PSYCHOSOCIAL

THEORIES OF SUICIDE
• The word suicide is used to indicate completed suicide attempts
• Shneidman defined suicide as “a conscious act of self-induced annihilation, best
understood as a multidimensional malaise in a needful individual who defines an
issue for which suicide is perceived as the best solution”
• Suicide attempts have 3 components:
1. Self initiated potentially injurious behaviour
2. Intent to die
3. Non-fatal outcome
• Approximately one million individuals worldwide died by suicide in 2000, and
estimates suggest that 10 to 20 times more individuals attempted suicide (World
Health Organization, 2008)
• Studies indicate a gap in understanding suicide. The reasons put forward are:
- The practical problem of a sample
- Individuals with suicidal behaviour are excluded from many studies for safety
concerns
- Previously, theoretical perspectives proposed to understand suicide regard to
individual dynamics and their interaction with the environment. However, none
of these were empirical and hence, did not provide concrete variables.
 MENTAL HEALTH CARE BILL

• 8th August 2016-Rajya Sabha passes the bill

• Decriminalises the attempt to suicide
• Previously, section 309- year of imprisonment
• Argued on the basis of the Mc Naughten’s rule- “nothing is an offense which
is done by a person who at the time of doing it, by reason of unsoundness of
mind, is incapable of knowing the nature of the act, or that he is doing what
is either wrong or contrary to law.”
• KEY CONSTRUCTS
• “suicide-related behaviours” (previously referred to as “suicidality”) can be
classified as ideations (i.e., thoughts), communications, and behaviours. All
suicide-related behaviours are self-initiated.
• Behaviours can vary in terms of the presence or absence of intent to die and
presence or absence of physical injury sustained.
• Self harm- term used to indicate behaviours where there is an absence of intent
to die.
 SUICIDE AND MENTAL ILLNESS

• Psychiatric diseases account for a large majority of suicides and suicide

attempts; numbers are at least 10 times as high as in the general population.
The reported percentage of completed suicides in this context ranges
between 60% and 98% of all suicides
• In the beginning of the 21st century, the highest mortality of unnatural
causes globally was due to depression (30%), followed by substance-use
related disorders (18%), schizophrenia (14%), and personality disorders
(13%)
• Whereas 45% of inpatient suicides were preceded by schizophrenia and
organic mental disorders, 32% of outpatients’ suicides occurred in the
context of depression, and substance-related, somatoform, anxiety, and
adjustment disorders.
• Special attention should be paid during the 4–12 weeks following discharge
from inpatient treatment, when suicide rates rise
 CLASSIFICATION OF SUICIDE

• DURKHEIM’S TYPOLOGY
1. Egoistic suicide- results from apathy and a loss of sense of meaning in life.
2. Altruistic suicide- suicide that is carried out as duty or in search of nirvana
3. Anomic suicide- arises out of unregulated emotions; irritation, anger,
weariness; or abrupt social change
4. Fatalistic suicide- arises due to excessive regulation of one’s life.
• SHNEIDMAN- FAREBROW’S CLASSIFICATION
1. Suicide as a means of better life
2. Suicide as a result of psychosis with associated delusions and hallucinations
3. Suicide as a revenge against a beloved person
4. Suicide as a release from pain, infirmity- old age
 THEORIES OF SUICIDE

DURKHEIM’S THEORY OF SUICIDE (1951)

• Suicide results from social causes
• The most particular social cause of suicide is the lack of social integration of
the group which an individual is a part of.
• He proposed this by the method of increasing generalization by
understanding the common factor among all suicides
• He proposed 3 second level generalizations
• Suicide varies inversely with the degree of religious society.
• Suicide varies inversely with the degree of domestic society.
• Suicide varies inversely with the degree of integration of political society.
• Finally, on the third level, he posited a grand hypothesis stating that suicide
varies inversely with the degree of integration of the social groups of which
the individual forms a part.
• In effect, Durkheim believed that any disturbance in the collective order
could lead to an increased suicide rate.
 Schneidman’s Psychological Model (1987)
• The model is based on 10 commonalities of suicide:
1. The common purpose of suicide is to seek a solution
2. The common goal of suicide is cessation of consciousness so that it can end
conscious

3. The common stimulus therefore is unendurable psychological pain referred

to as ‘metapain’

4. The common stressor in suicide is frustrated psychological needs

5. The common emotion in suicide is helplessness and/or hopelessness

6. The common cognitive state in suicide is ambivalence- not only towards

the self and other people but towards the act itself, between the need for

escape and yearning for rescue/intervention.

