Further Musings on Potential Predictors of Suicidal Behaivor

In the last post I discussed thoughts on why certain groupings of physiological measurements may turn out to be a better predictor of suicidal behavior than genes (check out that post here).  On top of that, I have some general ideas as to how this may play out.

I would imagine that each psychological disorder may end up having its own constellation of physiological factors with predictive power.  For instance, people with major depression without psychotic features would have a different constellation of physiological factors associated with suicidal behavior than people with schizophrenia.   The people in the major depression group may have lots of indicators of very low mood but a certain amount of anxiety / excitement too.  Currently, it is a commonly held belief among clinicians, researchers, and even the general public that a certain amount of energy is required to make a suicide attempt.  Rather than a 1 to 1 correlation between low mood and suicide - i.e. the people w/ the lowest mood are at the highest risk of making an attempt - low mood plus a certain amount of motivation/excitation to attempt is believed to be in the mix.  It's worth noting that the excitation wouldn't necessarily improve one's mood.  Low mood and excitation are not only likely to be separate and valid psychological constructs, but they would represent themselves differently physiological tests.   Speaking in terms of totally made up units of measurement to illustrate a point, a person with major depression may need lower than -100 endorphins (representing low mood) and somewhere between +15 and +30 cortisol (representing excitation) in order to qualify as being at imminent risk for suicide.  On the other hand, a person with schizophrenia may need lower than only -25 endorphins (representing low mood) and higher than +200 cortisol (representing excitation) to be at imminent risk for suicide attempt.  Continuing down the path of this totally fabricated example, high levels of excitation may be more indicative of imminent suicide risk in schizophrenia than in major depression for a couple of reasons.  If someone with schizophrenia attempts suicide, it has a decent likelihood of being because they heard a voice in their head commanding them to do so.  As such, the experience of hearing a scary voice telling them to kill themselves would hypothetically induce a physiologically state of excitation. On the other hand, a relatively low but existent amount of excitation would hypothetically be required for a person with major depressive disorder to attempt suicide.  Concurrently, their mood would presently need to be extremely low to be at risk for such destructive behavior.

Pulling back out of the examples and towards the larger picture, in short, I would imagine that each disorder would have it's own set of physiological risk factors.  Major depression, schizophrenia, bipolar, borderline personality disorder, etc. would all have different high-risk constellations.  Some more thoughts on the specifics to come.

Musings on Potential Predictors of Suicidal Behavior

I was recently asked for my thoughts about blood tests as a genetic predictor of suicide on Twitter.  I tweeted them out, but I thought I'd quickly organize them here as well.  It admittedly may be very flawed, but here's my logic:

1. Completing suicide is one isolated behavior that results from a complex myriad of genetic, biological, environmental, and situational factors.   As such, simply looking to genetics - the building blocks of life - to predict one isolated behavior seems far fetched.

2.  There's also a lot of noise introduced when your outcome is the one isolated behavior of a suicide attempt resulting in death.  Someone who may be prone to suicide, for instance, may die in an accident before they ever have the change to attempt suicide.   Further, people who may be prone to suicide otherwise may lead a charmed life & the thought may never cross their minds.  Alternatively, someone not genetically prone to suicide may have a terrible life, develop a substance abuse habit, and impulsively kill themselves one night while under the influence.  Because the environment and circumstance play such a large role in whether or not someone actually dies by suicide, looking to genetics intuitively doesn't feel right to me.  Studying epigenetic factors, however, may yield something very interesting, but my money isn't on it.  I don't think it will be the silver bullet we want it - or hype it - to be.  Think back to the human genome project. (P.S.  Psychologists will recognize this argument as part of the "low base rate behavior" issue.)

3.  It is true that suicidal behavior is linked with psychological disorders, but is perhaps more important to focus on this: the behavior of completing suicide is intimately tied to the circumstances in the immediate environment.  These immediate circumstances will have an immediate effect not a a person's genetics per se, but on their physiology.

For instance, on any given day, a woman with moderate depression may be at a certain point in her menstrual cycle, on substances, vulnerable from a myriad of factors (e.g. relationship stress, lack of sleep, health condition, etc.), and feeling particularly impulsive.  Lets just say that we add a life tragedy to this vulnerable mix of factors and she gets admitted to an inpatient unit for suicidal thoughts.  Eventually she reports her suicidal thoughts have remitted, she is discharged, and then our hypothetical woman unfortunately makes a suicide attempt.  Some of the aforementioned factors (e.g. menstrual cycle, etc.) have a specific physiological impact.  If we had measurements taken from the inpatient unit of this woman's estrogen/progesterone levels, oxytocin, waking levels of cortisol, toxicity, etc. it would result in a specific constellation of physiological factors.  Over time, scientists can examine which constellation(s) of physiological indicators most often co-occur with recent (serious) suicide attempts / completions.  Determining & using immediate constellations of physiological factors to predict suicidal behavior in the near future seems to me like it will be much more accurate (i.e. have "incremental predictive validity") than our current tools (e.g. self-report questionnaires).  The general idea is that in the future we may be able to divine what people are actually feeling based on physiological measures rather than self-report.

