Dean McKay and Eric A. Storch (eds.)Handbook of Assessing Variants and Complications in Anxiety Disorders201310.1007/978-1-4614-6452-5_9© Springer Science+Business Media New York 2013
9. Assessment of Suicidal and Non-suicidal Self-injury in Anxiety Disorders
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Department of Psychology, Fordham University, 441 East Fordham Road, Bronx, NY 10458, USA
Abstract
Suicide assessment is an important component of any thorough evaluation of symptoms associated with anxiety disorders. Nonsuicidal self-injury is less commonly assessed, but no less important as it contributes to morbidity in the target anxiety condition. Assessment methods, including functional evaluation and risk assessment, are described in order to fully integrate treatment of this facet of psychopathology into alleviating anxiety symptoms.
Suicide is a significant public health problem worldwide. In 2007, suicide was the 11th leading cause of death in the United States, and the second and third leading causes of death for individuals aged 25–34 and 15–24 years, respectively (Centers for Disease Control and Prevention, 2007). In addition, suicide attempts occur at a greater rate than suicide deaths. It is estimated that there are approximately 25 suicide attempts for each suicide death (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Other estimates suggest an even greater rate of suicide attempts to deaths; among those aged 15–19 years, Mann et al. (2006) report approximately 400 suicide attempts to each death for boys and 3,000 suicide attempts to each death for girls. In a nationally representative sample of individuals aged 15–54 years, 2.7% of those surveyed reported a suicide attempt during their lifetime, 3.9% reported having a suicide plan, and 13.5% reported suicidal ideation (Kessler, Borges, & Walters, 1999; Nock & Kessler, 2006). Similar prevalence rates have been found worldwide. In a cross-national survey of 17 countries, lifetime prevalence of suicide attempts was reported to be 2.7%, while 3.1% and 9.2% of those surveyed reported a suicide plan and suicidal ideation, respectively (Nock et al., 2008). In addition to the emotional and economic costs of attempted suicide, the strongest predictor of future suicidal behavior is a history of previous suicide attempts (Borges et al., 2006; Joiner et al., 2005), emphasizing the need for identification and clinical intervention.
Suicide deaths, suicide attempts, and suicidal ideation vary in terms of lethality and action, but all are defined as self-injurious thoughts and behaviors with intent to die (i.e., Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007). However, some individuals engage in self-injurious behaviors without suicidal intent. This behavior, non-suicidal self-injury (NSSI), involves deliberate injury to the body and includes behaviors such as cutting, burning, carving, scratching, and skin picking (Favazza, 1998; Prinstein, 2008). However, NSSI is performed without intent to die, distinguishing it from suicidal behaviors. NSSI differs from suicidal behaviors in several other important ways. The behavior is chronic and repetitive, while suicide attempts occur more infrequently, and NSSI is usually of lower lethality than attempted suicide (Muehlenkamp, 2005). Further, NSSI is more common than attempted suicide (CDC, 2007; Muehlenkamp & Gutierrez, 2004; Ross & Heath, 2002), with alarming prevalence rates in both clinical and nonclinical samples (Andover & Gibb, 2010; Briere & Gil, 1998; Klonsky, Oltmanns, & Turkheimer, 2003; Nijman et al., 1999; Zlotnick, Mattia, & Zimmerman, 1999); studies have shown that up to 38% of young adults engage in NSSI (Gratz, Conrad, & Roemer, 2002; Klonsky et al., 2003). The prevalence of the behavior emphasizes the need to include NSSI in clinical assessments.
Non-suicidal self-injury is often associated with borderline personality disorder (BPD), as it comprises a criteria symptom of the disorder (American Psychiatric Association [APA], 2000). However, it is important to realize that NSSI is neither necessary nor sufficient for a diagnosis of BPD, and a significant number of individuals who engage in NSSI do not meet criteria for BPD (Andover, Pepper, Ryabchenko, Orrico, & Gibb 2005; Zlotnick et al., 1999). Although NSSI does not necessarily occur within a psychiatric disorder and does not alone indicate existing psychopathology, the behavior can occur across psychiatric disorders (Briere & Gil, 1998; Zlotnick et al., 1999). Therefore, it is important for clinicians to recognize that NSSI is not restricted to a particular diagnosis and exists in individuals experiencing a range of psychiatric symptoms.
