disease use methods related to the part of the body where the disease is presumed to be localized: stabbing in the abdomen in case of pain in the digestive area, bullet in the head in case of headaches.
The choice of method depends on many factors. Imitation, whether of an example read, heard or seen directly, plays an important role. Ease in the implementation of the act may also call for imitation, although, usually, most people use what is readily available. However, there are also very unusual, even spectacular suicide methods, such as the use of dynamite, imitating the suicide of the bonze monks from Vietnam by setting oneself on fire, entering the cage of ferocious animals at the zoo.
Differential diagnosis of death by suicide
In forensic practice, suicide involves two types of differential diagnostic problems: differentiation between suicide and murder and/or accident (Lettieri 1974).
Differential diagnosis between murder and suicide
Arguments for suicide:
a) place of the injuries. When using the knife, the most frequently chosen area is the precordial area or the neck. In case of firearms, the likely target is the head, primarily the right temporal region or the ear, in the case of the right-handed;
b) absence of external violence injuries, especially the lack of bruises. Look for violence and fight lesions in the aggression areas (neck, skull, genital areas) or the defence areas (forearm, wrists);
c) scars of previous suicide attempts;
d) clothing condition (most often ordered in cases of suicide);
e) desperate, but not very explicit documents or letters, testimony of the entourage, the unfavourable circumstances of the suicide victim;
f) the method used. Hanging is the least suspected of concealing a crime, because in practice it is very difficult to attach a body to a height without causing bruising. Conversely, strangulation is almost always a crime. Immersion, the drowning body, is practiced often enough to hide the murder behind the presumption of suicide.
Differential diagnosis between suicide and accident
Hunting accidents sometimes raise such problems when they may also involve an accidental discharge of the firearm. In these cases, the investigation of the victims is a genuine "psychological autopsy" as the death intention is often questionable. Psychoanalysts have described, in this respect, sub-intended deaths or suicidal equivalents (Arffa 1983).
Methods of self-harm in parasuicide
Besides "the final" result, several authors found a lack of delimitations between suicide and parasuicide. However, there are a number of characteristics specific to attempted suicide, starting from the self-harming techniques used up to the circumstances in which the autolytic gesture is carried out.
The techniques are as different as in the case of suicide. However, it is evident that a quarter of cases use medical means, employed, in most cases, by women. The rate is even higher for female teenagers.
The most frequently used drugs are barbiturates, simple or combined. There come, in order, minor tranquilizers (including benzodiazepines), antihistamines, neuroleptics, non-barbiturate hypnotics, various medications (especially painkillers, ganglioplegics).
Among the physical and chemical means, carbon monoxide ranks first, sometimes associated with a tranquilizer; then, immersion; far less common are the physically aggressive methods (wrist cutting, hanging, firearms, defenestration) or chemical (e.g. cyanide). Most frequently, methods are combined: barbiturates with other drugs, even with carbon monoxide or alcohol. However, death does not occur because, in most cases, the actual risk of the methods used is not fully known by the subject. Moreover, the progress of modern reanimation manages to counter the most dangerous harming agents used with the firm intention of causing death.
Circumstances or triggers play a role in the precipitation of the autolytic gesture. These are either objective facts particularly traumatic for the subject's life or, on the contrary, meaningless incidents, far from being proportionate to the seriousness of the gesture it triggers. A more prolonged investigation can demonstrate that the factor invoked at first "covers" a much deeper and less circumstantial motivation. Such triggers often serve as rationalizations that the subject uses to give a satisfactory explanation for his or her gesture. They include: mourning, unwanted and illegitimate pregnancy, political threats.
The presumption or presence of a disease with a serious or shameful prognosis (cancer or syphilis) rarely leads to suicide. A drastic weight loss diet is a factor in increasing the fragility of the psyche. Even some psychotropic treatments produce this effect, incriminating the pro-suicidal role of antidepressants.
What might be called "location pathology" plays quite a significant role: recent or future relocation, threat of eviction, insufficient or overcrowded space. Frequently, the attempted suicide is an expression of chronic marital discords. In singles, an emotional conflict has a strong echo, triggering the suicidal gesture as retaliation. Alcohol was cited by many authors as belonging to attempted suicide paraphernalia, as many subjects take courage by first ingesting alcoholic beverages. Many parasuicide victims also leave behind a "good-bye" letter, apparently to explain or excuse their gesture. In parasuicide, this form of warning is intended more to make the entourage (parents, fiance, spouse) feel guilty, in which case the suicide victims can be suspected of emotional blackmail intent.
The time chosen for attempted suicide is not without importance. In many cases, they choose the afternoon and evening hours (between 6 p.m. and 0.00 a.m.), unlike suicides (especially the melancholics), who commit suicide especially in the morning. Frequent suicide attempts during the weekend or traditional holidays were explained by sociologists in contrast with the atmosphere of leisure, which further deepens the feelings of frustration and social isolation felt by the suicide victim. The attempted suicide should also be analyzed in terms of the possibility / probability of discovering the subject in time. This is an important factor in the subsequent assessment of the sincerity of the gesture, hence the degree of intent and lethality of the self-harm. Characteristic for a quarter of parasuicide cases is the arrangement made with the purpose of being discovered early enough. In a third of such cases the time between performing the attempted suicide and the discovery is under an hour.
The suicidal process
The aetiology of suicide is complex and multiple, even in cases where the symptoms of mental illness are dominant. Psychopathology is often combined with psychological processes that can be even found in "normal" suicide victims who commit rational suicide (Bir] 2002).
There is always a common way for attempted suicide and completed suicide; their finality depends on the traumatisation method chosen (knowledge, degree of lethality) and, why not, on fate, the chance factor.
The premises of attempted suicide and suicide are practically the same. Decreased serotonin transmission, determined either genetically or by a mental illness (depression), which in conjunction with circumstantial factors that increase vulnerability, such as negative life events, and the diminishing down to disappearance of the social support network, represent the turning point that triggers the suicidal behaviour.
If, in the aetiology of suicide, the major causal factors are individual (psychopathological or characteriological), the pretext appears in all cases to be social. Marital status indicates a clear disproportion of self-destructive behaviours, predominant in singles. Two thirds of reported cases include those who had a stable job, a quarter those unemployed and one-eighth those who quit the job before the destructive act.
Characteristics of the suicidal process
The suicidal process can be understood starting from the concept of suicidal function, also found in normal subjects (Bourgeois 1988). Authors describe, among psychological processes: impulse toward action, the defensive process, the punitive process, the aggressive process, the oblative process, the ludic process, the domination of the death instinct.
* Impulse toward action ("le passage a l 'act"): this psychological process so often mentioned, but often obscure, depends, in turn, on the facilitation processes of inhibition or derivation. Favouring conditions occur by summing certain psychotraumatizing life events through convergence of the psychopathological states with stressors, in contrast to the joy of others, the emotional role of certain anniversaries etc. Inhibition of the transition to completing the act may be due to moral or religious beliefs, self-control, failure of a previous attempt. The derivation is obtained by projecting aggression on another person, by sublimation, by investing the pulsional energy in works of charity, artistic, scientific, social creations.
* The defensive process gives suicide the value of a reaction to defend the individual in relation to the critical, psychological or social situation in which he finds himself. In a more particular form, Adler sees the desire for death as a defence and revenge reaction over-compensating for a sense of inferiority.
* The punitive process corresponds to a sense of guilt and a conduct of atonement. At the same time judge and accused, the suicide victim subjects himself/herself to moral and social imperatives. The process may be subconscious, corresponding to a neurotic behaviour of failure.
* The aggressive process can take precedence. According to psychoanalysts (Freud, Stekel), suicide is the subconscious equivalent of the death of someone else, through identification with the "object" and turning the aggressiveness on their own person. In this respect, the close relationship of suicide to homicide was also discussed.
* The oblative process leads the suicide victims to a sacrifice ritual. It is said that oblativity characterizes both the weak and the strong.
* The ludic process is determined by playing with one's own life. A ludic consciousness works in certain suicide victims. "The funeral game" or "the death game" is seen especially in children or adolescents. On the contrary, "the sublime game" is observed in people with aesthetic sense.
* The death instinct contradicts the instinct of self-preservation. The decrease in vital force and abolition of the self-preservation instinct, especially under the influence of psychopathological processes are the most common explanations (Lazarescu 2002).
Functions of suicide
The function or finality of suicide is to emphasize the intentionality of the auto-aggressive gesture.
The "suicide" function is the first in the order of enumeration. The autolytic intention, although always present, is sometimes hidden, so that it escapes the consciousness of both the entourage and the subject himself. For this reason, some authors recognize as a "real" attempted suicide only that in which the self-harm intention is clearly expressed.
The hetero-aggressive function: from the very beginning of psychoanalytic researches, it was admitted that the suicidal act involves aggressiveness against someone. This aggressiveness is sometimes deliberate, conscious: revenge, desire to cause trouble for the person who is the subject of aggression, attracting people's reprobation on that person, causing remorse. The phrase: "Death for me, mourning for you!" expresses, essentially, the mix of hetero--and auto-aggressiveness. Moreover, researchers also investigated the role of a subconscious mechanism of identifying the object of this aggression, causing an aggressiveness which then turns on one's own self. What is interesting to study is the attitude of the subject in relation to the environment over which they can unconsciously exert aggression. The subject becomes aggressive towards a person or group of persons only to the extent that one of his needs is felt to be dependent on and "unsatisfied" by their attitude (Muchielli 1987).
The appeal function was well studied by Stengel (1958), who described it as the most important for the attempted suicide (parasuicide). The suicide victim feels unable to cope with a situation perceived as unbearable. This function is found in the autolytic behaviour as often as the auto-aggressive intention. The frequency of the appeal function led to the creation of those types of organizations that approach it by answering the phone calls of those who convey a "cry for help." The concept of appeal points to demonstrativeness traits in the personality of these subjects, who, often enough, are histrionic personalities. (Ionescu 1997)
The ordeal function. Stengel (1958) described very thoroughly this function, as well. The ancient ordeal ritual consisted of a test, later--a legal proof to prove the guilt / innocence, a test to which the individual was subject or subjected himself voluntarily in front of the community, and whose result was regarded as a judgment by the gods. Similarly, some suicides put themselves in such conditions, so their gesture can be fatal or not, depending on the intervention or nonintervention of random factors. Fortunately, it seems that this type of suicidal behaviour is rare.
The catastrophic reaction. Attempted suicide may appear as a maladjusted, uncontrolled reaction, expressing despair, a state of panic in the face of an intolerable social and emotional situation. Stengel believes that such manifestations are part of "the catastrophic reactions." According to Kretschmer, this reaction is a "short-circuit," an unpredictable reaction both for the subject and for the family. Also, this type of reaction is different from the flight mechanism, because the process of conflict resolution does not appear. The act has no purpose, no finality, no intentionality. After the suicide attempt committed based on such a mechanism, there is no decrease in the emotional tension or interest in the reaction of others.
The blackmail function frequently occurs in cases of attempted suicide. The subject seeks, consciously or not, a secondary effect from his or her act. This function is close, in terms of features, to the appeal function, except that it uses blackmail from a simple warning to the formulation of the desired gratification for abandoning the fatal act. The aggression directed outwards is considerable. The method is frequent in female parasuicide.
The flight function expresses the subject's inability to cope with a danger, a threat, or an unbearable situation. This function is loosely connected to the catastrophic reaction, only it differs by its much more coherent, comprehensible character, appropriate to the circumstances. Unfortunately, choosing death instead of confronting the psycho-traumatizing situation, meaning a flight from one's own Self, is characteristic to suicide.
The ludic function. Any auto-aggression involves a touch of game, a bet with death. Racing death may seem very challenging for some people. There is also an issue of uncovering the "obscure" forces that can support the subject in the effort to continue his or her own life.
In conclusion, of the eight functions described, the most important are: the flight function, the appeal function, the blackmail function. As regards the mechanisms of auto--or hetero-aggressiveness, they are subordinate to the three major functions.
There are three typological categories of individuals with suicidal behaviour:
* individuals characterized by high auto-aggressiveness, a mechanism which is expressed by the flight function of suicide;
* individuals whose aggression is directed outward, where the autolytic gesture is based largely on the blackmail function;
* "appellants" who are at the same time both auto--and hetero-aggressive.
The meaning of suicide
There is a wide variety of formulations concerning the role of "the ecological niche" in determining self-destructive behaviour. Emile Durkheim provided the classical description, showing that the balance and imbalance of a society result from the confrontation between two antagonistic couples: the egotism-altruism couple which determines the degree of integration of the individual in a given society, and the anomy-fatalism couple which regulates individual desires. According to Durkheim, the process favouring self-destruction is centred on the failure to adjust oneself to the ecological niche in which the individual is included. According to these criteria, the author has divided suicide into four categories: egoistic, altruistic, anomic, fatalistic.
The followers of the sociological theories gathered over time a huge amount of geo-demographic and collective psychology information. Henry and Short propose a model derived from a comparative study of suicide to homicide. When external constraints are weak, as a consequence the individual must assume all responsibilities for the frustrations he or she experiences. Higher rates of suicide are estimated to occur in democratic countries compared to those with an autocratic type of social organization.
Another model is the ethological model proposed by Lorenz (1970). He stated that "hypereridism"--a morbid state of hostility and aggression--exists per se in certain individuals who, in response to repeated challenges from the environment, emanating from "the ecological niche," turn their native aggressiveness toward themselves: quiet rage.
Goldney (2000) brings up other ethological concepts, such as early imprinting of behavioural traits, innate release mechanisms, fixed action patterns.
Among other sociological theories, the one known as the incongruity status developed by Gibbs (quoted by Fremouw et al 1990) is worth noting. Gibbs argues that a subject is likely to commit suicide when, being part of a group with rigorously defined characteristics, he deviates from other group members through a basic feature. This is the suicide theory of deviance suicide.
