Warning signs of elevated suicide risk The following are general warning signs for potential suicidal behavior (National Institute of Mental Health [NIMH], 2018): ● Talking about feeling hopeless or having no purpose. ● Talking about feeling trapped or being in unbearable pain. ● Talking about being a burden to others. ● Increasing the use of alcohol or drugs. ● Acting anxious, agitated or reckless. ● Sleeping too little or too much. ● Withdrawing or feeling isolated. ● Showing rage or talking about seeking revenge. ● Displaying extreme mood swings. In addition to these general behaviors, additional clinical warning signs are defined and arranged in the mnemonic acronym “IS PATH WARM?” (See Table 2). It is also important to note that, whereas depression and/ or depressed mood are psychiatric problems associated with risk for suicide, they are not warning signs for suicide. So, for example, while a diagnosis of major depressive disorder may increase an individual’s risk for suicide, the diagnosis alone does not indicate that the individual may be suicidal. However, a number of the warning signs, such as hopelessness, withdrawal, and mood changes, are, in fact, symptoms of a depressive episode; therefore, noting changes in associated symptoms is necessary in providing ongoing care and supervision of those who are at heightened risk for suicide. Further information will be provided in subsequent sections to assist clinicians in differentiating general risk factors and warning signs from the most important factors in the upcoming suicide risk assessment section. ● Talking about wanting to die. ● Looking for a way to kill oneself. Predisposing factors 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 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 Distal factors Biological risk factors
Table 2: Warning Signs for Suicide: IS PATH WARM? Warning Sign Description Ideation Threats or talk of wish to hurt or kill self. Substance abuse Increasing alcohol or drug use. Purposelessness Expressing no reasons for living. Anxiety Agitation, restlessness, unable to sleep. Trapped Feeling that there is no way out. Hopelessness Self lacks value, others do not care, future is unchanging. Withdrawal From friends, family members; sleeping all the time; anhedonia.
Anger
Uncontrolled and excessive expressions of anger.
Recklessness Mood changes
Acting recklessly; high-risk behaviors.
Dramatic shifts from typical mood state: ask to get more information. Note . Adapted from “Know the Warning Signs,” by the American Association of Suicidology, n.d. Retrieved from http://www. suicidology.org/resources/warning-signs
are 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. 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
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