Although NSSI is a nonlethal behavior performed without suicidal intent, its negative consequences mandate clinical attention. By definition, NSSI results in physical injury ranging in medical severity and physical disfiguration. The behavior is frequent and repetitive (Briere & Gil, 1998; Muehlenkamp, 2005; Walsh, 2006), placing the individual at continual risk of harm. The behaviors are likely to increase in level of risk or lethality over time, resulting in more severe injuries, attempted suicide, or even death (Briere & Gil, 1998; Stellrecht et al., 2006). Further, individuals are impacted by social stigma, guilt, shame, and social isolation associated with the behavior (Gratz, 2003), and NSSI is associated with other risky behaviors, including illicit drug use and frequent binge drinking (Serras, Saules, Cranford, & Eisenberg, 2010).
Research has supported a functional model of NSSI. The behavior may be performed for automatic negative reinforcement (i.e., removal of an aversive stimulus), automatic positive reinforcement (i.e., generation of a favorable stimulus), social negative reinforcement (i.e., escape from interpersonal demands), and social positive reinforcement (i.e., gaining attention from others or access to environmental or interpersonal resources; Nock & Prinstein, 2004, 2005). Research suggests that while individuals who engage in NSSI endorse both automatic and social reinforcement from the behavior, NSSI may be performed most often for the function of automatic reinforcement, such as emotion regulation (Nock & Prinstein, 2004).
Despite differences between NSSI and attempted suicide, a significant number of individuals with a history of NSSI report past suicide attempts (Jacobson, Muehlenkamp, Miller, & Turner, 2008; Langbehn & Pfohl, 1993; Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006), and a history of NSSI has been found to statistically predict history of attempted suicide (Andover & Gibb, 2010; Whitlock & Knox, 2007). Individuals with a history of NSSI may be more likely to die from a suicide attempt than individuals without a history of NSSI because they tend to underestimate the lethality of their attempts (Stanley, Gameroff, Michalsen, & Mann, 2001), and NSSI and repeated suicide attempts may habituate individuals to the physical and emotional pain necessary to die by suicide (Van Orden et al., 2005).
An assessment of suicidal and non-suicidal thoughts and behaviors should be a routine part of any clinical assessment. In this chapter, we present an overview of the assessment of suicide and NSSI in anxiety disorders. Specifically, we will discuss the associations among suicide and NSSI and anxiety disorders, strategies for assessing suicidal thoughts and behaviors and NSSI, and issues pertinent to the assessment of suicide and NSSI among individuals with anxiety disorders.
Suicide and Anxiety Disorders
Risk for suicide may not be commonly considered in individuals with anxiety disorders, as clinicians often associate suicide risk with mood disorders (Simeon & Hollander, 2006). However, patients with anxiety disorders do experience significant suicidal ideation and make suicide attempts (Simeon & Hollander, 2006). Sixty percent of individuals in a nationally representative sample endorsing suicidal ideation and 70.4% of those reporting a suicide attempt met criteria for an anxiety disorder (Kessler, Berglund, Borges, Nock, & Wang, 2005). Specifically, among those endorsing a suicide attempt, 42.2% met criteria for a specific phobia, 41.5% social phobia, 35.1% panic disorder, 30.0% post-traumatic stress disorder (PTSD), 27.8% obsessive–compulsive disorder (OCD), 15.5% generalized anxiety disorder, and 6.8% agoraphobia without panic disorder (Kessler et al., 2005). This suggests that anxiety disorders are commonly experienced by individuals reporting significant suicidal thoughts and behaviors.
Several studies have found the presence of an anxiety disorder to be associated with suicidal ideation and attempts (Sareen, Cox et al., 2005), and researchers have suggested that anxiety disorders may be a significant risk factor for suicidality (Boden, Fergusson, & Horwood, 2007; Hawgood & De Leo, 2008). However, research is unclear as to the specific anxiety disorders that may be related to suicide. Goldston et al. (2009) found GAD and panic disorder to be associated with an increased risk of suicide attempts, while Nock and Kessler (2006) reported that simple phobia, but not social phobia, agoraphobia, panic disorder, GAD, or PTSD, was a risk factor for attempted suicide. Other studies report that disorders characterized by anxiety and agitation, such as PTSD, and poor impulse control most strongly predict the progression from suicidal ideation to suicide plans and attempts in longitudinal studies (Nock, Hwang, Sampson, & Kessler, 2010). Studies have demonstrated that severe or worsening symptoms of anxiety, rather than a diagnosis of an anxiety disorder, may be associated with suicide attempts (i.e., Tuisku et al., 2006; Simeon & Hollander, 2006).
