Suicide spectrum disorder (revisited)

Wikipedia definition of spectrum disorder

A spectrum as it applies to mental disorder is a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits."

Autism spectrum disorder

Substance use spectrum disorder

Suicide spectrum disorder

In suicide spectrum disorder at one end there are those situations where the death is clearly a suicidal act. At the other end there is behaviour that results in death which is clearly non suicidal, that is, clearly an accident.

To articulate the spectrum one has to isolate two aspects that relate to the act of suicide. In the suicidal individual there is

1. An experience of the urge or drive to engage in suicidal behaviour.

2. An ability to display behaviour that can result in a completed suicide.

It is hypothesized there is one group of individuals who have point 1 but not point 2 and another group who have point 2 but not point 1.

The ‘truly’ suicidal person has both point 1 and point 2. The ‘truly’ non suicidal person has neither point 1 nor point 2.

Hence we have our spectrum where there are two groups in the middle who if they die it is partly a suicide and partly an accident or the result of external actions or circumstances.

Suicide Spectrum Disorder

Case 1. Example of a person having (2. An ability to display behaviour that can result in a completed suicide.) and not having (1. An experience of the urge or drive to engage in suicidal behaviour.)

57 year old woman who has smoked cigarettes consistently since 17 years of age. She has given up once in that time for a two month period. In recent times she has been given medical advice that her lungs are starting to deteriorate significantly and should she continue to smoke she may have only about 5 years to live. Or at least in 5 years her physical health would be significantly compromised such that her standard of living is significantly reduced. The probability of her dying within the next 5 years is significant.

She states that she would like to give up smoking and in recent months has tried with in essence no reduction in her level of smoking. She is now of the view that should she die in her sixties that is OK. That it is quite a good life to have lived. To give up the pleasure she derives from smoking is simply not worth it.

This woman reports that she has never been suicidal, has never had any suicidal thoughts and has certainly never planned or attempted suicide.

This is a good example of a person who would fit in the accio-suicidal part of the Suicide Spectrum Disorder.

Case 2.  Example of a person having (1. An experience of the urge or drive to engage in suicidal behaviour.) and not having (2. An ability to display behaviour that can result in a completed suicide.)

This is a case study presented in my book - Working with suicidal individuals.

A thirty year old man states he has had thoughts of suicide but says he could never actually do it. He has never made a suicide attempt. Instead he describes his reckless behavior as:  "It's in the bad times when all the controls I have on myself I just let go of and it's, 'I will just do what I want'. This is when my drug taking becomes reckless. Also it's in those times when I can get full of drink, get in the car and go driving recklessly". When he is in this frame of mind the intravenous amphetamine use becomes reckless and there have been a number of hospitalizations due to over dose. 

This man reports he simply can never imagine himself taking his own life. He can not imagine it in his behavioral repertoire. (end case study)

Another good example of the accio-suicidal part of the Suicide Spectrum Disorder. 

In both cases the individual will not attempt to take their own life and hence will never die by what is usually seen as a suicide. Instead they will die by their own actions combined with external circumstances not in their control. Hence it is partly a suicide and partly an accident. It is a bit of both and hence we have a separate category on the suicide spectrum disorder.

In the first case example we have an interesting situation indeed. Here is a person who likes and enjoys her life and has no suicidal thoughts. In this way she could not be called suicidal at all. At the same time she is behaving consciously, consistently and over a long period of time in a way that is highly likely to cause her death. If she changed her conscious behaviour the likelihood of her dying is very significantly reduced.

One could argue she is suicidal and her suicidal urges are simply unconscious. Or one could argue this is not the case and is something else. If it is something else, what is it? Unfortunately at this juncture I do not have an answer to that question. I tend not to see it as unconscious because I know her very well and when one has unconscious urges they get expressed in some kind of way. I have not seen this happen with her, I know her history very well and have know her over a long period of time. If it is not hypothesized as unconscious then I have to be able to state what else it is and at the moment I cannot. I do not have the answer to that question.

Case two will be discussed further soon.

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Book is now available

The new book - Working with drug and alcohol users - is now available . You can find out more here.



Or look online for a copy

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Working with the depressed person

This is not a statement on how to treat depression but some things which are often factors in counselling the depressed person.

Stroke deprivation. Depressive like symptoms can result from a person experiencing stroke deprivation. They are not getting enough strokes (positive or negative) so as to satisfy the Free Child. The Free Child can put up with such deprivation for only so long before it starts to psychologically deteriorate. If the level of strokes is quite low then the rate of deterioration can be quite rapid

Put another way, we all have our own level of relational needs. We have to get “X” number of relational units met each day. We have to feel and be involved in relational contact with another person reasonably regularly. However it seems the level required can vary quite considerably from person to person. For some the number of units of relational needs required are quite low and for others it is quite high.

