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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