Research suggests that some anxiety disorders may be related to suicidal ideation, but not to suicide attempts. ten Have et al. (2009) found social phobia to be significantly associated with suicidal ideation, but not suicide attempts. However, although agoraphobia, specific phobia, and GAD were not associated with suicidal ideation, they were significantly associated with suicide attempts. Sareen, Cox et al. (2005) suggest that GAD, social phobia, and OCD may be directly related to suicidal ideation, but the association between anxiety disorders and attempted suicide may be mediated though other comorbid disorders.
Research investigating the association between suicide and anxiety disorders has yielded mixed results, particularly when evaluating anxiety disorders as an independent risk factor for suicide. Mood disorders are most strongly associated with suicidal ideation and suicide attempts, but several studies have demonstrated that anxiety disorders are also associated with suicidality, although not as strongly as mood disorders (Beautrais, Wells, McGee, & Oakely Browne, 2006; Nock et al., 2008). While the majority of studies do demonstrate that anxiety is associated with suicidal thoughts and behaviors, this relation appears to be due to comorbidity with other mental disorders, especially mood disorders (Hawgood & De Leo, 2008). However, individuals with comorbid anxiety disorders present a more severe clinical picture in terms of suicidal thoughts and behaviors. Comorbid mood and anxiety disorders are associated with a higher likelihood of suicide attempts than mood disorders alone (Sareen, Cox et al., 2005). Among individuals with depressive disorders, higher levels of anxiety symptoms are associated with increased suicide risk (Chioqueta & Stiles, 2003), and severe anxiety and agitation may precede suicidal behaviors among individuals with mood disorders (Fawcett, 2007). Although several studies demonstrate that the association among suicidality and anxiety disorders is nonsignificant when statistically controlling for the presence of mood disorders, Bolton et al. (2008) found that the presence of one or more anxiety disorders at baseline was significantly associated with suicide attempt during a 3-year follow-up period, even after statistically controlling for sociodemographic variables and depressive disorders. Some research suggests that panic disorder, PTSD, OCD, and social phobia may be associated with suicidality even after controlling for comorbid conditions (i.e., Hawgood & De Leo, 2008). For example, PTSD has been found to be independently associated with suicidal ideation and attempts when statistically controlling for mood disorders and substance use disorders (Sareen, Houlahan, Cox, & Asmundson, 2005). Other research suggests that GAD, social phobia, agoraphobia, and separation anxiety disorder are the most associated with suicide attempts through their association with other comorbid disorders (Nock et al., 2010).
Several factors have been associated with suicidality in anxiety disorders, including worsening symptoms, increasing functional impairment, poor social support, an acute life crisis, feelings of overwhelming anxiety and loss of control, onset or worsening of depressive symptoms, and comorbid personality or substance use disorders (Simeon & Hollander, 2006). Several explanations of the association between anxiety and suicidality have been proposed. First, individuals may consider or attempt suicide as an escape from severe or worsening anxiety symptoms (Bolton et al., 2008; Sareen, Cox et al., 2005). Second, comorbid conditions, such as mood disorders or substance use disorders, may influence the association between anxiety disorders and suicide (Sareen, Cox et al., 2005). Lastly, the presence of anxiety disorders may increase the likelihood of a third variable that may lead to suicidal behavior (Bolton et al., 2008). For example, alcohol may be used to relieve anxiety symptoms; however, this alcohol use may be associated with subsequent suicidality.
Considerable research has focused on the association between suicidality and panic disorder specifically. Using data from the Epidemiologic Catchment Area (ECA) study, Weissman, Klerman, Markowitz, and Ouellette (1989) reported that 20% of individuals with a history of panic disorder also reported a lifetime suicide attempt. Researchers have reported an increased risk of attempted suicide associated with both panic disorder and panic attacks; individuals with panic disorder were found to be more than ten times more likely to attempt suicide than individuals without a mental disorder, and those with a history of panic attacks were five times more likely to attempt suicide (Mannuzza, Aronowitz, Chapman, Klein, & Fyer, 1992). Similar to the association between suicidality and anxiety disorders in general, suicide attempts in panic disorder are strongly associated with comorbid mood disorders, substance use, and personality disorder, such as borderline personality disorder (Diaconu & Turecki, 2007; Friedman, Jones, Chernen, & Barlow, 1992; Simeon & Hollander, 2006; Vickers & McNally, 2004). Among individuals with panic disorder and history of suicide attempts, the attempt often preceded panic disorder onset and occurred during an episode of a mood substance disorder (Mannuzza et al., 1992). Individuals with panic disorder and major depressive disorder reported a suicide attempt rate of nearly 20%; although individuals with panic disorder alone reported a 7% suicide attempt rate, this is still significantly higher than found in the general population (Johnson, Weissman, & Klerman 1990; Diaconu & Turecki, 2007). Research on the association between pure panic disorder and suicide attempts is inconsistent; while some researchers have found that panic disorder is not associated with attempted suicide when statistically controlling for comorbid diagnoses (Hornig & McNally, 1995), others have reported panic disorder to be associated with a history of a suicide attempt in the past year, even when controlling for comorbidity (Goodwin & Roy-Byrne, 2006).
