Suicidality: Nomenclature


Suicide terminology or nomenclature describes the continuum of behaviors, actions, and events related to suicidal acts. A standard vocabulary and understanding of the distinction between commonly used terms are important to ensure clear communication about a complex topic. Multiple interpretations of suicide-related language can and have resulted in confusion and disagreement among clinicians and researchers. Although efforts are being made to improve the reliability and validity of suicide nomenclature, some common terms, discussed below, offer a framework for understanding the phenomenon.

Suicide ideation is the accepted term for thoughts of suicide without action. Thinking about suicide, however, can range from fleeting thoughts to detailed planning, making the term ideation incomplete. Suicidal actions that are unlikely to end in severe injury or death are sometimes called suicide gestures. Although gestures are usually considered a plea for help rather than an attempt at death, they should not be taken lightly. A suicide gesture can be an important point of intervention and a chance to possibly prevent future and possibly more lethal attempts. A suicide attempt is a suicidal action that is not fatal, while a completed suicide results in death. The distinction between attempted and completed suicides is not necessarily related to a person’s intentions. There are many factors that can alter the lethality of a suicide attempt. For example, an attempt that is primarily a plea for help may unintentionally end up as a fatality. Actions by someone determined to end his or her life may be thwarted by means that have low lethality or by rescue efforts. For many reasons, the current terminology fails to encompass the specificity and the complexity of the range of suicidal behaviors.

Intentionality is a subjective term that refers to the intended outcome of suicidal behavior and considers the elements of impulsivity, planning, knowledge of the possible outcome, and choice of means. The intended outcome of suicidal behavior may not always be death. Only the attempter can express intent and, without retrospective information, intent can be difficult to establish. For example, many young people who attempt to overdose on acetaminophen do not realize that its toxic effects are often irreversible and fatal, unlike aspirin, which is usually not fatal. Clinicians working with youth who have a history of suicide attempts can gain insight into the intended outcome by exploring intentionality. The suicide nomenclature is further complicated by terms such as parasuicide or deliberate self- harm, which are sometimes used to include all self-harm behaviors, regardless of whether the intended outcome was death.

As part of assessing intentionality, it is important to distinguish between impulsive suicidal behavior and behavior that is the result of forethought and planning. A number of recent studies have examined impulsive suicidal behavior and found that attempted suicide is often an impetuous decision fueled by drugs and alcohol. Attempters in these studies described impaired thinking with suicidal behaviors driven by anger, loss, hurt, depression, anxiety, and stress, all greatly exacerbated by acute drug and alcohol use. Attempters who had a history of suicidal behaviors often described their problems as long-standing, while the decision to kill themselves was made abruptly. Impulsive suicide attempters were more likely to have a personality disorder, a chaotic home life, difficulties with anger, drug and alcohol use, and a history of childhood abuse than attempters who planned their suicide attempts.

Lethality is an objective term that refers to the level of injury severity resulting from suicidal behavior, and the potential for the selected means and actions to result in death. It has been suggested that lethality of suicide attempts is an adequate proxy for intentionality; however, research indicates that the two are distinct and, further, are measured using different scales. More lethal means, such as the use of firearms, usually result in a higher degree of lethality. However, the lethality of means such as poison varies considerably depending on the type of poison available. In the United States, suicide attempts using poison are sometimes considered to be of low intent, and typical poisons used in suicide attempts have low fatality rates. Conversely, in rural Asia, highly toxic pesticides are easily accessible, often used in suicide attempts, and highly lethal. In both areas, poisons may be selected as a means to suicide because of their ready availability, but the outcome is very different.

When an attempter’s knowledge about lethality is coexistent with access to highly lethal means, risk for death increases. Evidence indicates that a suicide attempter’s knowledge of the lethality of his or her method is highly correlated with degree of injury. Intent and lethality become increasingly correlated depending on how well informed the individual is about lethality levels of various means of suicide. Suicide completion-attempt ratios also increase with age, as knowledge of suicidal means and access to more lethal methods of suicide increase. The availability of lethal means (chemicals, firearms) may be more prevalent in certain communities or countries.

Means refers to the use of implements, substances, weapons, or actions as the mechanism of injury or death. The choice of means is strongly correlated with both intent and lethality. The availability of lethal means is an important focus of prevention efforts. Legal, technological, and educational efforts to restrict access to highly lethal means have been successful in reducing the number of deaths resulting from suicide attempts. For example, waiting periods on firearm purchases, mechanical barriers on bridges, detoxification of domestic gas, modifications to automobiles, and prescription drug limitations may provide effective countermeasures.

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