7. The common perceptual state is constriction of affect and intellect -

overpowering emotions and constricted logic and perception.

8. The common action in suicide is aggression

9. The common interpersonal act is communication of intention – signaling

of distress

10.The common consistency in suicide is with lifelong coping patterns.

These components are common to all acts of suicide

Lethality is a crucial factor in suicide as it indicates towards the acquired ability

of an individual to carry out a lethal act of self harm
• Cause of suicide is ‘psychache’- “general psychological and emotional pain
that reaches intolerable intensity”. It is an intense intolerable emotional
pain that is different from depression and hopelessness.
• The individual suffering from psychache seeks relief form pain until there is
not solution but death.
• He proposed 2 types of needs- biological (primary) and psychological
(secondary)
• Psychological needs- love and belongingness, sense of control, positive self-
image and meaningful relationships are some of them.
• Frustration of the psychological needs occur through failure, rejection and
loss and this leads to the development of psychache.
• Based on the above he then proposed a cubic model made of 125 cubelets
with 25 cubes on the plane (5*5). Each corresponding component of the
model is one facet of the cube.
• The 3 components are:
1. Pain- results from thwarted psychological needs, represented on the front
of the cube
2. Perturbation- is the “state of being”, it is represented on the side plane
and is rated on a 5 point rating scale. This includes a strong tendency for
precipitation of self harm and constriction of perception.
3. Press- this component s borrowed from Murray (1938). It includes aspects
of the inner and outer world which have an effect on an individual
(positive/negative & actual/imagined).
According to this model, cubelet number 5-5-5 is vital. While it is not essential
that everyone in this cubelet commits suicide, those who do commit suicide
are the ones in this cubelet. The implication for therapy is reducing one
dimension, if not all three to bring down the risk of suicide
 PSYCHOANALYTIC THEORIES

• According to Freud, suicide is motivated by unconscious intentions. The

focus of the action is in the unconscious even though the individual may be
conscious of the plan.
• The root cause of suicide is the loss or rejection of a highly cathected object-
meaning a person on whom a significant portion of mental or emotional
energy is invested upon.
 Suicidal individual
Identification with Feelings of
Ambivalence- displays an overly
the lost/rejected aggression, Suicide as an act
feeling of regressive
person vengeful ideas, of self-
Preoccupation affection and attachment
murderous punishment due
with the loss hostility for the Attachment is the known as
wishes, impulses to the experience
lost/rejected basis of narcissistic
and needs are of severe guilt
object identification attachment with
turned inwards
the object
• Karl Meninger’s triad- he proposed 3 components of hostility in suicide
1. The wish to kill- particularly to kill loved ones. This emerges primarily from
aggressiveness
2. The wish to be killed- associated with the guilt of having the murderous
urges. The primary aggressiveness gets converted into the wish to be killed
3. The wish to die-depression and hopelessness arising from such factors as
self-hate and habitual restrictions on aggressive impulses
 Melanie Klein
• PARANOID SCHZOID POSITION • DEPRESSIVE POSITION

Tendency to project hatred onto the object Ego integrates the good and bad components as
being characteristics of the same object
Object is given a persecutory characteristic
Results in depressive anxiety, fear of the loss of
2 consequences- annihilatory anxiety & loss of the object and guilt for having destructive,
good object due to the destruction of the bad sadistic urges towards the object
object
Guilt feelings attempt to correct the imaginary or
One tends to attack the bad object to protect real consequences of the aggressive urges by
oneself or the good object undoing
Hence when the bad object is projected onto When guilt is pathological, one develops feelings
one’s own body, suicide occurs as a means to of badness towards oneself for being destructive
destroy the bad object.
Suicide follows as an attempt to cleanse the world
and prevent destruction
 NEO FREUDIANS