4.  One last thought about the utility (and sensitivity) of genetic testing for suicide:
Not only do I think that blood tests for genetic factors will not yield reliable predictors of suicide completion, they will likely not be of much practical utility.  Consider this: what course of action must a clinician take with the information that a person is at genetic risk for suicide?  If someone is admitted to a psychiatric inpatient unit because of depression and suicidal thoughts, at some point they report they are not imminently at risk.  At that point, we must then discharge them from the hospital.  We would not be able to detain them longer based on a genetic test.  Correct?  How much longer would we keep someone on an inpatient unit based on a genetic test?  Genetic markers are not what we call sensitive measures - they are not sensitive to change.  They are static.  We would, however, have a more firm basis for detaining someone in the hospital if we had evidence that certain physiological constellations were present in a person & evidence that this type of constellation is associated with imminent risk of suicide.  Over time, we would have an idea about how generally someone would be feeling based on the output of physiological tests. Of course, how accurate or difficult to manipulate these hypothetical physiological constellations may be is unknown.  But if I were a betting woman, I would put my money on the scientists examining circumstantial physiological compositions winning the race of determining the most accurate, useful, & sensitive predictor of suicidal behavior.

In short, a suicide attempt is a behavior, not a disorder.  I'm not so sure that treating suicide attempts like a disorder by examining genetic contributions will produce the best predictors of this behavior.  Exploring physiological factors that represent immediate shifts in a person's internal experience however, intuitively feels more promising to me.

P.S.  This post was in response to this CNN article: link.

"Suicide is Selfish"

I often hear people say things like "suicide is the most selfish thing you can do" and "suicidal people must not care about their families at all."

Well, I just don't think that is the case.

First of all, many do not have families who are particularly supportive, which may be part of the problem in the first place. In fact, many times people who attempt suicide are surrounded by people who are extremely abusive. Especially if the person is a teenager or has limited resources, they may see no way out.

And even if people who have attempted suicide do have people in their lives that are supportive, the person may be truly in so much psychological pain - e.g. they may be bombarded with flashbacks of a very traumatic event or paralyzed by depression - that it might be nearly impossible to take into consideration the perspective of a loved one.

On top of this, some people may feel so worthless that they think ending their lives will actually be doing their loved ones a favor. What's even more upsetting is that in some situations, the person's perception may be accurate - it isn't always, but it could be.  Stigma against people with mental health is strong and I'm sure some family members might consider a person with mental health issues to be a burden.  Of course, this isn't always the case, but it's certainly a possibility.

Please note that whether or not a person's family actually does believe them to be a burden has no bearing on whether or not a person should kill themselves.  Clearly this question is out of the depth of this blog post.  In this post I am merely illustrating reasons why it is myopic to negatively judge people who have suicidal thoughts.  I've heard stories so horrific, it seems incredible that a person could have any will to live at all.  It is not a therapist's job to judge whether or not a person should kill themselves.  It is our job, however, to do everything possible to teach skills that can make life more bearable.

My advice is simply this: don't be so quick to judge.

Near Death Euphoria and the Link to Suicide

I was asked by a friend if I ever came across someone who attempted suicide not to escape suffering, but because they knew it would feel good.  Although not suicidal, the person asking the question was curious because he had experienced a near-death situation in which he was injured and felt euphoria.

I thought this was a really thought-provoking question. The link between near-death euphoria and suicide never crossed my mind before.

This was my response:

I have heard of people recounting similar types of experiences, but I had never considered the link between near-death euphoria and the intention to commit suicide.

A brief discussion of Thomas Joiner's theory of suicide is in order. The basic gist is that people may build a tolerance for the negative feelings associated with hurting / killing themselves by engaging in self-injurious or thrill seeking activities. While it is not necessarily intentional, the negative feelings about death may lessen over time.

Let's just say a person regularly sky dives. Then, for whatever reason, they become suicidal. If you're already used to jumping out of planes, the idea is maybe you won't be that scared to jump off of a bridge.

There is another relevant example to this discussion as well. Namely, if a person regularly cuts themselves (without intent to die) when they're upset, they may not be scared to make life-threatening incisions when suicidal urges come up.

While I formerly thought of this concept as similar to "building up the courage" to attempt suicide via repeated episodes of cutting / dare-devil behavior, this question has me thinking differently. Perhaps there is an additional component here that is consistent with Joiner's theory.

When people cut their skin with no intent to die, it is thought that endorphins are released. This would create reduction in the negative feelings that may prompt self-injury, like shame, anxiety, sadness, etc. Perhaps people also feel mild euphoria, or positive feelings, from the endorphins. This might suggest that for some, self-injury has at least two psychological functions - reducing negative feelings and increasing positive feelings - perhaps produced by the same biological mechanism (i.e. endorphin release).

In any event, a link between injuring oneself and feeling good is formed. Maybe this association generalizes to suicide in the sense that injuring yourself is linked with feeling good.

Now, getting more to the point of suicide, endorphins are not only relesaed during self-injury, but during a traumatic / near-death event as well. This is very interesting to me because a link can be formed between feeling good and death, specifically. In the sky diving example used above, an association is formed between feeling good and jumping from a height, but not necessarily death. In the case of a traumatic event, the link is formed between feeling good and specifically being near-death.

While people may not report chasing the feeling of euphoria that comes with being close to death, if they've experienced it, the drive for this positive feeling could theoretically propel future suicidal behavior. Whether or not the person is aware that they are driven to suicide because of past feelings of euphoria when close to death, it could be a biological function maintaining the behavior.

In short, while I had formerly thought of suicide as a behavior maintained by the function of wanting to escape pain, this point raises the question of whether or not people want to commit suicide to actually feel better. Again, while I don't think people would necessarily report wanting to die to feel that euphoria, it could influence their suicidal drive and behavior.

[For people familiar with psychology lingo on this blog, the function may not necessarily just be automatic negative reinforcement, but automatic positive reinforcement as well.]

Truly, a fascinating point. Thank you so much for asking.

For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.