Panic disorder and panic attacks are also associated with increased risk for suicidal ideation (Goodwin & Roy-Byrne, 2006; Pilowsky et al., 2006). Individuals with panic disorder report similar levels of suicidal ideation as individuals with depressive disorders (Diaconu & Turecki, 2007). Unlike findings regarding the relation between panic disorder and attempted suicide, research generally suggests that the association between panic disorder and suicidal ideation continues to be significant after statistically controlling for comorbid conditions (Goodwin & Roy-Byrne, 2006). Suicidal ideation may be experienced as a result of the symptoms and functional impairment associated with panic disorder (Simeon & Hollander, 2006). Research has suggested that the relation between suicidal ideation and panic disorder may be associated with specific anxiety-related variables, such as overall anxiety severity, anticipatory anxiety, increased attention toward and avoidance of somatic sensations, and phrenophobia, a fear of cognitive incapacitation (Schmidt, Woolaway-Bickel, & Bates, 2001).
NSSI and Anxiety Disorders
Few studies have investigated the association between NSSI and specific anxiety disorders. However, studies have demonstrated increased levels of anxiety among individuals with a history of NSSI (Andover et al., 2005; Bennum & Phil, 1983; Klonsky et al., 2003; Penn, Esposito, Schaeffer, Fritz, & Spirito, 2003; Ross & Heath, 2002). High levels of anxiety may also be related to a specific subgroup of NSSI; Klonsky and Olino (2008) reported that one class of individuals with NSSI was characterized by use of several methods of NSSI, endorsement of both automatic and social functions of the behavior, and high levels of anxiety. Studies have suggested that individuals with NSSI report a history of elevated symptoms of anxiety dating back to childhood (i.e., Fulwiler, Forbes, Santangelo, & Folstein, 1997).
The subjective experience of anxiety is often reported by individuals who engage in NSSI. Nearly half of a sample of individuals who engaged in NSSI reported that feelings of anxiety and tension precipitated their NSSI (Bennum & Phil, 1983). The behavior is commonly performed for the function of automatic negative reinforcement (i.e., Nock & Prinstein, 2004), which can serve to decrease aversive feelings of arousal or anxiety. Further supporting this function of NSSI, several studies have demonstrated physiological (Brain, Haines, & Williams, 1998; Haines, Williams, Brain, & Wilson, 1995) and subjective (Darche, 1990; Herpertz, 1995; Favazza, 1989) tension reducing qualities associated with the behavior. Researchers have reported a decrease in physiological arousal while imagining NSSI as measured by heart rate, respiration, galvanic skin response, and finger pulse amplitude (Brain et al., 1998; Brain, Haines, & Williams, 2002; Haines et al., 1995). This pattern of activation is consistent with the function of automatic negative reinforcement; NSSI is maintained as it decreases autonomic arousal.
Specific methods of NSSI are also associated with anxiety disorders. Specifically, skin picking behaviors are often comorbid with anxiety disorders. The majority of individuals with psychogenic excoriation (i.e., skin picking) at a dermatology clinic were diagnosed with a current anxiety disorder (Arnold et al., 1998), and over half of a sample of individuals engaging in self-injurious skin picking met criteria for an OCD diagnosis (Wilhelm et al., 1999). Self-injury is also associated with obsessive–compulsive symptoms outside a diagnosis of OCD. Hayes, Storch, and Berlanga (2009) report that score on a measure of skin picking severity is positively correlated with measures of obsessive–compulsive symptoms and impulsivity, and body-focused repetitive behaviors (e.g., skin picking, hair pulling) are often considered under the obsessive–compulsive spectrum (Hayes et al., 2009).