To strengthen the scientific integrity of these studies, authors developed an entire taxonomy of the ecological factors that should be incriminated for the increased suicide rate, such as: population density, social, economic, and educational status, cultural level, etc. However, these researchers seldom use the researches and the results of the clinicians. The lack of social support, with long-term isolation, also plays an important role in increasing the suicide rate. According to Stengel (1958), social isolation plays an equally important role both in suicide and parasuicide cases. Moreover, social isolation is recognized as an important predictor of autolytic behaviour and is included in most prediction scales.
The most popular is the Freudian psychoanalytic model. Freud argues that two groups of antagonistic forces struggle within the human being: one pushes the individual to self-destruction, while the other acts as a positive force, constructive for the whole personality. In Mourning and Melancholia, he explains how, in his view, one comes to the autolytic act. Mourning and melancholia are two painful and crippling emotional reactions generated by the loss of a loved one or an abstract substitute: homeland, freedom, ideal. Love that lost its object and the object itself do not disappear, they are narcissistically intertwined in the SELF and become a living part of it, through identification, so that by committing suicide, the melancholic "does not kill himself, but kills this vampire that replaces him." For Freud, suicide is the death of someone else's memory and not one's own self. This model applies more in the particular case of the reaction to mourning, as there are frequent cases of suicide significantly related to the anniversary of the deceased loved one (parent, wife, fiancee, lover, etc.).
Other psychoanalysts, such as Reitler, connect suicide with the primary fear, born of repressing the sexual instinct.
Sadger sees in suicide the revenge of the individual who cannot quench the thirst for affection, while Steckel argues that to commit suicide, one must have first wished the death of someone else.
Adler developed the theory of blackmail suicide. The first weapon of children in conquering the affection of the entourage is subordination and obedience. They exploit their own sufferings and weaknesses to escape responsibility and, in exchange, to gain protection and sympathy, but this does not relieve them from feeling humiliated, insulted and inferior. All failures are attributed to others. The individual will then react and try to dominate, in turn, by opposition, revenge, obstinacy, suicide.
Menninger (1938) starts from the Freudian theory of life and death impulses and discovers the unstable equilibrium extant between them, in each individual. Suicide is considered by this author a particular form of death, which mixes three elements: to die, to kill, to be killed. He states: "The desire to kill, hijacked by external circumstances or the objects of unconscious gratification, turns against the person who has this desire and is completed in the form of suicide." The desire to be killed expresses a total and eroticized subordination, the pleasure derived from punishment--masochism--which is directly proportional to the aggressiveness, conscious or not, against another. The desire to die is explained as follows: in suicide there is a sudden and brutal acceleration of the self-destructive energy that normally leads everyone, gradually, to death.
Grunberger argues that suicide is specific to individuals who have failed to accept "the paradise lost" by birth and thus compensate for the great "initial narcissistic injury." While the most unfortunate blame the world around them, the melancholic blames himself and cannot escape his pride, he feels the need to assert his unique value, including by self-mutilation. Having decided to kill himself, the subject is peaceful, sometimes even happy, as his narcissism emerged victorious from the battle with the Super Ego.
Melanie Klein, in the line of the Freudian theory on Super Ego, states that a person may want to kill just one aspect of himself, in the hope of resolving the tension between a very authoritarian Super Ego and Ego.
Bettelheim reiterates the same idea: "Although the individual turns his aggressiveness onto himself, he does not want to hurt himself. On the contrary, it is the same desire that leads him to commit acts of violence on others: he seeks in this way to relieve his suffering, to get rid of that part of himself which is, according to him, the source of all his troubles. In trying to kill himself, he tries to destroy what exists in the depths of himself and makes his life intolerable."
"Trap" theory is the latest theory about suicidal behaviour, originating in the cognitivist model of processing information. (Gilbert & Allan 1998)
"The trap" is defined as the suicidal person's inability to turn away from an unfavourable environment (physical or spiritual) after suffering a loss, defeat or humiliation. The individual differences in processing information, while providing meanings of defeat can be observed in the promptness with which helplessness schemes are activated in people vulnerable to suicide risk, even in minor cases. Such persons renew their script of being "trapped" in any situation of failure or that could suggest failure.
Can it be that an act of autolytic behaviour produced in conjunction with a mental disorder or a major stressor might induce easier, in future, in vulnerable people behaviours of helplessness, hopelessness or suicide? Psychology research aims to answer the question by describing the psychological model of the cry for pain (Williams 2001). Just as a bird trapped in a cage tends to take flight, but strikes the bars with its wings and screeches in pain, so the suicidal person, defeated and humiliated by the events of life, signals by this act their desire to escape from a situation they consider intolerable.
The cry for pain model has three components:
--the pressing desire to escape from the current situation (need to escape);
--the feeling that escape, liberation is impossible (unable to escape);
--the tendency to believe that the future holds no chance of escape either (will be no rescue).
The Christian perspective
For Christians it is a sin to commit suicide.
Early Christians accepted death with ease in exchange for the grace of being saved. But their martyrdom was not and is not interpreted as suicide, as those punished and martyred did not seek death, but, on the contrary, they praised life, the new life acquired by accepting God's Son as Lord and personal Saviour.
Catholic tradition records the Council of Toledo (639 AD), where St. Augustine decreed the excommunication penalty for those who had a suicidal behaviour, as they were considered usurpers of God's prerogatives. Also, suicide victims could not be buried in a Christian ceremony and their relatives were oppressed or even lost their properties.
Nowhere does the Bible refer directly to the problem of suicide, but in many places throughout it we can see how the act of killing is perceived: "If any man defile the temple of God, him shall God destroy; for the temple of God is holy, which temple you are."
The value of life is irreplaceable as human life is rendered valuable by the substance of the Holy Spirit who dwells in people: "Do you not know that your body is a temple of the Holy Spirit who is in you, whom you have received from God, and that you are not your own?"
Thus any aggressive attitude directed towards one's own body or someone else's body is equally condemned by The One we belong to. The Supreme Creator has made an investment in every human being, and because this investment is not ours, we are not allowed to destroy it by drifting in non-life.
Biological and neuropsychological aspects of the suicidal behaviour
Classical research on suicide focused largely on the psychological and social problems, causes for autolytic behaviour. Suicidal behaviour should be studied today from multiple angles, including that of biological and neuropsychological researches, especially since there is evidence of increased suicidal risk in all psychiatric disorders.
Predisposition for suicidal behaviour
Mann (2003) proposes the term diathesis as the central concept to understanding suicidal behaviour observed in some people. Suicidal diathesis, defined as a predisposition to suicidal risk, causes a person to react in a specific manner to external stimuli. The most typical features of such individuals include aggressiveness, impulsivity, pessimism, anxiety, despair. However, the biological foundations of this suicidal diathesis should be distinguished from the determinant factors of mental illness.
It is a generally shared view that suicide is a complication of depression and that it very rarely occurs in the context of other psychiatric disorders. Although relevant examples in this respect are also provided by mood disorders, many researches confirm the significant presence of suicide or suicide attempts in individuals with schizophrenia, with chronic alcohol or drug addiction, personality disorders or anxiety disorders.
Biological aspects of suicide
The biological factors were considered until recently as being of secondary importance for the onset and evolution of suicidal behaviour. Recently some research directions suggested a possible correlation between autolytic behaviour and biological factors within, but also besides, depression. (Healy 1987)
The role of serotonin
Variations in the activity of the serotoninergic system play an important role in differentiating individuals with regard to mood and affectivity, impulsivity or aggression. A genetic predisposition of the serotoninergic dysfunction interacts with random factors in the environment, causing the accelerated journey on the road toward depression, suicidal ideation and transition to the fatal auto-aggressive act.
The relationship between the level of 5-HIAA in cephalorachidian fluid and suicidal behaviour has been confirmed by researchers such as Asberg and Traskman, van Praag, Montgomery and Montgomery, Palanappian, Banki and Perez de los Cobos, both in depressed patients and in patients suffering from other conditions: psychopathy, schizophrenia, alcoholism, adjustment disorders. (Asberg et al 1986)
Since 1976, researches in biological psychiatry at Karolinska Institute, led by Marie Asberg, furthered the study of the role of aggression in suicidal behaviour. The author highlighted the link between low levels of 5-HIAA (5hydroxyindoleacetic acid) and increased suicide risk. The decrease of the CSF serotonin metabolite is considered as a specific marker of the vulnerability of the person with suicidal risk, suggesting difficulties in controlling aggressive impulses (Cohen et al 1987; Healy & Leonard 1987), whether it is a major depressive episode, a personality disorder or schizophrenia.
A percentage of 40% of patients with low 5-HIAA level attempted suicide during the depressive episode compared to those with normal 5-HIAA levels, where only in 15% of cases there were recorded suicide attempts. In addition, low levels of 5-HIAA were associated with subsequent suicide risk. Furthermore, the attempts were also more categorical, with a preference for violent methods.
In comparison, people in the subgroup with normal 5-HIAA, who had suicide attempts, preferred in most cases less violent/brutal methods, such as drug overdose.
The researches of Asberg et al (1986) point out that the association between decreased 5-HIAA levels and suicide was also found in cases with other diagnoses than depression (schizophrenia, personality disorder, chronic alcoholism).
Marusic & McGuffin (2005), quoting Deakin (1996), argues that, while serotoninergic activity has an essential role in dispositional state, impulsivity, aggression, the activity of the serotonin receptors varies from one type of receptor to another. Thus, variations in 5-HIAA receptor are associated with depressive ideation, while the 5-HT2 receptor is associated with hopelessness and suicidal ideation.
Candidate genes that could cause suicidal diathesis are responsible for 3 directions of the serotoninergic function:
Serotoninergic system dysfunction, as a genetic characteristic, could also be evidenced after the disappearance of the major depressive episode in patients who had developed suicidal behaviour on the psychopathological background of depression.
The role of dopamine
The concentration of dopamine metabolite, the homovanillic acid (HVA) in LCR is reduced in depression, to an even greater extent than the concentration of 5-HIAA, to which it is actually linked. Still, it is unknown whether these two metabolites are correlated through the common transport mechanism or due to functional connections between their precursor amines.
Some studies have obtained data consistent enough for dopamine involvement in suicidal behaviour. Low levels of HVA (homovanillic acid), the major metabolite of dopamine, were found in depressives who had attempted suicide.
The hypothesis that a low cholesterol level may be a suicidal risk factor originally derived from the epidemiological research that examined the relationship between cholesterol levels and mortality. The first researchers who reported this finding (Lindberg et al 1992) noted the increase of suicidal risk in men and women with cholesterol values below 160 mg/dl. Other researchers linked suicidal risk in people with low cholesterol with the finding that lowering cholesterol affects the structure of the neuronal membrane, resulting in decreased sensitivity of the serotoninergic receptors. Research in this area is just beginning and researchers are also analyzing the role interleukin-2 plays by inhibiting the production of cholesterol or by inhibiting the melatonine secretion (Pentinen 1995; Biali et al 1995).
The role of melatonine and magnesium
Recently, studies were published which linked two other biological parameters, plasma melatonine and magnesium, to suicidal behaviour. Moreover, both factors are related, in some respects, to the activity of the serotoninergic system.
Hyperactivity of the hypothalamic-pituitary corticoadrenal axis
In 1986, Baumgartner et al reported that patients seriously intending to commit suicide had an unusually high excretion of cortisol metabolites before the act. In a subsequent study, Schmidtke (1998) demonstrated the link between elevated plasma cortisol and the final suicide.
The hypothesis of "the glucocorticoid cascade" highlights the activity overcharge of the hypothalamic-pituitary-corticoadrenal axis under prolonged stress, resulting in neuronal damage, especially in the hippocampus region which consecutively generates cognitive dysfunctions (O'Brien 1997). The hypothesis is also supported by psychology researches (Williams 1997) describing the inability of individuals with suicidal behaviour to remember some very significant events for them, that is, an inefficiency in the mnesic connections related to autobiographical memory (mnemonic interlock).
Suicide and the thyroid axis
TSR low response to TRH, observed in depression, could be associated with an increased rate of attempted suicide and completed suicide. Bauer & Whybrow (2001) reported an increased response of TSR to TRH in suicidal patients compared with the control group. The reason for this discrepancy is unknown, but it is interesting that it was demonstrated the correlation between the basal plasma TSH level and the value of items specific to suicidal ideation in various SADS scales.
Cognitive psychology researches
The first cognitivist studies of suicidal behaviour derived from cognitive theories of depression. Just as the depressed, suicidal people persist in negative automatic thoughts (overgeneralization, catastrophism, dichotomical thought, etc.) and in a tendency to use preformed schemes of thought and beliefs when confronted with life events.
In addition to the general cognitive characteristics of depression, Beck (1979) reported hopelessness as a specific feature of the person with suicidal risk. Suicidal people focus on this range of ideas and turn to suicide to escape the intolerable despair that grinds their life. Thoughts and attitudes during the auto-aggressive action are predictors for a future suicide attempt. Therefore, Beck (1975) put great emphasis on the accurate assessment of suicidal intent for attempted suicide. He developed the Suicide Intent Scale to determine not only suicidal intention, but the lethality of the method used, despair and helplessness levels in front of the adverse circumstances of life (Beck 1974). Beck also believes that of all the variables highlighted by these scales, the most relevant for predicting suicide in the more or less distant future are: the existence of associated alcoholism, unemployment and the person's caution to not be discovered during the attempt or previous attempts.
In other clinical scales of hetero-assessment of depression, such as MADRS (Montgomery and Asberg Depression Rating Scale) and HDRS (Hamilton Depression Rating Scale), there are also items that address the detection of suicidal ideation in depression.
