disorders are associated with significant risk for suicide attempt or death. At present, if the patient does not report suicidal ideation or behavior during the mental status examination, and there is no evidence for depression or borderline personality disorder, there is no natural place for the clinician to be primed to identify past suicidal behavior. Likewise, a patient reporting a history of suicidal behavior in the absence of a depression or BPD diagnosis may not receive a clinically useful diagnostic code to facilitate further risk monitoring or intervention. With the inclusion of a SBD diagnosis, hospitals or clinics with robust methods for documentation of suicide risk may be able to structure medical records so that this data is always recorded; in less structured environments, the risk of non- identification is significant. Major risk factors for suicide Before going in-depth into various risk factors for suicide, it is important for clinicians to have an overall picture of the major risk factors for suicide. A combination of individual, relationship, community, and societal factors contribute to the risk of suicide. Common risk factors are not necessarily direct causes of suicidal behavior but are often key markers for future suicidal behavior. Some of the most common risk factors for suicide include: ● Family history of suicide. ● Family history of child maltreatment. ● Previous suicide attempt(s). ● History of mental disorders, particularly clinical depression. ● History of alcohol and substance abuse. ● Feelings of hopelessness. Although there are numerous risk factors for suicide, these are often presented without much context as to when the risk factor might occur or what kind of relationship they may have to an episode of suicidal behavior. By breaking down risk factors into specific types, clinicians, educators, and families can better understand the ways in which a specific factor might be connected to suicidal behavior, and how long before the suicidal behavior such a risk factor may occur. Risk factors for suicidal behavior can be divided into three types in terms of timing in relation to suicidal behavior: distal risk factors, proximal risk factors, and potentiating factors. Distal factors Distal risk factors are separated further in time from suicidal behavior, potentially having occurred months, years, or even decades before suicidal behavior. Distal factors are important because they create a statistical potential for suicidal ideation and behaviors; they set the stage for later problems with suicide, so to speak. Proximal factors Proximal factors refer to those risk factors that arise in close temporal proximity to acute suicidal behavior, meaning they are Biological risk factors Biological risk factors for suicide can be both distal and proximal. Genetic factors, for example, are a distal risk factor arising at birth, and have been linked to suicide outcomes in large population-based studies (Erlangsen, Appradurai, Wang, Turecki, Mors, Werge, et al., 2018). However, it is important to note that the effects of any one genetic polymorphism on suicidal behavior are relatively small and no clear genetic combination has been found to have large effects in predicting suicidal behavior. Other biological distal factors can include abnormalities in neurotransmitter physiology, hormonal factors, and neurophysiological abnormalities (Turecki & Brent, 2016). Important proximal biological risk factors include suffering from physical illness, chronic pain, cancer, and/or a disability as near-term stressors that could precipitate a suicide crisis (Ferro,
Although there may be a number of clinically-useful merits to establishing an official SBD diagnosis in the DSM , such a move is not without opposition. Opponents of creating such a diagnosis argue that suicide is, by definition, not a disease but a death that is caused by self-inflicted intentional action or behavior and that a new DSM-5 diagnosis of SBD would automatically make suicide a mental disorder. They also contend that the inclusion of suicide attempts as a diagnostic criterion of borderline personality disorder, despite limited evidence to support the link, led to an increased stigmatization of suicide attempters (Obergi, 2019). At present, there is no clear consensus in the field as to whether SBD should be officially included in the next revision of the DSM . In the meantime, more research is being devoted to the question of whether SBD will make a valid addition to the existing diagnostic system.
RISK FACTORS FOR SUICIDE AND ASSOCIATED FEATURES
● Impulsive or aggressive tendencies. ● Cultural and religious beliefs (e.g., belief that suicide is noble resolution of a personal dilemma). ● Local epidemics of suicide. ● Isolation or feeling cut off from other people. ● Barriers to accessing mental health treatment. ● Loss (relational, social, work, or financial). ● Physical illness. ● Easy access to lethal methods. ● Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts. (CDC, 2017a)
TYPES OF RISK FACTORS
often viewed by others, family, or society as “triggering” events that spur acute (recent) suicidal behavior. Indeed, proximal factors can increase individual motivations for suicide, and proximal risk factors can also determine the timing of suicidal behavior by translating the statistical potential of distal risk factors into action (Franklin, et al., 2016). Precipitating stressors or crises have substantial predictive value with respect to suicide attempts. Stressful life events have been found to have occurred for most individuals on the day they attempted suicide (Shen, Cunha, & Williams, 2016) or died by suicide (Howarth et al., 2020). Potentiating factors Potentiating factors represent a particularly powerful proximal risk factor, and typically involve the availability of lethal means (e.g., owning a gun, access to pills), recent or ongoing major stressors, illness, and so forth. Potentiating factors might be thought of as “triggers” for suicidal behavior, and often align with the warning signs for imminent suicidal behavior as previously discussed. Clinicians should be aware, however, that many patients will not be able to identify potentiating factors for their suicidal behavior. Rhodes, Kimber, Duncan, Boyle, et al., 2017; Henson, Brock, Charnock, et al., 2019; Lund, Nadorff, Winer, & Seader, 2016; Racine, 2018). Although biological risk factors likely play a role in the suicidal ideation and behavior of some patients, meta-analytic research has found that many biological links to suicidal behavior are relatively small (Chang et al., 2016), so while it is important to consider biological risk factors, suicide risk assessment and intervention should primarily focus on proximal biological risk factors (e.g., chronic pain or illness) as well as behavioral and psychosocial risk factors.
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