• Adler (1937) :An individual’s striving to overcome his innate inferiority,

would lead to a loss of self-esteem would push him to attempt to hurt
others by hurting himself

• Carl Jung: Hypothesized the self-destructive act to be an effort at rebirth

and a way of escaping intolerable conditions of the present
• Sullivan: An individual evaluates himself in terms of the reactions of significant
others toward him. When hostile appraisals of significant others are received early
in life-> leads to a negative self concept which is frequently expressed in hostile
attitudes toward others.

- In the context of unbearable situations, the individual transfers the “bad me” into
a “not me”. His hostile attitude, which has been towards other people, is redirected
against the self.
 COGNITIVE BEHAVIOUR THEORIES
• Beck at al (1963, 1967, 1979): Suicide is associated with depression, the critical link
between depression and suicide being hopelessness.

• Hopelessness, in terms of negative expectations about the self as well as the future,
appears to be the critical factor in the suicide.

• The same was established in their study of patients who were hospitalised for having
suicidal ideation (initial work) or those who were recruited for psychotherapy (later
work). Among those who committed suicide, the variable of hopelessness was
predictive of the same.

• Previous suicidal experiences sensitizes the individual to negative thoughts.

 • Future is viewed in an unrealistically negative
manner where an individual anticipates
Future: suffering, hardships, deprivation etc.
Unrealistically • The self is viewed as incompetent, helpless
negative, and feelings of guilt is experienced along
with subjecting the self to criticism. This
leads to a low self-evaluation.
• The world is evaluated as hopeless and an
unfair place
• All the cognitions mentioned above are
accepted as accurate. However, because
Self: Incompetent,
these are cognitive distortions, they increase
World: Hopeless, the possibility of experiencing negative
helpless, low self
unfair
evaluation affect and increased frequency of the
experience of negative affect predisposes an
individual for suicidal behaviour.
 SOCIAL LEARNING THEORY
• Lester (1987): Suicide is conceptualized as a learned behavior. Lester
summarized the theories of Bandura, Pavlov and Skinner.

• Childhood experiences + forces in the environment shape the suicidal person

and precipitate the act as well as reinforce the same.

• Child-rearing practices especially how the child perceives and experiences

punishment -> determine expression of aggression
• A suicidal individual learns that aggressive impulses need to be inhibited
and what is also simultaneously learnt is to turn those impulses inward,
towards the self.
• An individual’s thoughts act as a stimuli to which suicide is the imagined
response.
• Suicide may also be a manipulative act, reinforced by significant others -> attention,
care, fulfilling unmet needs, reducing expectations. A reinforcement maybe
expected through the act of suicide.

• Act of suicide can be vicariously learnt or reinforced through environmental factors-

> subcultural norms, suggestions on television, gender preferences for specific
methods, suicide in significant others (modelling), a network of family and friends,
cultural patterns.

• Suicide can also occur when an individual is not socialized into his culture which
further indicates that normal values of life and death may not be learnt.
 Stress – diathesis model
• From a stress-diathesis view, suicide can be seen as an interplay of genetic,
behavioral, biological traits -> self-destructive urges when faced with a stressor,
arising from psychosocial factors in the environment or a psychiatric illness.

• By identifying predisposing/vulnerability factors, one can recognize the potential

risk factors for suicidal behavior
Risk factors for suicide

• Personality or trait factors:

- Impulsivity and proneness to aggression associated with self-injurious or
suicidal behavior.

- Borderline personality disorder - more prone to suicide and self –injurious

behavior owing to their impulsive behavior and difficulties in emotion
regulation
• State factors
- Recurrent maladaptive factors - depressed mood, psychotic symptoms
within a psychiatric illness, negative life events -> loss of a job, death of
significant other can lead to feelings of hopelessness and suicidal ideation
• Childhood experiences
- Loss of parent before 15 yrs -> difficulties in the resolution of the mourning
process may increase the risk for psychological distress and suicide.