Other personality traits considered as possible predictors of autolytic behaviour are hostility, impulsivity, and aggression. Priest, Caine, Hope, Foulds applied hostility questionnaires in patients with affective disorders who committed suicide attempts using The Hostility and Direction of Hostility Questionnaire--HDHQ.
Williams (2001) focuses on the "arrested flight" model which, through its three components, would explain the ease with which people with suicidal risk slip into the auto-aggressive process, whether depressed or not.
The need to escape from a situation perceived as a failure is the first component of the model. It causes a person to interpret even such neutral events as a defeat or humiliation.
The second component is represented by the feeling of being unable to escape the situation. It is generated by difficulties in successfully solving the problems of life, especially the relational, interpersonal issues. In cognitivist terms, a deficit of refreshing the autobiographical memory was observed, the memory of one's own life being engrammed in schematic manner, with catastrophic overgeneralizations and lack of scale in rendering details and nuances of personal events. The mnesic content is mostly focused on negative events, failures, circumstances in which the person was in an unflattering, embarrassing situation.
The third component--there is no hope of salvation for the future (there will be no rescue)--manifests in a person's tendency to project the current defeat or failure on the future, thus paving the way for the clinical signs of despair and depression.
The "arrested flight" model is appealing, but it is quite ambiguous, as it can also be associated with the variable of long-term vulnerability, that is, the personality traits, but it can also move along the variable of status, which represents the current precipitating factors. It is necessary to develop an explanatory model of suicidal behaviour, lethal or non-lethal, indicating which of the suicidal people remain vulnerable in the future, even though they were apparently restored and show signs of recovery from the suicidal crisis.
Neurobiology of the predisposition to suicide risk
Several features distinguish the suicidal from the non-suicidal:
a. A feature commonly observed is that of a very special sensitivity to certain life events, namely those which signify defeat in the relationships with others. This difficulty in bearing defeat or the lack of success generates a generalized cognitive rigidity (loser status). The personality traits that mediate the sensitivity to interpersonal events are temperamental dimensions, such as reward dependence (Cloninger et al 1993) and stability (Engstrom 1996).
In people with suicide attempts, low reward dependence was found, their characteristic being the emotional distance developed towards interpersonal relationships (aloofness).
This emotional distance was negatively correlated with urinary cortisol level, reflecting the activity of the HCS axis. It can be concluded that there is a predisposition constantly manifested, a feature that creates dysfunctions in the development of interpersonal relationships and activates the hypothalamic-pituitary-corticoadrenal axis, possibly through deficits and attentional biases (Van Heeringen 2003). To highlight this cognitive configuration, the Stroop test was used (Becker et al 1999), which identified the relationship between the augmentation of the suicidal ideation in the depressed and biases in selective attention.
Moreover, the relationship between low reward dependence and low cerebral blood flow in specific brain areas (parahippocampus, temporal cortex, frontal cortex) indicates the involvement of the noradrenergic system and attentional disorders in the predisposition to suicide.
Other studies investigated the role of oxytocin and vasopressin as modulators of the temperamental trait of reward dependence (Heinrichs et al 2003). It was concluded that these neuropeptides serve to mitigate social stress. In the future, a possible therapeutic solution is foreseen for patients with suicidal risk diathesis by administering oxytocin, as a treatment to modulate the negative impact of life events, to eliminate the precipitating factors of autolytic impulses.
b. The dysfunction in perceiving the meaning of stressful events which is closely correlated with a stable personality trait, such as the inability to solve problems, is the second psychological and neuropsychological component of suicidal diathesis.
The feeling of being trapped in a hopeless situation--no escape--is associated with a personal problem-solving manner. As problem solving skills are related to previous events, thus to autobiographical memory, this predisposition to suicidal behaviour correlates with deficiencies in using it to generate optimal solutions to current problems. Several studies have shown an association between suicide attempts and the over-generalization of autobiographical memory.
At any given moment in life, there occur processes of conversion, of translating the sensory input (perception) into abstract symbols (concepts). For the suicidal person, during the process of determining the meaning of the perceived stressors, it is very important that sequences of past experiences replay correctly and in detail. Through the process of overgeneralizing the autobiographical memory, a biasing of the interpretations occurs towards the pole of failure, generating few and inconsistent solutions to the dilemma. As such, the significance given to a personal event depends heavily on the conceptual significance given to the fact itself. The concept of self (insight learning) in particular is involved in the predisposition to suicidal behaviour, as the person sees oneself right from the start as a loser (loser status).
The temporal lobe and the hippocampus play the main role in declarative memory, but the prefrontal cortex is involved as well through the storage function which influences the fluidity of the working memory.
c. Deficiencies in prospective cognitive processes, due to the inefficiency of the mechanisms that generate positive cognitive "rescue" scenarios (no rescue) from the current dramatic or just disadvantageous situation.
Verbal fluency tests are used to demonstrate this deficiency. It was shown that the results of these tests are related to the level of despair, so that the less fluent is the patient in imagining positive events in the future, the higher the level of despair (hopelessness). Neuropsychological researches (van Heeringen 2003) used SPECT to demonstrate the negative correlation between the activity of the 5-HT2A receptors in the prefrontal cortex (dorsolateral) and the level of despair in patients with recent suicide attempts. There are emphasized the dysfunctional attitudes in imagining the future with the serotoninergic hypoactivity of the prefrontal cortex, a hypoactivity manifested clinically by despair, inhibited behaviour, insecurity and anxiety under adverse and stressful conditions.
It can be assumed that the augmentation of behavioural inhibition (anxious evasion) is the primary mechanism that propels the person towards suicidal behaviour only in the presence of a (dopamine-modulated) activity which would be sufficiently expressed to overcome the initial inhibition and drive a person towards passage a l 'acte. This role is explained through serotonindopamine antagonism, so that the depletion of the serotoninergic system triggers the disinhibition of behaviours dependent on the dopaminergic system, including the impulsive and aggressive behaviour.
In conclusion, the three fundamental psychological characteristics of suicidal predisposition (loser status associated with the urge to escape, the inability to escape, the impossibility to save oneself in the future) associate with biasing the neuropsychological activity in attention, autobiographical memory and the ability to explore the future.
The first component--attention biasing in stressors reception--is set in the level of the frontotemporal cortex and is modulated by the serotoninergic (5-HT1A) and non-adrenergic system. Hypersensitivity to life events is associated with hyperactivity of the HCS axis, resulting in increased production of cortisol.
The neurobiological aspects related to the second component--decrease in the problem-solving ability combined with autobiographical memory deficiencies--are less clarified. Here too is mentioned the involvement of the frontal cortex and the glutamatergic and GABA-ergic systems.
The third component--the impossibility to generate optimistic prospective scenarios--is related to the dysfunction of the serotoninergic system (5-HT2A) in the prefrontal cortex and the amygdala, resulting in increased behavioural inhibition and despair.
These studies reinforce the belief that any treatment plan that addresses individuals with suicide risk must combine the psychopharmacological treatment with psychotherapy, especially cognitive-behavioural therapy. In support of these associations come neuroimaging studies that have shown a marked decrease in the activity of the brain regions that are primarily involved in social learning (Oquendo et al 2003).
Genetics of suicide
The genetic aetiology of suicide, attempted suicide or suicidal ideation is a subject towards which many clinicians have reservations. However, this human behaviour can also be judged in the light of the genetic approach to the phenomenon, as the interrelation between genes and the life events of the suicidal person are wheels of a complex gear. From a phenotypical point of view, death by suicide is most likely the best defined phenotype of behavioural genetics. It is more difficult to define the phenotype of the suicide attempt and, even more, it is difficult to delineate the phenotype of the suicidal ideation.
There is scientific evidence that the genes which induce vulnerability to suicide operate independently of the genes that transmit a mental disorder with increased suicidal risk, such as depression. Suicidal concerns and proclivity for death in general are considered today as a morbid, but stable personality trait which is exacerbated in the presence of psychiatric disorders such as depression, without entirely disappearing with the remission of the illness.
A number of clinical studies, studies on twins and on adopted people and, more recently, certain molecular genetics studies have demonstrated a genetic predisposition of suicidal behaviour, most probably with polygenic transmission.
The candidate genes that could trigger suicidal diathesis are involved in the regulation of the serotoninergic function and correspond to three directions of the serotonin metabolism (5-HT) by:
--genes involved in the synthesis of 5-HT through the tryptophan hydroxylase gene, responsible for limiting the serotonin secretion. There are 4 variables that can modulate the activity of this gene. Positive results were presented in relation to the genetic variance of the 3'end of the TPH gene. This variance may be a genetic susceptibility factor for a phenotype combining highly lethal suicide attempts with aggressive behaviour. Other studies on the tryptophan hydroxylase gene (TPH) have shown that the presence of L (779C) allele confers an increased suicide risk.
--genes involved in the transport of 5-HT through the serotonin transport gene (SERT gene --human platelet serotonin transport) that regulates the uptake of this neurotransmitter in presynaptic neurons;
--genes involved in 5-HT catabolism, e.g. MAO-A gene, susceptible to engender personality traits such as impulsivity and aggressiveness. This would be an EcoRV polymorphism of the MAO-A gene, whose alleles are associated with the enzymatic activity of serotonin catabolism. This correlation could be evidenced only for males.
Molecular genetics studies
Other genes that called the attention of researchers as being involved in triggering the autolytic act or maintaining death ideation are the genes of the serotoninergic receptors. Du et al (2000) reported an association between the polymorphism of the 5-HT2A receptor gene and suicidal ideation in patients with depression. Yet another serotonin receptor is studied by researchers, namely 5-HT1B. This receptor gene polymorphism was associated in a population-based study conducted in 18 centres by Sanders et al (apud Marusic & McGuffin 2005), with alcoholism and delinquency, as well as suicide attempts of patients with personality disorders.
However, no evidence linked to the onset of suicidal ideation or behaviour could be obtained as regards the 5-HT1A receptor gene polymorphism.
Dopamine receptor genes were also discussed, especially those related to D4 receptor gene polymorphism. This gene is expressed by an increased index of the temperamental trait of novelty seeking and risky behaviours. It is interesting that both this gene and the TPH gene are located proximally, in the short arm of chromosome 11.
Clinical genetics studies
Studies on psychiatric patients show that a family history of suicidal behaviour increases the suicidal risk in these patients. Also, there was a statistically significant difference in the frequency of suicidal behaviour between patients diagnosed with major depression and a family history of suicidal behaviour and patients diagnosed with major depression, but without any family history of suicidal behaviour (Mitterauer 1990).
Studies on Amish populations have shown a high frequency of suicidal behaviour only in some families where the prevalence of major affective disorders was higher, while in other families the frequency of suicidal behaviour was significantly lower (Egeland & Sussex 1985).
Studies on twins
A higher frequency of suicidal behaviour of both twins was found in monozygotic twins than in dizygotic twins (Kallman & Anastasio 1947).
This has also been demonstrated both in regard to suicide and attempted suicide (Roy & Segal 2001).
Moreover, a higher frequency of suicidal ideation and suicidal behaviour was demonstrated in monozygotic twins than in dizygotic twins in the general population (Statham et al 1998).
Individuals separated from their biological families at birth or shortly after birth present the same genetic susceptibility, but develop in different living environments. Conversely, adopted people live in the same environment with the adoptive families, but do not have the same genetic susceptibilities.
A higher frequency of suicidal behaviour was evidenced in the biological families of the adopted individuals who have committed suicide compared to the adoptive families (Schlusinger et al 1979). It was also suggested that this genetic predisposition is in keeping with the subject's inability to control impulsive behaviour (Kety 1986).
In conclusion, genes operate in a probabilistic rather than deterministic manner when shaping personality and behavioural traits that increase the individuals vulnerability to suicide or selfharm (Marusic & McGuffin 2005).
Chronobiology research--seasonal pattern in suicide behaviour
The concept of periodicity is very frequently used as a diagnosis and evolution criterion both in somatic medicine and in psychiatry. There are, however, regularly manifested diseases whose periodicity is strictly related to the beginning of a season. In this case, the name used in recent decades is that of seasonality, equivalent to that of seasonal pattern. Medicine has recorded ever since the antiquity the role of climatic factors in the onset or recurrence of the illness (Baran 1995), because ancient physicians excelled in describing illnesses according to evolutionary temporal criteria. Hippocrates considered that meteorological factors had a leading role both in maintaining health and in the occurrence of the disease, believing that these factors contribute to the balance or imbalance of humours. "Most diseases occur when season change and during the seasons, through extreme changes of cold and heat ..."
A certain connection between the succession of seasons and suicidal behaviour has been shown by empirical studies since the nineteenth century. Durkheim, a sociologist, was the first to see that "suicide occurs when nature is most beautiful and temperature is the sweetest."
The first psychiatrists who observed the existence of a periodicity in the occurrence of mental illness were Esquirol in 1845, then Kraepelin in 1921.
More recently, the most prestigious researches on seasonality were conducted at the University of Nice (Souetre et al 1998) and Rosenthal et al (1987) at NIMH-Bethesda. The clinical and epidemiological researches of Rosenthal and Wehr (1987), introduced the concept of seasonality in the DSM classification of affective disorders, with the qualifier "with seasonal pattern." The Seasonal Affective Disorders (SAD) group includes the major depressive episodes in bipolar disorder I and II, and the recurrent major depressive disorder. For SAD, the essential characteristic is the onset and remission of the major depressive episode in a certain period of the year. In most cases, episodes start in the fall or winter and enter remission in the spring. There is an increased prevalence of depressive episodes in parents of the subjects with SAD, indicating a possible genetic transmission. The duration and severity of a depressive episode is influenced to some extent by geographic latitude, as the depressed subjects in the northern hemisphere benefit from a symptom relief by simply travelling south. Recently, there were also described some variants of depression during summer associated with euthymic mood in the fall and winter--these subgroups are called reverse-SAD.