Childhood depression is an interesting phenomena

However if they are not met then depression can result. Whilst the treatment of this seems clear, that is to have more relational contact, for some that is a most difficult thing to do as the schizoid personality will tell you. If it was easy to do they would have already done it and would not need to come to counselling to deal with it. In addition establishing a social life is not an easy thing to do. It takes time and sustained effort. 

If one is socially isolated making ongoing friendships is not that easy. People have busy lives and if a new person enters into your social world that means one other must drop out because there is only a certain number of hours in the day.

High Critical Parent. This is common in the depressed person. If the person drinks alcohol ask them if they feel the depression lift when they first feel the effects of the alcohol. If it does then you know a high CP plays a role in this persons depression. As I discuss in my book - Working with alcohol and drug users - alcohol quickly and effectively blocks out the CP. This can make drinking appealing to the depressed person because it gives them temporary relief from what can be a very savage and relentless internal critic inside their head. However this can result in a drinking problem.

Also what happens most often is the depressed person will keep drinking and then the personality is effected in other ways, the person gets drunk and then they end up worse off and feeling even more depressed. Whilst there is an initial positive outcome by turning off the CP if they continue to drink then this positive is lost amongst more negatives that result from the continued drinking.

Repressed emotion especially anger. Depression can result because the person has emotions they are not expressing and then releasing. This is especially so with any anger that is not being expressed. Instead it sits like a sore in the persons psyche slowly but surely pulling them down into depression. This again is a problem for the FC, as stroke deprivation is. A basic FC need is not being met and over time the person will psychologically deteriorate as I mentioned above.

The repression of emotion can occur in a number of ways

1. Don’t feel

2. Don’t feel x, feel y

3. Don’t express your feelings

4. Feel x, but express y.

In number 1 the person is not even aware they are having a feeling When the FC is that repressed or detached the person may not even be aware they are feeling angry, sad or scared. If they are not aware of it, they certainly are not going to express it in a productive and healthy way.

In number 2 the person becomes aware they are experiencing a feeling but it is a substituted feeling. Typically women do this when they feel anger and they substitute it for sadness. Typically men when they feel sad they substitute it for anger. Either way there is not the possibility of a healthy expression of the feeling such that depression can result.

Number 3 highlights the difference between the experience of a feeling and actually expressing a feeling. Two quite different psychological processes. Some people are aware of the feeling they have and it is an appropriate feeling but have an inhibition against the expression of the feeling.

In number 4 the person feels the right feeling but expresses a different one. When the woman who get angry starts crying which is more appropriate for sadness. Or the man who feels sad and all of a sudden he is showing anger.

In any of these depression can result because feelings are not being expressed in a psychologically healthy way.

Response to trauma not been worked through. This is similar to the one just mentioned but entails much more than just the expression of emotion. In this instance the person can see that the  timing of depression is related to an event. The person may have been in a bad car accident or been assaulted. They do not work through the trauma and hence depression can result.

Secondary gains. All of us have what is sometimes called normal person depression. We all experience depression to some degree from time to time. But it is not bad enough to be debilitating and we struggle through it and come out the other side without too much difficulty.

As with any neurotic state there is always the possibility of secondary gains forming. The woman who feels starved of love starts to feel a bit depressed and she tells a few of her friends and husband. She discovers that as a result of her disclosure all of a sudden she finds people being loving and caring of her because she is ‘ill’. A secondary gain has formed that meets her need to feel loved hence the depression can persist and magnify in intensity, often this is out of her awareness.

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Taking a history of depression

History taking is a pivotal part of any therapy or counselling process. The more complete a history one can get the better as the possible paths the client may go in the future can be anticipated and treatment can be designed to deal with those. 

One obvious problem with history taking is you can not take a history if the client does not have one. That is, a client who is 17 years old has much less history then a 37 year old. This can be a significant disadvantage when working with the younger client. In my book Working with Suicidal Individuals, I discuss depression including what to look for when assessing the history of a client who reports experiencing depression.

To assist with this I constructed a graph depicting the key components in taking a history of the depressed person. This graph is presented below:

Most depression is cyclical as shown in the diagram with the mood changing over time from a normal level to a depressed level and back. As shown in the diagram one can move from a normal mood range down into the range of dsythymia. In this phase the depressive symptoms are at a moderate degree. Historically this has also been known as neurotic depression. This is seen as less severe than the next level down which is called a major depression. Sometimes this is called 'clinical depression' where the individual is significantly incapacitated and is very depressed. Also at this level one can have a condition known as psychotic depression. This is where the individual has the symptoms of major depression plus some psychotic symptoms.