- Self-destruction may be motivated by the need for unison with the lost
parent

- Other traumatic experiences - also increase the risk for self-injurious

behavior later in life.
• Interpersonal issues
- Interpersonal stressors such as loss of love
- Older adults may be subjected to long standing psychosocial stressors that
may increase the chances of suicide, especially in the events of death of a
spouse, divorce
• Neuropsychological correlates
- Found to have cognitive styles that display impulsivity, impair decision
making and cognitive flexibility
 Baumeister’s escape theory
• Suicide is analysed in terms of motivations to escape from aversive self-awareness.

• The causal chain begins with events that fall severely short of standards and expectations. These
failures are attributed internally, which makes self-awareness painful.

• Awareness of the self's inadequacies generates negative affect, and the individual therefore desires
to escape from self-awareness and the associated affect.

• The person tries to achieve a state of cognitive deconstruction, which helps prevent meaningful
self-awareness and emotion.

• The deconstructed state brings irrationality and disinhibition, making drastic measures seem
acceptable. Suicide can be seen as an ultimate step in the effort to escape from self and world.
 Linehan’s theory of self-harm and suicide
• Biological deficits, exposure to trauma, and the failure to acquire adaptive
ways of tolerating and handling negative emotion all contribute to suicidal
behavior

• Emotion dysregulation-> core problem in suicidal behavior

• Self injury, according to her view, is an attempt to regulate emotions
• Those who are dysregulated are likely to face a variety of provocative
situations
 INTERPERSONAL THEORY

• The most dangerous form of suicidal desire is caused by the simultaneous

presence of two interpersonal constructs—thwarted belongingness and
perceived burdensomeness and one construct related to capability-
acquired capability of suicide.
• Separates desire to engage in suicidal behaviour from the capability to
engage in the same
• Thwarted belongingness-Humans have a fundamental need to belong.
That, when unmet, leads to a range of negative health outcomes including
increased rate of suicide ideation, attempts and fatalities. This is a potential
risk factor. The dimensions of thwarted belongingness include loneliness
and the absence of reciprocal care. Components of these dimensions
include self-reported loneliness, fewer friends, living alone, non-intact
family, social withdrawal, and family conflict
• Perceived burdensomeness- related to the incorrect mental calculation that
individuals make regarding their death being worth more than their life to
others. The theory posits that individuals who think about, attempt, and die
by suicide mistakenly translate their self-hatred into feelings of
expendability. Thus, the dimensions of perceived burdensomeness include
perceptions of liability and self-hate.
• Perceived burdensomeness may represent a fatal miscalculation by suicidal
individuals regarding the need to sacrifice themselves
• HYPOTHESIS- the relationship between these constructs have been put
forward as hypotheses.
• Thwarted belongingness and perceived burdensomeness are proximal and
sufficient causes of passive suicidal ideation.
• The simultaneous presence of thwarted belongingness and perceived
burdensomeness, when perceived as stable and unchanging (i.e., hopelessness
regarding these states), is a proximal and sufficient cause of active suicidal
desire.
• The simultaneous presence of suicidal desire and lowered fear of death serves
as the condition under which suicidal desire will transform into suicidal intent.
• The outcome of serious suicidal behaviour (i.e., lethal or near lethal suicide
attempts) is most likely to occur in the context of thwarted belongingness,
perceived burdensomeness (and hopelessness regarding both), reduced fear of
suicide, and elevated physical pain tolerance.
 BIOLOGICAL MODELS
• Data from clinical and post-mortem studies suggest that reduced
serotonergic input constitutes a critical element in the vulnerability to
suicidal behaviour, irrespective of the associated psychiatric illness.
• A high concentration of norepinephrine (NE) with decreased alpha2-
adrenergic bindings has been observed in the prefrontal cortex of suicide
victims. Higher levels of norepinephrine were related to higher levels of
aggression.
• HPA axis hyperactivity at baseline levels may increase the risk of eventual
suicide by as much as 14-fold
THANK
YOU