Data from literature (Attar 1997; Barker et al 1994) on the seasonality of suicidal or parasuicidal behaviour are inconclusive, although several authors (Fisher et al 1997; Yip et al 1998) published statistics regarding the seasonal distribution of suicides. Chew and McLeary (1995), analyzing the data collected in 1960-1980 from a total of 28 countries, confirmed the suicide peak in the spring. A bi-seasonal presence (spring and fall) of the suicide risk peak was reported in the US, UK, Italy, Finland, Australia (Hawton & van Heeringen 2000). In Finland, in areas near the Arctic Circle winter days are dark and only last a few hours a day. Yet the suicide rate is not higher in winter, although during this period SAD cases are more frequent. On the contrary, between December
and February the lowest rate of suicide is recorded.
The explanations of seasonal variation in suicide rates include sociological causes and biological causes (Cosman 2000). Durkheim, according to his experience as a sociologist, assigned an important role to the relation between the cycle of human activities (especially those in agriculture) and the increase in suicide rate once spring comes. The coming of spring could not hide the lack of motivation and hope of the depressed, stagnant and dormant in winter, who decompensate in the spring, and the psychological pressure induced by the rhythm of farming. As a matter of fact, other authors (Chew & McLeary 1995), 100 years after Durkheim's observation, found that the maximum rate of spring suicide occurs in agricultural workers. This theory is the more consistent since epidemiological data provided by tropical countries where there is no climate variability have not reported the seasonal distribution registered in temperate countries.
The seasonal distribution of suicide can be explained not only by the social or psychological factors mentioned above, but also by changes in the circadian rhythm of body functions in relation to seasons and the degree of persistence of light during the day (photoperiod). In support of this theory come the researches that have validated the seasonal correlation of the suicide rate with the seasonal variation of the L-tryptophan level (Maes et al 1995). Studies on volunteers showed seasonal variation in plasma L-tryptophan. There were detected seasonal variations of Ltryptophan, and the L-tryptophan / amino acids (valine, leukine, isoleukine, tyrosine, phenylalanine) connection, by detecting their significantly lower values in spring compared to other seasons. The results show a bimodal seasonal pattern of plasma L-tryptophan concentration, which thus provides a possible explanation related to the seasonal variation of violent suicide (Pine 1995). The seasonal variation of L-tryptophan has also been correlated with the evolution of other bioclimatic factors: high temperature, relatively high humidity, low atmospheric pressure.
A possible explanation for the major differences in suicide rates in different people would be the differences recorded in the presence of neurotransmitters (especially serotonin) in the Central Nervous System. Lester (1991) found a significant correlation between the density of 3Himipramine receptors in peoples of eight countries in the world and the national rate of suicide. Moreover, the same author also reported seasonal changes in suicide rates linked with the annual rhythm of central and peripheral serotonin turnover. Serotonin turnover changes represent a vulnerability factor for depression and susceptibility to psychosocial stressors, thus building the favouring constellation for "impulse toward action," in the autolysis process.
A link was also found between elevated levels of urinary cortisol and suicide rate, the peak values were also detected in spring, in May, June, and in fall, in September.
The seasonal pattern of suicide found in countries with climatic fluctuations and variations of diurnal light depending on seasons brings about the issue of regulating the endogenous rhythms depending on the exogenous one. Endogenous rhythms are controlled by a molecular clock located in the suprachiasmatic nuclei. The hormone secreted by the epiphysis, melatonin, regulates the rhythmical development of all the processes in the body. Regulating the melatonin secretion is influenced by light exposure time, light intensity, and the circadian variation in eye sensitivity to light; in this way, light, with all its characteristics, is the strongest signal that sets or resets the circadian rhythms. The body's internal clock is monitored in turn by an autonomous moleculargenetic oscillator. Certain genes have been detected to act in this sense--PER in the central nervous system whose activity is under the control of external light, that is, the length of the photoperiod (Kelly 1999). The existence of these genes--light detection genes--would influence the susceptibility to develop SAD and the possibility of relapse during the evolution of major depressive episodes.
Sufficient data show the link between the onset or relapse of the depressive episode once the light period (photoperiod) is shortened in the winter months, but this correlation does not explain the obvious increase in suicides when spring comes. Elevated suicide rates are also maintained in the summer and after a lull period a new peak of suicides follows at the beginning of fall. Although the seasonal curve of suicides does not overlap that of depression, it can be seen that, at least for temperate countries in the northern hemisphere, there is a link between a maximum incidence of depression in the months leading up to the maximum rate of suicide. A possible explanation for the susceptibility to the increasing variations of the photoperiod in a certain season of year (spring), with values up to 19 minutes from one week to another, is that the maximum light period drastically suppresses melatonin secretion, resulting in neuro-endocrine mechanisms responsible for increasing the propensity towards impulsive actions, specific to suicidal behaviour.
In Romania, a study conducted over a period of 10 years (Cosman & Coman 2001) showed the seasonal influence on the growth suicide rate in certain periods of the year. The study covered a period of 10 years and referred to a number of 1097 suicides and 1239 cases of parasuicide in Cluj County. The study calculated the relationship between the variation of light duration / week in the annual cyclicity (independent variable) and the weekly rate of suicidal behaviour (dependent variable). It demonstrated the positive correlation of suicide with the increasing variation of the photoperiod from one week to another, with the most significant period of the year being that between the spring equinox and the summer solstice.
Bioclimatic research (biometeorology)
Studies on the effect of meteorological factors on suicidal behaviour produced mixed and often contradictory results. More and more researches all across the globe report positive correlations with temperature and atmospheric pressure. Authors from Italy, Spain, UK, Mongolia, reported that over long periods of time they observed the seasonal influence on suicide rates, especially in the elderly population.
However, these statistical data, sometimes very meticulously collected over two or three decades, have not provided an explanation for the triggering mechanism of the autolytic act, so that bioclimatology remains in the "shadow" of suicidological research.
The epidemiology of suicide
Statistical analyses of suicide rates are being carried out worldwide these days. Annually, WHO publishes centralized data. Medical statistics serve as support for comparison in time and location, as global indicators of public health, or in a certain region, or country. The WHO and other international organization statistics serve as a basis for drawing up and implementing international and national suicide prevention programs.
Is suicide on the rise? The situation differs from one country to another (Baraclough 1973). In 1989, only 39 out of 166 countries, members of the United Nations, reported data on deaths by suicide, in the World Health Statistics Annual (Last 1991; Ross & Kreitman 1975). In full, these 39 countries reported 208,349 deaths by suicide in a year. These figures show an incomplete epidemiology, unable to reproduce the amplitude of the phenomenon, at the global level. Suicides happen in all countries, even in those that did not communicate statistical data, and it is likely that in those countries the suicide rate is equal to or exceeds the officially reported one. In the countries that reported, it is estimated that a considerable number of suicide deaths are not registered as such, a proportion that varies between 30% and 200%. If we link these remarks with the fact that, in most countries suicide ranks among the first 10 causes of death, in all ages, and among the first 2 or 3 causes of death in the 15 to 34-year age group, the inevitable conclusion is that suicidal death is a serious public health concern. Some authors consider that now, in industrialized countries, the number of self-murder deaths outnumbers road accident deaths. In the last two decades, road accident mortality has progressively decreased, while the suicide rate has increased rapidly, especially in teenagers and young adults. For all this, in all countries, without exception, the resources used to intervene in case of suicide, or to prevent suicide behavior represent only a fraction of the means allotted to road accident prevention.
Another public health issue related to suicidal behavior is that the number of persons with attempted suicides, or deliberately produced lesions, in many cases so serious that necessitate specialized medical care, are tenfold higher than the number of self-murderers.
Knowledge about the magnitude of the parasuicidal phenomenon is extremely limited, even when compared with achieved suicide. There are parasuicide reports in every country of the world. One can also notice a large variance of the operational criteria used in including some cases in the parasuicide category. Population survey studies show that only 1 of 4 attempted suicide cases are in accordance with WHO's criteria of parasuicide definition. Anyhow, in many countries, parasuicide is one of the most frequent reasons of emergency medical services in young adults, as most of the attempts are made by those under 35 years.
The global suicide rate
Any national or international research related to the suicide rate must ask how valid and reliable are the mortality rate data collected from descriptions, analyses and even national statistics. The methods and criteria for identifying suicide are very different, with diverse world populations, which results in notable differences in computing the mortality rate by suicide (Moscicki et al 1989).
Some authors argue that cultural attitudes toward suicide significantly affect official statistics, that these become non-operant.
In 1968, WHO nominated a working team that made comparative studies on suicide statistics. The report read: "The ineluctable conclusion is that now, the official statistics have only a limited value. Epidemiological and socio-demographic theories about suicide remain hazardous." Seven years later, another working team initiated by WHO reached the opposite conclusion, and expressed their confidence in the statistics on suicide in European countries.
A review of the statistics in many European countries shows that the differences in data collection on the suicide mortality rate does not fully account for the differences in suicide rate in diverse populations. The conclusion is supported by the persistence of obvious differences in the suicide rate between social and demographic national groups, registered over long (even a century) time periods, in spite of the political changes that may change the statistical registration procedures.
There are clear-cut variations in the suicide mortality rate in all European countries between reporting countries: from 6 deaths of women in Malta to a peak of 851 men in Hungary in one million people. But the greatest number of suicide deaths was registered in Sri Lanka, namely 114 suicides in 100,000 residents in 1995. (Diekstra 1985)
The suicide rate in European countries (per 100,000 inhabitants) (World Health Statistics. Annual, WHO, 1988-90) Hungary 41.4 Russia 37.5 Latvia 36.5 Finland 33.6 Estonia 32.7 Lithuania 32.7 Denmark 29.2 East Germany 28.6 Ukraine 26.3 Switzerland 25.2 Austria 25.0 France 24.3 Sweden 24.2 Belarus 23.3 Belgium 22.4 Czechoslovakia 21.0 Portugal 20.3 West Germany 18.7 Yugoslavia 17.4 Poland 17.2 Norway 16.7 Bulgaria 16.6 Scotland 14.6 Iceland 13.5 England and Wales 11.9 Romania 11.4 Holland 10.7 Northern Ireland 10.3 Ireland 10.2 Italy 8.3 Spain 8.1 Malta 5.2 Greece 4.0 Albania 2.3
The yearly number of suicide deaths reported in all countries included in statistics was about 120,000. It may give an image of the suicide tendency, through the effort of registration and reporting.
The previous table reveals an acting model since the first half of the 19th century, that South Europe countries have the lowest suicide rates, followed by countries in the north-west (Great Britain and Holland) with somewhat higher rates. Nordic countries form a third group, with relatively higher suicide mortality. The fourth group, with somewhat higher mortality, is on the median geographic line of Europe, from Belgium and France in the west, next to Switzerland, Austria and Hungary and at last with Russia in the east.
Suicide in Europe between 1881 and 1988 (From WHO archives) Country 1881- 1925- 1951- 1967- 1921 1961 1961 1974 Austria 16.1 23.6 28.3 28 Belgium 11.4 15.5 13.4 23 Denmark 22.5 24.6 13.8 28.9 Finland 3.9 24.2 12.7 24.6 France 20.7 15.8 19.5 21.8 Germany 20.9 20.6 22.1 21.4 Ireland 2.3 3.4 2.8 7.5 Italy 4.9 5.6 8.8 5.3 Holland 5.5 8.7 6.2 11.6 Norway 6.8 9.4 5.8 14.4 Portugal - 8.7 6.9 10.2 Spain 2.4 4.3 5.6 7.2 Sweden 10.7 20.4 14.4 19.4 Switzerland 22.7 19.6 23.1 24.7 Great Britain 7.7 7.8 10.1 8.7 Scotland 5.5 8.3 6.6 10.7 Country 1972- 1984- 1987- 1982 1988 1989 Austria 21.9 25 21.9 Belgium 14.1 22.5 14.1 Denmark 18.3 28 18.3 Finland 20.7 27.6 20.7 France 15.5 22.1 15.5 Germany 18.6 17.9 18.9 Ireland 2.3 6.9 2.5 Italy 6.5 8.3 5.4 Holland 6.3 11 6.5 Norway 7.1 15.5 7.5 Portugal 10.2 8.1 - Spain 5.9 7.8 6 Sweden 17.2 18.5 18 Switzerland 21.8 22.7 18.1 Great Britain 10.1 8.5 11.8 Scotland 5.6 11.9 8.5
This geographical distribution of suicide was more or less characteristic of Europe throughout a century (Diekstra et al 1978). 16 reporting countries have registered suicide mortality for more than a century, so that the tendency of suicides could be easily traced.
In 9 countries, the suicide rate rose to a much higher level in the last decade than in the previous one, while in another group of 7 countries the peak mortality by suicide occurred in the first part of the century. In spite of all these national differences, there is evidence that during the whole period, in all of the 16 countries, mortality grew significantly along the last century which suggests that prevalence of self-killing continues to be correlated with cultural differences, traditions, religious beliefs, public opinion, climate conditions and other factors which influence human behavior. As national differences level down, the countries of Europe come closer, and so does the suicide rate.
In the United States, the suicide rate fluctuated through the last century. So, if at the beginning of the 20th century this rate was 10.2/ 100.000 residents, it increased to 16.2 in 1915, then abruptly decreased to 10.2 in 1920 (Diekstra 1982). After 1925 it slowly increased, to attain a maximum of 17.4 in 1932. Since then, it has remained constantly under this level: 13.3 in 1977, and 12.7 in 1987. (Farberow 1992)
The epidemiology of parasuicide
Difficulty in data collecting for official statistics concerning parasuicide makes its epidemiology rather similar (Murphy & Wetzel 1980). However, English, Dutch and Scandinavian authors insist that research about suicide and parasuicide are related (Murphy et al 1980; Kreitman & Dyer 1997). They show that the rate of hospital commitment for parasuicide of adolescents and young adults in the 1965-1980 period increased, concurrently with the suicide rates in the same countries.