In taking a history of the depressed person one need to look at four aspects of the depressive cycle W, X, Y and Z. Firstly one is wanting to assess the length of the non depressed periods (W) and the lengths of the depressive episodes (X). How many have there been and how long were they? Also were there any precipitating factors such as marital problems or financial difficulties that lead to the depressive episodes. These can then be charted on a graph as is shown in diagram.




One also needs to assess the quality of the depressive episodes by making an assessment of the 'Y' component. Here one assesses how depressed the person becomes, how the person has felt in past episodes. As mentioned before the system being presented here distinguishes between normal mood, dysthymia or neurotic depression, major depression and psychotic depression.

Finally in the diagram one needs to make an assessment of 'Z' in the depressive cycle. Suicide risk may increase as the person improves particularly from a major depression or a psychotic depression. In these depressive states the person is so depressed they can become incapacitated. They are so depressed that they literally do not have the energy to think seriously of suicide or certainly making any definite planning. As the depressed state lifts, along with that comes an increase in energy which may bring about an increased ability to act on any self destructive wishes, as they improve one may need to be more vigilant as they reach the “Z” part of the depressive cycle.




If one can get reasonable quality information on these four aspects of the depressive cycle then one has a good understanding of the depressive history of the client.

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Psychology 101 and suicide

The following comes from an article about factors in suicide printed in the journal - Australian Institute of Criminology. It cites various research findings

Locality. For much of this century suicide rates have been higher in Australian cities than in rural areas.

Media. The average daily rate of suicide in Australia increases significantly after the publication of suicide stories in the Australian media.

Economic Cycles. In this century suicide trends in Australia show a strong correlation

between unemployment and the suicide rate.

Occupation. The general pattern in Australia is that those in unskilled and semi-skilled blue-collar occupations which are characterised by low job autonomy, greater external supervision, less on-the-job training, poorer promotional possibilities, lower wage levels and greater sensitivity to market forces tend to have high suicide rates.

Migration and Ethnicity. The suicide rate of overseas-born is significantly higher than Australian born and among the immigrant groups from different countries suicide rates also vary considerably.

Temporal Variation. The incidence of suicide appears to follow a distinct weekly cycle. Monday tends to have the highest average daily suicide followed by Tuesday, and Saturday has the lowest average.

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When I was a young, fresh faced psychology student we were taught about the science of psychology. This was serious business I can assure you. One thing that they drilled into our little, pliable, malleable brains was the difference between correlation and cause and effect. This we were told was one of the basic principles of science and one must always, and at all times keep them separate. It was tattooed in our little minds for ever. And quite rightly so, one could say.

The six factors listed above are all correlations, none of them are statements about cause and effect. Most suicides occur on a Monday. This is a statement of correlation and one must never, I was told in psychology 101, assume this means Mondays for some reason cause people to suicide. That would be a statement of cause and effect.

What causes odd behaviour is different to what correlates with odd behaviour. "Wearing hats makes men try and mow the roads".

Media reports on suicide correlate with an increase in the suicide rate. This is not saying that media reports cause people to be suicidal. Again one differentiates between correlation and cause and effect. Unfortunately in the area of suicide people often mix up correlation with cause and effect. This is commonly done when depression is discussed. One often hears comments like depression causes suicide.

Depression has never caused suicide. We are cited statistics like 5% to 10% of people with major depression will die by suicide. Major depression is the worst kind of depression where the person is really, really depressed. 

However, and this is major problem in the literature on suicide, these statistics also tell us that 90% to 95% of people with major depression do not die from suicide. If depression caused suicide how come the vast majority of people who are the most severely depressed never kill themselves in suicide.

Some people with depression suicide and some do not. In the vast majority of the literature you never get this explained. They can’t explain it because they mix up cause and effect with correlation. However in my book - Working with suicidal individuals - I provide a clear explanation for it, which I discuss at length. A suicidal person is one who has made the suicide decision early in life. Some people make such a decision and some do not. 

This is now a statement about cause and effect. What causes people to be suicidal is they have made one of the seven possible suicide decisions. What depression, media reports, Mondays, stress and so forth do do, is make an already suicidal person more likely to act on the suicidal urges. Thus one can say depression has never made anyone suicidal. If someone has not made the early suicide decision then no matter how depressed they get they will not suicide.

This has significant implications for treatment. To deal with a person’s suicidality one must not get distracted into treating the depression, one needs to treat the early decision that was made.

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