On the other hand, other research seems to indicate that parasuicide is the clearest predictor for suicide (Asgard et al 1987). Follow-up studies show that 10-14% of people with attempted suicide have a higher probability of suicide death, the suicide risk being 100 times higher than in the general population.
Other studies (Kreitman 1982; Kendell & Zealley 1988) targeted the reasons that might drive someone to parasuicidal behavior, estimating that the wish to cut out consciousness and the cry for help to mobilize others to change their behavior toward the subject are the most frequent motivations for parasuicide.
A multi-institutional study of parasuicide, with data from 10 countries (Finland, France, Hungary, Italy, Holland, Norway, Spain, Sweden, Germany, and Denmark), initiated by WHO, indicates that the suicide rate in 1989 considerably oscillated between different centers. The highest suicide rate for males was located in Helsinki (Finland), namely 414/100,000, and lowest in Leiden (Holland), of 61/100,000. For women, the highest rate, of 595/100,000, was found in Guipuzcoa (Spain).
Generally speaking, all of the centers confirm that the parasuicide rate is higher in females than in males. There is one exception, in Helsinki, where male parasuicide is rather more remarkable. As for the age, when this behavior is displayed, it is usually placed between 14 and 44 years. There is considerable variation among countries regarding the age category that shows the highest suicide rate. In some countries of Europe the decade 15-24, in others the decade 25-34 are best represented. (Kreitman & Schreiber 1979; Mintz 1970)
Estimations of the prevalence of parasuicide during one's lifespan vary from 1% to 20% (Paykel et al 1974; Pronovost et al 1990). A number of studies calculate the prevalence of parasuicide for teenagers only. It would be reasonable to expect an increase of the prevalence rate with the age, as time passes, yet a series of stressors accumulate that supposedly increase the risk of parasuicide. Surprisingly, the rates of parasuicide during someone's lifespan, when reported to the general population do not rise above the rates for teenagers. A possible explanation might be the precocious age, when the auto-aggressive behavior is displayed for the first time.
The prevalence of parasuicide during the life span Study Year Prevalence (%) Paykel and coworkers 1974 1.1 Hallstom 1977 4.5 Smith and coworkers 1986 10.5 Moscicki and coworkers 1989 2.9 Dubow and coworkers 1989 7.0 Rubinstein and coworker 1989 20.0 Andrews and coworkers 1990 6.8 Kienhorst and coworkers 1990 2.2 Nagy and coworkers 1990 12.1 Pronovost and coworkers 1990 3.5 Diekstra and coworkers 1991 4.8 Study Subjects Paykel and coworkers Adolescents Hallstom Women only Smith and coworkers Adolescents/young adults Moscicki and coworkers Adolescents Dubow and coworkers Adolescents Rubinstein and coworker Adolescents Andrews and coworkers Adolescents Kienhorst and coworkers Adolescents Nagy and coworkers Adolescents Pronovost and coworkers Adolescents Diekstra and coworkers Adolescents
Statistical data of suicide in children
The majority of the authors think that suicide risks increase with age. Indeed, suicide achievement is extremely rare in childhood--before the age of 12--and begins to become more common at puberty, the risk and incidence of suicide increasing with every teenage year.
In Great Britain 5 suicides/million /year was registered for children between 0 to 14 years (Kreitman 1981). A higher proportion of suicides was found in boys. While males show a propensity for methods with greater lethal potential (hanging, shooting, electrocution), by contrast females seem to prefer acute voluntary intoxications (mainly with analgesics and tranquilizers). In the 1990th, British authors signaled the latest 'fashion' among teenagers, of using paracetamol in acute voluntary intoxications.
Statistical data of suicide in teenagers
Stigma attached to a suicidal act create difficulties in assessing the real magnitude of this public health issue at very young ages (Barraclough et al 1974).
Rarely recognized, suicide-declared mortality is low before the age of 15. The refusal to accept the idea of voluntary death in a child or preadolescent leads to the underestimation of suicide diagnosis in favor of accidental death.
On the other hand, after the age of 15, suicide reporting increases and defines as a neat fact, so that all European statistics rank it among the first three death causes in teenagers, after accidents and cancer.
Global suicide rates seldom figure as death causes, yet suicide is the most important cause of premature death, and this could also be expressed in potential years of lost life. By this evaluation, suicide is placed among the global health indicators, ranking third among death causes (WHO data from 1994).
Austria, the USA, Denmark, and Switzerland are countries with a high frequency of suicide in teenagers, by international estimations. The global values for both sexes are situated from 23/ 100,000 people upwards in the USA and Denmark. Lower suicide rates are recorded in Great Britain: 4.1/100,000 residents and in the Netherlands, 6/100,000 people. (Barraclough & Pallis 1975)
Recent statistics delivered by a group of epidemiologists from Lyon, under the supervision of prof. Terra, found that suicide death in teenagers in France is the second death cause, the first one being road accidents.
Generally, the suicide rate in young populations (from 15 to 30 years), was much lower in 1970 than in 1987, as the data provided by Buda and Tsuang, for the United States, seem to show.
There is a dramatic difference between male and female adolescent suicide rate, of 4:1 in favor of males. But 90% of attempted suicides are in female adolescents. These results are surprising, due to the possibility of comorbidity with depression, more prevalent in female adolescents.
An increase of the number of female suicide in the 18-24-year group was signaled, so that the males versus female suicide rate changed from 3:1 to 2:1 (Bem 1987)
A study (Cosman et al 1997) targeted suicide for the 15-19-year age group living in urban areas, namely the city of Cluj-Napoca. Data were collected by the Legal Medicine Institute of Cluj, and also from decease certificates issued by Cluj-Napoca Mayor Hall. The reference period was 1985-1991, and covered a period of seven years.
The suicide rate we found is the lowest figure in history, so that a doubt arises about the accuracy of the statements on death causes in adolescents. The number of deceases per year was reported to the global city population of that year. The lowest suicide rate was registered in 1985, namely 2/100,000 residents. For 1990-1991, a rate of 1,2/100,000 was calculated.
The global gender report for all of the 7 years was somewhat lower, of 2/1, favoring the males (gender-ratio m/f = 1.8/1).
The most frequent cause of death was hanging (57%), a method selected mostly by males, but also by females. Another favourite manner of self-murder was barbiturates intoxication (Diekstra et al 1982), while electrocution, self-ignition, acid or insecticide intoxication were used only in singular cases.
Suicide data for Europe show that, in these countries, there were two periods with higher mortality in adolescents. The former was represented by the 80s. In fact, Alfred Adler and Sigmund Freud, alerted by the events in 1910, organized, in Vienna, the first scientific conference on suicidological problems, under the patronage of the Vienna Psychoanalytical Society. As statistics showed dramatic increases of suicide in high schools, the term "school epidemic" was coined to reflect the phenomenon.
Following that peak, the suicide rates decreased continuously until the '50s; after 1980, the adolescent suicide rate started to rise again, reaching the level of 1910.
In France, juvenile and adolescent suicide incidence shows a prevalence of male as compared to female suicide, the male suicide rate being 2.9 times higher. The suicide rate rose in a significant way, in mid '70s. In fact, since the 1950-1970 period, suicide incidence among adolescents, within the framework of a global stability of the suicide rate, represented by 20 deaths per 100,000 inhabitants, increased slowly but steadily. This increase was explosive at the appearance of the hippie movement, which was followed by the increase in drug addiction, with morphine, heroin, hashish, LSD, and so on.
It is possible that in the future, juvenile and adolescent suicide may follow a development path related to schemes and cultural attitudes, which have gone international through mass media and the Internet. Environmental factors imprint a specific lifestyle, hence the increased availability of drug use, of firearms purchase, and other aspects that generally disrupt an individual's life. Beyond social factors that tend to become more and more uniform across the globe, the fact that there is a general augmentation of depressions at young ages cannot be overlooked.
In the United States, there has been an increase of suicides in young population too. So, for adolescents and youth, suicide rates increased from 6.3/100,000 in 1955 to 20/100,000 in 1980, and for adolescent girls the increase was from 2/ 100,000 in 1955 to 4.2/100,000 in 1980.
Estimation of attempted suicide and parasuicide rate. At adolescence, there is a contrast ratio between suicide and attempted suicide, favoring the latter. If, in the general population, the suicide rate in adolescents is about 0.35/100,000, for attempted suicide it is 7.5/100,000 for boys and 13/100,000 for girls. The computed proportion is: a death for 60 attempted suicides at adolescence, to a death in 13 attempted suicide at all other ages. Another general characteristic of attempted suicides in adolescents is that they are recurrent. In other words, it may be said that, after a first attempt, one of two adolescents will reiterate the auto-aggressive gesture. Gender distribution favors young male adolescents, with a peak at the age of 17 years. (Schmidke et al 1996)
For attempted suicides, statistics demonstrate a high frequency of disorganized families, or with divorced parents, where the absence of paternal authority seems to be of particular significance. The presence of numerous suicidal behaviors, psychiatric disorders and alcohol dependence in their familial antecedents has also been detected in adolescents with attempted suicide. (Landy 1984)
Sociologists also considered the demographic characteristics that could influence the suicide rate in adolescents. An increase of the rate at this age is observed, as the percentage of adolescents is higher in the general population. (Bem 1987; Cosman et al 1997)
Statistical data specific to suicide in adults
Recent statistics, from 1998-1990, attest that the male suicide rate is higher than female suicide rate, in adulthood too.
Generally, the suicide rate increases with age, for both sexes. In countries like Canada, females commit suicide most frequently between the age of 35 to 44 years, and in the USA, Sweden and Holland the female suicide peak is situated in the decade 55-64 years (Diekstra et al 1989).
In adult men, the lowest suicide rate in Europe is registered in Malta, (10.4/100,000 inhabitants). At the opposite extreme is the Hungarian male suicide rate (58.1/100,0000 inhabitants).
Female suicide in the 45-64 decade is very low in England (5.1/100,000 inhabitants) and worryingly high in Denmark (27.3/100,000 inhabitants) (Landy 1984).
Statistical data specific to suicide in the elderly people
In almost all countries of the world, the suicide rate in elderly people is higher than in the general population. In Europe, the suicide rate of 100,000 residents per year delimits three groups of countries: the first group includes countries such as Hungary, Austria, France, Belgium and Switzerland, in which the suicide rate in the elderly is higher than 60/100,000 inhabitants; the median group, with a suicide rate in elders of 60/100,000 inhabitants (Landy 1984; Makinen 1997), is represented by the Scandinavian countries (excepting Norway), namely Finland, Denmark and Sweden. Germany and Italy belong to this group too (Moens 1990). The countries of the last group, namely Holand, Norway, Great Britain and Ireland, have a rate of 20-40 suicides in 100,000 inhabitants/year. In other industrialized countries, like the USA and Japan, the suicide rate for the elderly is identical with that of the median group; and in Canada and Australia, the suicide rate in the elderly is identical with that of the European countries with the lowest rate (20-40/100,000 residents/year). (Ross & Kreitman 1975)
A possible explanation for the abovementioned suicide/attempted suicide rate, one that would partly account for this statistical evidence, lies in the fact that death wish looks extremely convincing in elderly people. If in adults a suicide corresponds with 10-20 unsuccessful attempts, in elderly people a suicide corresponds with 2-4 unsuccessful attempts. (Sainsbury 1986)
Suicide in Romania
Suicide has a multiple causality, it appears at almost all ages and life cycles, and is prevalent in all cultures and societies. In different historical epochs, and in diverse geographical areas, the ideas of suicide have been influenced by specific psychological, cultural, and spiritual factors. But deceases by suicide have constantly occurred, having as their common denominator the action of intentional self-murder.
Differences between the suicide rates in various nations are self-revealing and stable. The mortality rate by suicide oscillates between enormous rates (around 40/100,000 inhabitants in Sri Lanka, Lithuania, Estonia, between 19941996) and the zero level, the absence of suicide as mortality cause (zero rate at 100,000 inhabitants in 1999, in Jordan, the Dominican Republic, Honduras). (Sainsbury et al 1981; Hafner & Schmidtke 1985; Goldney & Katsikitis 1983)
Though accessible, it is difficult to correctly estimate the rate of suicides in Romania, in the absence of some instruments and authorized institutions abilitated to carry out serious epidemiological research. Communication with WHO regarding suicides, once prohibited by the Ceausescu regime, became possible in the post-revolutionary years. This really gratifying fact was made possible, among others, by the inventory of self-murder behavior in the legal medicine network, given the suicide's character of "violent death." (Linehan 1987)
Suicide rate in Romania. Demographic aspects
In the last 10 years, Romania communicated values of a total suicide rate between 12.7 (1994) and 13.3 (2003) for 100.000 inhabitants.
In a series of suicide rates in 34 European countries, Romania is ranked 24th, the first place going to Lithuania, and the last one to Greece with 4.1/100,000 inhabitants.
The suicide rate in Romania (In conformity with the Report on the activity of the National Network of Legal Medicine in 1998) Risk zones Counties Suicide rate/100,000 inhabitants/year Alarm zones Salaj 37.00 Harghita 36.01 Covasna 29.62 High risk zones Tulcea 24.88 Arad 23.54 Satu Mare 21.34 Middle risk zones Sibiu 16.05 Brasov 17.74 Botosani 17.52 Cluj 14.90 Minimal risk zones Alba 8.57 Prahova 6.06 Mehedinti 5.06 Vrancea 4.21
Romania is surrounded by countries with higher suicide rates. So, classifying the European countries as to the level of suicide rate in 100,000 inhabitants, Hungary ranks 4th, Ukraine 8th, Serbia and Croatia 10th, Republic of Moldova 17th, and Bulgaria 18th. (Bertolote 2001)
This analysis demonstrates that in Romania, the suicide rate is below the European average, namely lower than 20/100.000 inhabitants.
In Romania, the situation is different from one geographic zone to another. One could find counties with a suicide rate higher than 25/ 100,000, counties with a suicide rate between 10 and 25/100,000, and counties with a lower rate, under 10/100,000 inhabitants.
The interpretation of these statistical data that demonstrate a big difference in suicide rate from one geographical area of Romania to another one, uses demographic data, taking into account the composite character of the population, mainly in Transylvania, but not only there (see also Tulcea county). The incidence of a significant number of Hungarian ethnics in Harghita and Covasna counties that come first as to the suicide rate in Romania is well-known.
Several Romanian psychiatrists (Cosman 1995; Veress 1997) demonstrated, in their epidemiological research, the connection between a higher suicide rate, above the county average, and the high presence of Hungarian ethnics in the population from various Transylvanian zones.
Thus, in her PhD thesis, Cosman (1995) found a correlation between the suicide rate and the population composition in Cluj. The demographic data were obtained from Population Statistics and the Population and Dwellings Census in Romania on January 7th, 1992 (volume 1) with the assistance of the Regional Council Cluj.
In conformity with the data provided by the census, the Romanian population of Cluj-Napoca counted 248,572 inhabitants (75.6%) in late 1991, while the Hungarian population counted 74,871 inhabitants (22.7%). Ethnic membership suicide distribution was in 1991 as follows: Romanians--30 deaths, Hungarians--16 deaths, and 2 deaths in persons of another nationality (see the table below).
The suicide rate in Romanians is equal to the country average of 12/100,000, but in Hungarians it is almost double--21.3/100,000 inhabitants.
The suicide rate correlated with suicide nationality distribution in Cluj-Napoca population Inhabitants in Cluj-Napoca Romanian Hungarian German Population 328.602 248,572 74,871 1,149 Percent (75.6%) (22.7%) (0.3%) No. Suicides 48 30 16 0 Suicide rate/ 14.6 12 21.3 0 100.000 inhabitants Inhabitants in Cluj-Napoca Romani Jew Other ethnics Population 328.602 3,201 344 512 Percent (1%) (0.1%) (0.2%) No. Suicides 48 0 0 2 Suicide rate/ 14.6 0 0 11.7 100.000 inhabitants
The census also evidenced some peculiarities valid not only in Cluj-Napoca population but also for other zones of Romania. As expected, the male mortality rate was higher than the general population rate (17.5/100,000 male inhabitants to 14.6/100,000 inhabitants in the general population). The female mortality rate, although lower than the male one (11.8/100,000 inhabitants) was however an alarm signal for its relatively high value, and provided us with a convincing proof of the increasing suicide rate among women. A change of the male/female suicide ratio of 3/1 to 2/1 has also been noted in some regions of Europe (e.g. in France). In Cluj-Napoca, this ratio is even lower, 1.3/1, and fits into the general pattern of Romania, which shows an increase of female suicide in urban areas.
Mortality by suicide in the three age groups (adolescents, active population--persons between 20 and 60 years--and elderly people) was studied and the following rates were calculated:
* The suicide rate in adolescents: 10.3 in 100.000 adolescents;
* The suicide rate in active population: 17/ 100.000 inhabitants;
* The suicide rates in the elderly people: 31.7/ 100.000 over 60 years.
The conclusion, following the correlation of our data with the demographic data obtained from the suicide census in Cluj-Napoca, is that the maximum suicidal risk occurs in three population categories: the elderly (31.7/100,000 inhabitants), the Hungarian ethnics (17.5/ 100.000 Hungarian ethnics in 21.3/100,000 inhabitants), males (17.5/100,000 inhabitants). The suicide rate in Cluj-Napoca population is approximately the same as the average suicide rate in Romania. The figure doubles for the Hungarian population, it is however lower than in Hungary (41.4/100,000 inhabitants, according to WHO statistics Annual 1988-1990).
By contrast, in Covasna and Harghita counties, the suicide rate is constantly high, and these counties come first and second. Since 1993, in Harghita county, constant values of over 30/ 100,000 suicide rate have been registered, the highest in all of Romania. The maximum value of this public health indicator was reached in 1993, by 38.45 in 100,000 inhabitants. (Cosman 1985)
As for the counties with a low suicide rate (Mehedinti, Vrancea), mention must be made that the Romanian population prevails (more than 95% are Romanians).
The research carried by the Romanian authors mentioned earlier confirms the hypothesis of Cavalli-Sforza (1994), namely that the migrating Agra-Finch populations that invaded Europe in the 9th century, and settled down on present-day Hungarian territory, and in the northern zones of Europe, imprinted a genetic component to the contemporary population, to be found in such behavioral features as increased impulsivity, emotional lability, instinctual disinhibition features that, under certain circumstances, might favor suicidal behavior. This also corroborates with the variability of the suicide rate from country to country, at a European level, which decreases from northeast to southwest. It so happens that in Romania, the suicide rate is lower than in all the surrounding countries, except for the two counties with a majority of Hungarian population, which show higher suicide rates, closer to those of Hungary rather than to those of Romania.
Suicide distribution on gender and age groups
Suicidal behavior in Romanians seems to be similar to that of other people in Europe and the United States, in the sense that the incidence of male suicide is higher than female suicide. So, gender suicide distribution shows a male prevalence of 3/1 as compared to female suicide.
Urban and rural males had a continuous increase of suicide incidence, from 16.3 to 22.5 in 100,000 inhabitants, from 1994 to 2003. For the same decade, the most significant increases were registered in the 40-59 age group (from 26 to 39.9/100,000) and in the 60-79 age group (from 26.3 to 33.3 in 100,000 inhabitants).
During the same period of time, suicide rates show an insignificant decrease (from 5.5 to 4.6/ 100,000) in females.
Risk factors and, implicitly, prevention methods may be differentiated by analyzing suicide rates related to age particularities, and adapting them to the clear-cut differences in the self-murder method to the specific stress factors, or the prevalence of some psychopathological disorders, for different ages.
In Romania, in the last decade of the 20th century, the suicide rate in the 40-59 years group age, that represents the most active population of the country, but also the most vulnerable to stress (from 16.9 in 1994 to 22.8/100,000 in 2003) increased. Unemployment is cited by various authors (Platt 1986; Moser 1987) as generating a two-times higher suicide risk increase, relative to persons of the same age, than those who do not suffer from the stress generated by this problem.
Suicide distribution increases with age, so much so that in absolute values, in Romania, the greatest number of suicides is registered in the age group above 65 years. Increased suicide rates in the elderly population versus the active population has social explanations too. The elderly were born in a constitutional monarchy, in a small state, yet with a flourishing economy. This is the generation of war veterans, who carried the burden of the world conflict on their shoulders, the same who, once back home, had to accept the coming to power of the Communist regime and to keep silent. Taught never to neglect their duty, they raised and consolidated the socialist Romania, lest "their descendants should be deprived of anything." Defeated by historical evolution for a second time, they woke up overnight, discriminated by the Revolution. The transition period, through its tough mechanisms, instead of treating them as they deserved, transformed them into the poor population category in the country, depriving them, to a large extent, of the dignity of decent living. (Cosman 1995)
A further remark on the suicide of elderly women: they suicide twice as frequently as women under 40. Data are from the research carried out in Cluj county, covering a 14 year period (1984-1998).
In Romania, the suicide rate in adolescents is a hardly known, and rarely recognized problem. Declared mortality from suicide under 15 years of age is low. However, after 15 years of age, the number of reported suicide cases increases, generating concern, especially in conditions of easy access to drugs and maximal lethality means, for self-murder actions (firearms).
International studies on suicide assessment place Austria, the United States, Denmark, Switzerland, among the countries with increased suicide rates in teenagers; it comes third as death cause, after road accidents and cancer. Estimated values for both sexes are 23/100,000 for Switzerland, 18/100,000 in Austria, 12/100,000 in the USA and Denmark.
Recent epidemiological studies in Romania register very low suicide rates in adolescents, around 3/100,000, which raises questions about the accuracy of declared causes of mortality, for this age category.
A study performed between 1985 and 1997, exclusively in the urban medium, on the 15-19 year age group, registered lower results than those reported by literature, which makes us doubt the accuracy of the declared causes of death in adolescents. The highest rate of suicide in adolescents was reported in 1985: 9/100,000 inhabitants. Beginning with 1986, the rate decreased until 1996, when it reached 0.4/ 100.000 inhabitants. The gender suicide rate for the entire period shows a prevalence of male suicide (M/F = 2.8/1). (Cosman 1997; Cosman 1999; Cosman 2001)
Psychopathological aspects related to suicide
Extremely high suicide risks generated by certain psychiatric disorders which, associated with stable, or contextual social factors, trigger the passage to the self-killing act, are well known.
Many psychiatrists have associated suicidal risks with depressive disorders. The depressive syndrome occupies a central position, and so does its comorbidity with other psychiatric disorders (schizophrenia, drug dependence, chronic alcoholism, anxiety disorders), and also with somatic disorders (cardiovascular diseases, cancer, AIDS).
In Romania, there are few statistical data related to the proportion of persons with psychiatric disorders, in suicide deaths, and only inconsistent data referring to psychosomatic diseases that constitute the obvious reason for committing suicide. Painstaking research, such as psychological autopsy to attest and certify the causal relation between a disorder and the self murder gesture is needed. However, in Romania, psychological autopsy is the exception rather than the rule as an investigation method, mostly because catamnestic data are difficult to collect, particularly from persons involved in the mourning process.
The Medical Psychology Department in the University of Medicine and Pharmacy in Cluj-Napoca carried out, more like an experiment, a study covering a 14 year period. (Cosman &Mali]a 2002)
By means of psychological autopsy, a psychopathological history was evidenced in 1207 persons deceased by suicide in the county of Cluj for the 1985-1998 period. Of these, 223 subjects suffered from psychiatric disorders. Established diagnoses show the prevalence of chronic alcoholism and affective disorders for about 1/3 of them.
Some remarks are necessary. From this regional study, the diagnosis of disorder induced by drug consumption is missing, as this trouble did not constitute a significant presence in Romanian psychopathology before 1995.
By contrast, one could see a massive presence of the diagnosis of chronic alcoholism, a percentage equal to that of the depressive episode. The observation has consequences in the psychopathological and also the social field, as chronic alcoholism affects a significant number of the country's young population.
Whatever the diagnostic composition of the suicide cases with psychiatric history, the suicide risk increases rapidly in the period following immediately the externalization from the psychiatric ward. Goldacre and coworkers (1993) communicated a suicide risk 200 times higher for the patient recently externalized than for the other persons. In Romania, it was not possible to calculate this risk, due to the lack of a national registers for psychiatric casuistics. As an empirical observation, in 2003 the dysfunctionality in the allowance of psychotropic medications, including antidepressants, was followed by a wave of suicides in the patients, for such diagnoses as psychoses, bipolar affective disorders, or major depressive episodes.
In fact, the system of medical assistance in cases of suicidal risk is at fault, in Romania. The hospitals cannot afford to provide long term treatment to patients with a medium or severe suicide risk, who no matter what the diagnosis is, need longer hospitalization. Swift externalizations, before the due term, could cause the increase of the suicide rate, in persons with suicidal ideation. As a countermeasure to this situation, mention should be made of the inception of The National Programs of Psychiatry, with formal functioning (in the psychiatric wards), and also on an out-patient basis (in polyclinics, ambulatories of the psychiatric wards, mental health centers). In 2003, The National Program of Psychiatry ensured modern antidepressant medications to all of the county hospitals in the country, for the whole period of its implementation.
Diagnosis distribution in 23 patients who committed suicide between 1985 and 1998 Diagnostic category % Category No. of Code suicides Mental disorders due to F10 76 alcoholism 32.61 Mood disorders 32.18 F30-F39 75 Neurotic disorders correlated with F40-F49 52 stress and somatic disorders 22.31 Schizophrenia, schizotype and F20-F29 20 delusional disorders 8.58 Personality disorders 4.2 F60-F69 10 Total 100 233
Seasonality of suicides in Romania
The influence of meteorological factors on suicidal behavior was first mentioned in the 19th century by Durkheim. In Romania a pertinent, tenyear long study for the seasonal impact on the increase of suicide rates during certain periods of the year was done too. A first peak was identified in May, June, July, August and a second one in October-December. (Cosman & Coman 2001)
The same bimodal distribution was found in male suicides, together with a positive correlation of suicide with the rising variation of the photoperiod from week to week, the most significant period of the year being between the spring equinox and summer solstice. Maximum luminosity drastically suppresses melatonine secretion, generating neuroendocrine mechanisms responsible for increased impulsivity and propension to get out of control actions, specific of suicidal behavior.
This research relates factors triggering or favoring suicidal behavior, with prevention measures to be taken in the future, in a coherent program and in accordance with Romanian conditions.
The implication of social conditions on the suicidal behavior
We have few data about suicidal behavior in Romania during the communist totalitarian regime. Suicide statistics were not publicly released, nor were they handed to international medical or political organisms and forums. This strategy was meant to cover up the sad reality of the concentration camp conditions in which most of the population lived. The isolation typical of totalitarian regimes, in addition to its psychological impact, caused an immense shortage of treatment resources in medicine that accounts for the major differences between Romanian and European or American psychiatry. Although it is generally thought that social factors do not have a direct impact on suicide rates, there is however, indirect evidence that the social context is responsible for the suicide statistics in Romania.
We actually carried out a statistical study covering five years of Ceausescu's regime, which continued in the next transition period.
A decrease in the suicide rate from 23.8/ 100,000 to 15.4/100,000 since 1985 to 1989 may be observed. Compared with the preceding years, the period after 1989 displays the same tendency, with figures that reach 11.2/100,000 in 1992 and even 9/100,000 in 1995.
The suicide rate in Cluj-Napoca, in 1985-1998 Year No. inhabitants No. deceased Suicide rate/year/ in Cluj-Napoca /year by suicide 100,000 inhabitants 1985 309,843 74 23.8 1986 310,017 69 22.2 1987 314,017 61 19.4 1988 315,687 55 17.4 1989 317,914 49 15.4 1990 329,234 51 15.5 1991 328,602 48 14.6 1992 312,712 36 11.2 1993 325,918 41 12.0 1994 331,635 41 13.2 1995 330,843 30 9.0 1996 332,297 51 15.3 1997 332,792 41 12.3 1998 332,498 43 12.9
A comparison of the overall suicide rates (the cumulated rate of male and female suicide) from the 1985-1986 period with the 1992, 1995, 19971998 years shows a clear difference between these two different political regimes. The drastic demise (as much as 50%) of the suicide rate in the years following the December 1989 Revolution is obvious. But was the change of political regime the decisive factor for this dramatic change?
Poor social and economic conditions, illness and all types of frustrations seem to have made a huge difference on suicidal behavior during the communist regime. Since the 1989 Revolution, psychiatric assistance has greatly improved, and so has the quality of treatment: suicidal risk cases are identified much earlier, a psychiatric assistance network has been created, and generally speaking, drugstores are better supplied with highly efficient antidepressants, even though most of them are imported.
In the last years of the millenium, a slight increase of the suicide rate, mainly in men was however noticed. The most important factor to be mentioned was alcohol consumption, rather more frequently associated with suicidal behavior after 1989.
The impact of drug consumption and drug addiction on the suicide rate are not yet known, even if, at present, these are very carefully monitored in all psychiatric wards and reported through the Directions of Public Health to the Ministry of Health. It is well-known that a drug consumer has a 20 times higher risk to commit suicide than a person who is not drug-dependent.
Contemporary society is permissive, and self-destructive means may be acquired easily. The methods to commit suicide in these last years oscillate from gentle (medicine ingestion, mainly by the women) to some extremely brutal (hanging, precipitation and so on), the frequency of lethal methods (firearms) by the young ones being noteworthy.
The social impact on suicidal behavior may result, in the future, also from the change in the population composition, in the increase of the urban population at the expense of the rural one. If the changes that are now taking place in the rural areas of Romania substitute too quickly new mores for well-established Romanian traditions, one could see a destabilization of norms, values and interpersonal relationships, which undermine the social integration of the individual in the community.
Retrospective epideomiological studies - psychological autopsy
The actual study of the phenomenon of suicide is based mainly on prospective and retrospective surveys and epidemiological characteristics.
Retrospective studies, as they refer to a strictly definite case, in which death occurs as a result of a specific and well-individualized action, are most revealing.
These studies consist of either personal, biographical observations of some representative cases (well-known patients, celebrities) with their uniqueness, paradoxes, and epidemiological data, or of surveys conducted on large samples.
If epidemiological studies have as an objective the identification of suicide risk factors, these retrospective surveys, called psychological autopsies, seek for the motivation, by determining the psychological profile of the deceased person, with the help of information collected from surveys conducted on large samples (family, friends, colleagues, associates, physicians). The investigation of the personality profile of the deceased allows for the correct interpretation of epidemiological investigations, and the identification of psychological differences between various typologies of self-harm is useful for the assessment and prevention of the suicidal risk.
At the origin of psychological autopsy is the study performed by Robins, one of the 'fathers' of DSM-III and DSM-IV. His investigation (1959) focused on the general population (St. Louis--USA) and not only on the population sample with psychiatric antecedents. The relatives of the deceased by suicide were asked to respond to structured questionnaires, one year after the event. 134 cases of decease by suicide were investigated, by interviewing 305 persons, the structure of the interview covering not only the medical domain (medical antecedents, psychiatric history, details of the self-destructive act) but also the family and social circumstances (family life, personal history, life events). The most important result was the relation found between the self-destructive act and the psychiatric pathology, represented mainly by affective disorders and/ or chronic alcoholism.
Thoroughgoing studies were also conducted in Great Britain by the members of the Chicester Group: Sainsbury and Barraclough (1968). 14 years after the psychological autopsy conducted by Robins in New Orleans, Barraclough and coworkers carried out a retrospective type research in England, on 100 cases, that is still a model of methodological perfection for psychological autopsy. The authors used a questionnaire of 252 items, and analyzed medical documents from psychiatric hospitals. The originality of their approach lies in the fact that they also used control groups from a psychiatric healthy batch, a batch of depressives, and a batch with chronic alcoholism. The results they reached were similar to what their American colleagues had found by a different approach. The British researchers concluded that 90% of the self-murderers pertained to the group diagnoses of depression, respectively chronic alcoholism.
The conclusions of the three studies are similar, as suicide is associated with psychiatric disorders in a significant proportion (for over 93% of the deceased), the pathologies most frequently identified being depression and chronic alcoholism. If depressive persons commit suicide in relationship to the lack of hope, guilty feelings, those with chronic alcoholism have an appreciable charge of negative life events represented mainly by the social consequences of the abuse and dependence on the psychoactive substance (family conflicts, problems with the justice, professional failure, financial losses). In this last group, the somatic sufferings triggered by massive and prolonged drug consumption (hepatic cirrhosis, chronic pancreatitis, superior digestive bleeding, and so on) should be added.
In Hungary, Arato and coworkers (Veress 1997) performed the psychological autopsy of 200 cases of suicide committed in Budapest, in 1985. This retrospective study also revealed the high frequency of psychiatric diagnoses in the deceased: recent major depression (58%), reactive depression (5.5%), chronic alcoholism (20%), without psychiatric diagnosis (19%).
The same surveys also showed that the percentage of sane suicides is low, represented by only 7% of the deceased. However, in these cases one may speak about suicide as a prime and unique signal of the onset of psychiatric suffering.
Mention must also be made that in the last year of their life, the persons who committed suicide had repetitively asked for medical services. In the study conducted by Robins, 73% of the persons who committed suicide were under medical care, 87% in Dorpat's, while in Barraclough's the percentage was maximum, i.e. 100% of the deceased. With reference to the study by Sainsbury and Barraclough, it is surprising that 40% consulted a doctor in the last week of their life, and 19% in the last month. What results from these data is the recognition of the symptoms of the depression, its degrees of severity, and the necessity of emergency hospitalization the moment the suicidal risk is identified.
The number of studies of this type have lately increased. A recent study carried out by Cho (1997) demonstrated that the suicidal risk factors in Japan are the same as in Europe and in the United States. Even if Japan is a country with specific types of suicidal risk (seppuku, kamikaze), the rate of suicide is lower than in many European countries. Of the 93 cases studied by the Japanese author, 46% had diagnoses of depressive disorders, 26% of schizophrenia, and 6% of drug abuse. The significant percentage of schizophrenia diagnoses among those deceased may be correlated with the increased rate of this diagnosis in the population of Japan. The conclusion of the Japanese authors leads to the idea that, with schizophrenics, the suicidal risk factors are represented by increased aggressivity accompanied by impulsivity and the wish to die, while with depressive individuals, the risk factors are similar to those identified by European and American authors: the initial period of depression, the first episode of major depression, the comorbidity with personality disorders and somatic illnesses.
The psychological autopsy by Finnish research workers (WHO 2002) also revealed the importance of other risk factors, in the triggering and the achievement of suicide, like stress, difficulties in social integration, peculiarities of daily life, mostly isolation, and also the prevalence of some psychosomatic illnesses and several types of personality disorders.
Retrospective surveys face many methodological problems. The first one is the uncertainty regarding the cause and nature of the suicide. This appears when the intention is ambivalent, when the self-destructive method is inconclusive, or when death occurs after a considerable delay. In such situations, when a different interpretation could be given to the causes of death, the term of equivocal suicide is used. A supplementary problem in the analysis of these cases is the lack of information about the victim, that could help investigators reconstruct the psychological profile of the deceased person, due to negation, evasion, concealment, and even suppression of the proofs given by the relatives. The police seem to be uninterested in such cases, as long as there is no suspicion of homicide.
The emotional responses of the investigators may sometimes interfere with their objective judgment. A non-experimented research worker may identify himself with the mourning family, and reach the conclusion that it is not a suicide case, in spite of self-revealing proofs. The proofs that certify emotional distress are the objections of the family to the emitters of the diagnosis of death by suicide, or the requests of the attorney to have this diagnosis changed. A motivation for the relatives would be to obtain some material benefits, such as life insurance.
A methodological requirement is the specification of the onset of psychological autopsy. The majority of the authors agree that the best time to start it is from 4 months to one year after the suicide, in order to permit people to overcome the most dramatic portion of the process of the post-suicide mourning, even if some authors make retrospective surveys as early as 3 months after the event. Of course, the birthday of the deceased person and other family anniversary days and holidays should be avoided.
The initial contact with the family should be established by means of a letter, followed by a phone call.
The interview shall be conducted by persons with experience in psychological counseling. It begins with indirect questions, and direct questions after that. It is recommended to avoid excessive transcriptions of the family testimony in order to permit free expression, verbally and emotionally.
The integrity of the memory of the deceased should be respected, and also the desire of the relatives to avoid discussing some particular aspects. It was demonstrated that discussions might also have a therapeutic potential, by reducing the guilt feeling of the survivors, thus speeding up the postvention process.
Some persons feel more at peace with themselves after the psychological autopsy, due to the attention given to the case. After the survey, they may accept the death of the victim more easily, by clarifying their own feelings related to the tragic event that marked the family in case.
In order to assess the diagnosis of psychiatric disorder, the internationally used diagnostic criteria cannot be used, as they may not be familiar to the family members. For that reason, the diagnosis is only presumptive, given the behavioural and attitudinal details, or convictions perceived as pathological by the relatives. For the evaluation of personality disorders, the use of standard scales is recommended, so as to avoid embarrassing testimonies, particularly when they refer to personality traits with negative connotations (impulsivity, hostility, aggressivity).
Another aspect of the research concerns the validity of the data, because it is impossible to avoid the selective recall, by the tutors of the patient, as they tend to focus on those facts and life events that project a positive image of the deceased and, implicitly, elude the negative ones. For this reason, the use of at least two information sources is recommended.
As an epidemiological investigation method, the psychological autopsy is an exception rather than the rule, in suicidology. The main methodological difficulties reside in the difficulty of collecting catamnestic data, and in the increased risk of counterfeiting them by the persons involved in the mourning process. Psychological autopsy opens up the discussion with the family about the factors incriminated in triggering the suicide, and arrives at more realistic conclusions related to this fatal act, wrapped in mystery and shame until then.
As suicide is a rare statistic behavior, with an uncertain possibility of prediction, the discovery of the specific risk factors (psychiatric pathology, depression and addictions, associated with negative life events) through retrospective studies is of paramount importance for the national prevention programs. (Alexandrescu 1993)
The suicidal risk
Suicide, "the absence of the others," as Paul Valery says, is an example of human behavior in which both genetic and environmental factors are important and necessary, since none of them is sufficient in itself (Hoy 1982).
The genetic risk
Hypotheses suggesting the influence of the genetic factor have seldom been analyzed. Although families with a higher suicide rate are known and reported in literature (Kerman et al 1985), this has been explained with reference to cultural and psychological aspects specific of these families, without invoking the genetic factor.
In 1967, Haberlandt found a concordance of 18% of the suicide rate in a total of 51 pairs of monozygotic siblings and no concordance in dizygotic siblings. Recently, Juel-Nielsen and Videbeck found a significant number of suicides in pairs of monozygotic siblings.
The study on Amish families carried out in Pennsylvania, over a period of 100 years is certainly noteworthy. The authors recorded 26 suicides, most of which were committed in 4 families, characterized by a high incidence of depressive mood disorders (Egeland & Hostetter 1983).
In 1983, Roy and Tsuang simultaneously and independently observed a significantly higher risk of suicidal behavior in patients whose families had a history of suicide, than in the relatives of those without such antecedents. So, it seems that there is a genetic factor that favors suicide and operates independently, in addition to depression and other major psychoses. There is every prospect of the genetic predisposition to suicide representing a tendency to impulsive behavior, in which suicide is the first way of manifestation. It is possible that the genetic factor of suicide may be represented by the individuals' incapacity to control their impulsive behavior (Cohen et al 1987), while depression and other psychiatric diseases serve as mechanisms that enhance that behavior, and act as triggers that hasten the transition to the act of self-inflicted harm.
In conclusion: studies on families, the few comparative studies on monozygotic and dizygotic twins, as well as adoption studies push forward the idea of the existence of a genetic vulnerability for suicidal conduct. This genetic factor, specific to the type of suicidal behavior (personality characteristics of the suicidal type, the control of impulses, the way of reacting to stressful events) is independent of the genetic markers supposed to cause other mental diseases, especially depression. Recent molecular biology research studies on the tryptophan hidroxilase gene that controls the activity of the enzymes limiting the serotonin synthesis have produced some very promising results.
The suicidal risk in psychiatric disorders
The study of the suicide risk in psychiatric disorders has benefited from the valuable contribution of the German and Austrian psychiatric schools which, through the pioneering papers of Ringel, Poldinger, Faust, designed the suicide risk concept and the presuicidal syndrome.
Ringel (1953) gave the definition of the presuicidal syndrome as a psychodynamic complex appearing both in healthy persons, as well as in the sick ones, characterized by dynamic, progressive narrowing auto-aggression inhibition, refuge in an imaginary world.
Poldinger divided the presuicidal conduct in three stages.
1. Suicide is taken into account as a solution for the life problems of the individual. Suggestive events, or non-externalized aggressivity, the fight between self-defense and self-destruction forces, play an important role. The environment, or the group does not realize the danger, although 80% of the self-murderers clearly expressed the intention to die. It is the so-called "cry for help" (Farberow & Shneidman 1961). Isolation may become by itself a motivation for suicide, especially in elderly people, disabled persons, or those with disharmonious personality structure.
2. A period of ambivalence follows.
3. The person takes the definitive decision. The calm that appears after a period of restlessness and agitation usually surprises the entourage.
In Switzerland, the works of Kieholtz and Angst highlight the possibility of the appearance of suicidal behavior due to masked depression.
In the United States, Robins and Roy (1992) performed meta-analysis type of studies based on the statistics of many suicidology centers of the world. Their special interest focused on defining the relationship between a certain diagnosis and the types of behavior with suicidal potential. The authors found psychopathological correlations between suicide and affective disorders, suicide and alcoholism, suicide and schizophrenia, suicide and personality disorders.
Kiev and Wilkins classified the groups of risk (in order of their importance) as follows:
1. The higher risk is represented by depressions (irrespective of the clinical form)
3. Isolated elderly persons
4. Subjects who announced their intentions
5. Subjects with one or more suicide attempts.
Depression may appear in any type of mental disease and may be accompanied by self-destructive behavior, a reason to look upon it as a medical-psychiatric emergency.
In a classical way, depression is one of most frequently found psychiatric disorders, from the neurotic syndromes in somatic diseases, to the depressive phases of the manic depressive psychosis, in which occurs its most characteristic form. (Predescu et al 1997)
Depression may have the value of:
* Nosologic entity (bipolar depressive disorder, major depressive episode, recurrent depression)
* Symptom in a psychiatric or somatic disease (Macrea 1998).
The comorbidity of depression with some neurological and somatic disorders exponentially increases the suicidogenic potential of the person. We must take into account especially those situations in which the depressive syndrome is associated with:
* disorders of the central nervous system: epilepsy, multiple sclerosis, cerebral vascular accidents, cerebral tumors, meningitis, encephalitis, Huntington's chorea, and so on;
* gastrointestinal disorders: gastric ulcer, hepatic cirrhosis (Fodor 1973);
* urogenital system disorders: cancer or prostate adenoma, erectile dysfunction;
* cardiovascular disorders: cardiac troubles, vascular diseases, high blood pressure;
* respiratory troubles: asthma, COBP, TB;
* muscular disorders: arthritis, motor disabilities;
* endocrine and metabolic disorders: diabetes, thyroid dysfunction, Addison's disease. (Whitlock 1986)
This disease generates a suicide risk estimated at 15% of alcohol addicts. Some of the authors mention that, in contrast with depression, suicide in alcoholics occurs relatively late in life (Motto 1980). Predictive variables are also considered: recent loss of one's life partner or a parent, social isolation, deterioration of the subject's condition, and the stage of massive consumption. As a result, the association of alcoholism with a severe depressive simptomatology could be very dangerous. (Murphy 1986)
Pharmacodepdency is a slow suicide. Persons in this category usually present dysthymia and lower self-esteem and low tolerance to frustration. Suicide occurs in secondary depressive states, in confusional dream states, and is sometimes used as a blackmail tool to obtain toxic substances.
Schizophrenic psychosis generates a high percentage of suicide rate, it accounts for 10% attempted suicides, and 2% rate of success. The suicidal act in schizophrenics has some peculiarities: it appears mainly in the onset stage, in most of the cases, the motivation is absent, and is carried out by atrocious, brutal means. (Roy 1986)
Psychopathies provide a favorable field for suicidal acts. Cyclothymics, mainly sensitive, shy and ambitious, stiff persons, present suicide inclinations in the depressive stages. In this category, we should also include the "blackmail suicide," which air-mongers and those with hysteric temperaments tend to resort to.
Suicide is rarely found in neurotic disorders. It appears mainly in those with dysthymic disorder, and marks the decompensation of a neurotic state, well compensated until then. The passage to act depends on the defense structures of the ego. Identification and imitation processes intervene sometimes. The number of suicides in neuroses has lately increased, primarily when associated with toxicomania. Reactive depressive states appear in the course of a very frustrating event, suicide fulfilling, in such situations, a call function, too. In obsessive disorders, where suicide obsession prevails, the fatal act is rare. In the conversion disorder, suicidal behavior, represented mainly by parasuicide, has a theatrical aspect, so that, on many occasions, suspicions about the sincerity of the act arise (Seager 1986).
According to Poldinger and Sonnek, the possibility of suicide should be examined with reference to:
1. Risk groups (depressives, toxicomania, elderly persons, isolated persons, subjects who publicized their intention, subjects with antecedent attempts).
2. Crises triggered by negative life events.
3. Vulnerability to stress. (Wilson et al 1988)
4. Developments of the suicidal process.
5. Presuicidal syndrome.
Suicidal risk in neurological conditions
Due to the increased incidence of major depressions in cerebral organic disorders, the association of suicidal behavior with neurological pathology is not surprising. A high frequency of the suicide rate is cited in epilepsy, multiple sclerosis, post-traumatic disorders, cerebral vascular disorders, Huntington's chorea, mental organic disorders followed by cognitive deterioration, cerebral tumors and so on.
The clinical syndrome of secondary depression consequent to such neurological disorders is characterized by lentor of ideation, presuicidal syndrome, hypomnesia, psychomotor inhibition, and occasionlly conceptual disorganization. The decay of intellectual performances and motor activities is hardly accepted by patients, who start to consider themselves as a useless burden for their family. Hence the idea of one's uselessness, for whom suicide is the only solution.
The suicide risk in epileptics is 4 times higher than in the general population, perhaps because epileptics have a personality characterized by increased impulsivity, and have at their disposal large doses of antiepileptic substances, especially barbiturates. Epilepsy is described by some authors as a disorder in which the suicidal behavior could suddenly appear, without any prior depressive, or anxious state. On the other hand, severe depressive episodes may appear post-act, especially if comitial crises frequently succeed one another.
A meta-analysis of 11 scientific articles, carried out by Barraclough and coworkers (1981) regarding suicide in epileptics found that the expectancy of suicide achievement in this type of patients has a 5/1 rate of committed versus expected suicides. Particularly, temporal lobe epilepsy generates fatal suicidal behavior.
Another triggering condition of autoaggressive behavior is comorbidity between epilepsy and psychoses, mainly those with schizophrenogenic symptoms. (Bond 1998)
From a psychological point of view, the person suffering from epilepsy may feel this disease as intolerable, due to the unexpected emergence of epileptic crises and to social restrictions imposed by the client. Women seem to have more difficulties than men in tolerating social restrictions imposed by the manifestations of epilepsy.
In Huntington's chorea, a genetically transmitted disease by a dominant autosomal gene, suicidal behavior appears as a very early evolving tendency. Otherwise, several authors describe many psychiatric disorders that may be associated with that disease as: paranoid psychosis, personality disorder, dementia, severe depressive episode. The suicidal behavior appears at an early age, a short time after the specific chorea symptomatology is triggered, as it usually associates with a depressive symptomatology. The suicide rate differs from hospitalized to external patients, increases in the latter to 6.3 deaths in 100,000 inhabitants, in conformity with some British statistics.
Even Huntington (cited by Folstein 1983) characterized that disease as follows: "it is a disorder with tendencies to madness and suicide."
Multiple sclerosis correlated with depression is found in 25% of the cases. On many occasions, depressive syndromes prodrome the emergence of pathognomic neurological signs. The moment of diagnosis of this disease is extremely tensed psychologically, due to the fact that patients are aware of the evolution of the illness, of their situation of functional impotence, and their strict dependence on health care.
Cognitive deterioration, consecutive to an average or prolonged evolution, is found in 2/3 of the cases. Of this category, the most frequent symptoms are fixation hypomnesia and diminution of conceptual thinking. Kahana (cited by Bond) reported the association of the suicidal risk with major and severe changes in the patients' personality, either induced by the appearance of depression, or generated by cognitive deterioration. (Kellner et al 1984)
Even though in statistical terms the suicide rate in post-trauma patients is not significant, it is taken into discussion as a possible evolutionary complication in craniocerebral injuries. Studies done on veterans of the Vietnam War showed that the longer the incapacity period due to the trauma, the higher the suicide risk. (Levin et al 1979)
Cerebral vascular diseases
Nonfatal suicidal behavior and suicidal ideation are reported by various authors for the patients who suffered from cerebral vascular accidents, mainly the ischemic type, and subarachnoid hemorrhage. Vertebral basilary arterial deficiency is also cited as generating cases of attempted suicide. Of course, one cause of this self-destructive behavior is represented by the old age (a 3-6 times higher risk, as reported to adult age). Another cause that potentiates the suicide risk in that category is the comorbidity with arterial tension, a disease generating by itself irritability, emotional lability, and even impulsivity followed by uncontrolled behavior.
Depression is frequently found in the evolution of vascular accidents, which justifies the association of modern therapy with antidepressants, in this category of sick persons.
It is appreciated that in about 10% of cases with cerebral tumors suicidal ideation is found.
The majority of authors, however, do not see any difference between suicide prevalence in the general population and people with cerebral tumors.
The Parkinson disease
Psychiatric disorders are frequently found in the Parkinson disease. Of these we will enumerate: paranoid psychoses, obsessional syndromes, cognitive deterioration and dementia. In cases of people deceased by suicide, the main cause is the presence of a severe psychotic episode and no-reactive depression.
In the Parkinson disease, one may argue about the role of medication with dopamine-prepared drugs, that could induce a change in the regulation of serotonin metabolism.
AIDS constitutes the first death cause in males, in the 24-44 age category in the United States. Some groups are exposed to a maximum risk namely homosexuals, bisexuals, persons with multiple partners, drug addicts who use narcotics in injectable form. The inefficiency of therapeutic means in the treatment of this disorder places an equal sign between HIV seropositivity and the certitude of a demise. The diagnosis of this illness, or the recent news of the screening of HIV infection, may trigger the suicidal behavior. The most edifying statistics in that sense was produced in the United States. Marzuk and coworkers found that the suicide rate in HIV seropositive persons in New York City was 36.3 higher than in men from the adult age group (2059 years). For men diagnosed with AIDS this rate was 66 times higher.
The nature of the correlation between AIDS/ seropositivity diagnosis and suicide is not yet fully elucidated. Several authors tend to interpret the high suicide rate in this category as being caused by the multitude of psychological and social problems implied by the disease. After establishing this diagnosis, the person is condemned to solitude and medical care. In order to highlight the specific problems of AIDS and seropositive patients a new term was created: "AIDS-related stressors." The increased suicide risk factors are: the presence of AIDS in the partner, many friends with AIDS, removal from, or even rejection by the family and the work colleagues.
To put it differently, AIDS is considered to be a potential generator of mental disorders, which may evolve in parallel with the neurological symptoms of sub-acute encephalopathy.
Somatic diseases with suidogenic potential
The depressive states do not appear only in mental organic syndromes, they may also result from somatic disorders, and for this reason are often called "secondary depressions." They are frequently found in comorbidity situations, when antecedents of the medical history of a family, charged with psychiatric or neurological pathology, are involved. The secondary depression notion has in view not only a chronological, but also an etiopathogenetic and phenomenological criterion.
There are complex sequential relationships between secondary depression and somatic disorder, as the depressive syndrome precedes-accompanies-follows-maintains the somatic disorder.
It is certain that the emergence of a secondary depression makes difficult the healing or the improvement process of the subjacent medical condition (Luban-Plozza et al 1996). In addition, this type of depression raises therapeutic problems due to the toleration difficulties of antidepressant medication by the somatic patient.
Among the principal clinical conditions correlated with depressive syndromes with suicide risk, mention should be made of only digestive diseases, cancer, diabetes, renal insufficiency, and endocrine diseases.
Gastrointestinal disorders most frequently associated with the depressive syndrome are biliary dyskinesia and ulcer.
The personality of the patients with biliary dyskinesia is characterized by depressive tendencies, inhibitions, asthenia, hyper-emotiveness, shyness and dependence on the social environment, professional failures, and failures in family life, which are more intensely felt and prolonged, so that suicidal conduct is not rare, mainly in women.
The pathogenesis of ulcer is multifactorial. Alexander, the initiator of the psychosomatic medicine school, described the patient with ulcers as "a man whose existence develops between two incompatible poles--that of passive dependence and that of aggressive autonomy." This permanent intrapsychological conflict has a negative impact on family life, on profession and social relations, relations that are charged with hostility, frequent open conflicts, generating aggressive conduct. All these would indirectly constitute the reason to call for self-destructive conduct, as an irrational way out of a difficult situation. Dunbar remarked that there is an incapacity of patients with ulcer "to externalize their emotions, their incapacity of relaxation, their continuous tendency to claim liberty and independence."
Carcinogenesis, mainly of the digestive tube, hepatic, pancreatic or colon cancer too, frequently produces depressive states. It is considered that 40% of these patients also present secondary depressions that evolve with a severe clinical symptomatology and necessitate psychiatric treatment. Some clinicians draw attention to the fact that, in certain carcinogenic processes, the depression manifests as an early symptom (asthenia, fatigability, insomnia, inappetence, lowering of the elan vital, pessimism, helplessness, and so on). Comorbidity between cancer and the depressive syndrome makes the individual put off seeing the oncologist.
The imunosuppressive influence of stress factors on the normal defense mechanisms of the organism (Razavi & Delvaux 2002) is presented as a possible mechanism of stress in cancerogenesis. Another problem targets the possible involvement of behavior, or personality traits predisposing to cancer. This type of personality is characterized by a repressive psychological style, with a suppression of emotional responses, high social conformity, lack of self-affirmation. Both oncologists (Elhazin 1999) and psychologists (Eysenck 1995) show that emotiveness inhibition, which appeared as characteristic of persons from their childhood, may decrease the number of NK cells and may present a cancerization risk.
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|Title Annotation:||p. 16-59|
|Publication:||Romanian Journal of Artistic Creativity|
|Date:||Dec 22, 2015|
|Previous Article:||On the death of the other.|