Research has shown that suicidal and non-suicidal thoughts and behaviors are associated with anxiety in general and specific anxiety disorders. Although researchers may be mixed in their evaluation of anxiety disorders as independent risk factors for suicide, research indicates that anxiety disorders are associated with suicidality, even if that association occurs largely in the context of mood disorders, and individuals with comorbid anxiety and mood disorders are at greater risk for suicidal behaviors than individuals with either disorder alone. For these reasons, it is important to assess for suicidality and NSSI among individuals presenting with anxiety symptoms, regardless of the presence of a mood disorder.
Assessing Suicidal Ideation and Behaviors
Assessment of suicide risk may occur in an intake evaluation, where psychiatric history is being obtained, or during the course of therapy. It is essential that the clinician be prepared with an approach to handle the assessment of suicide risk, and a suicide risk assessment should be performed and documented with all patients (Berman, 2006). During the assessment, the clinician should identify factors that may increase or decrease risk while addressing the patient’s immediate safety (APA, 2003). It is important that the patient feel comfortable in discussing previous or current suicidal thoughts or behaviors; therefore, rapport or therapeutic alliance should be established.
Before the Assessment: Considerations
Suicide is a psychiatric condition that can result in the death of a patient, a fact that may overwhelm clinicians. It is important to recognize that asking about suicide does not increase a patient’s risk for suicide or give the patient the idea of suicide (APA, 2003). Not asking about suicide or avoiding a suicide risk assessment is more likely to place a patient at increased risk. Suicide is a topic that can be frankly confronted and managed in a clinical setting. The thought of discussing suicide with a patient may feel intimidating or overwhelming, but it is important that the clinician approach the conversation in a calm, matter-of-fact manner, communicating comfort in discussing the topic and a willingness to listen to the patient. A severe or hesitant approach will not facilitate the patient’s disclosure of sensitive and often stigmatized information. Discussion of suicidal thoughts and behaviors in a concerned but straightforward manner may increase the patient’s willingness to disclose suicidal thoughts and behaviors.
Conducting a Suicide Risk Assessment
A suicide risk assessment includes an evaluation of a patient’s suicidal ideation, suicide plan, and suicidal intent. Below is a description of each area, including suggestions for questions clinicians may use to assess that area.
Assessing Suicidal Ideation
Suicidal ideation is common in clinical and community samples. Nearly 14% of a national representative sample report suicidal ideation during their lifetime; this percentage is greater among individuals in mental health settings (Kessler et al., 1999; Paykel, Myers, Lindenthal, & Tanner, 1974). The majority of patients who report suicidal ideation will not attempt suicide (Crosby, Cheltenham, & Sacks, 1999; Mann et al., 2006); however, suicidal ideation is quite serious as it indicates an increased risk for suicide. Suicidal ideation may consist of thoughts of death (passive suicidal ideation) and thoughts of killing oneself (active suicidal ideation). Assessment of suicidal ideation should be direct and specific (i.e., “Have you been thinking about killing yourself?”). The clinician may specifically ask about killing oneself—as opposed to hurting oneself—to differentiate between suicidal and non-suicidal ideation. Frequency, intensity, and duration of the suicidal ideation should also be assessed. Research indicates that more frequent, intense, and long-lasting suicidal ideation is more troubling for the patient and may indicate increased suicide risk (APA, 2003; Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999; Joiner, Rudd, & Rajab, 1997). If any suicidal ideation is reported, the suicide risk assessment will continue with an assessment of a suicide plan.
Assessing Suicide Plan
Once suicidal ideation has been established, existence and details of a plan for suicide must be assessed. This is best accomplished using open-ended questions, such as “Do you have a plan for how you would kill yourself?” or “What have you been thinking about doing to kill yourself?” Method of suicide should be assessed, as well as availability of the method, level of detail, timing, setting, and precautions against rescue or discovery. Regardless of the detail of the suicide plan, suicidal intent should be assessed among those who indicate having a plan for suicide.
Assessing Suicidal Intent
Finally, a suicide risk assessment must include an assessment of suicidal intent. Suicidal intent refers to the patient’s expectation and desire to die as a result of suicide (APA, 2003). Suicidal intent can be assessed with questions such as “How likely do you think it is that you will try to kill yourself?” or “How strong is your desire to kill yourself?” Level of detail of the suicide plan can also indicate suicidal intent. For example, if a patient has taken action to prepare for the suicide, such as collecting pills for an overdose, making plans to be alone to prevent discovery, giving away possessions, or writing a suicide note, this may indicate increased suicidal intent. Strength of patient’s intent to die and belief in the potential lethality of the suicide plan should be considered. Clinicians may also assess the patient’s subjective courage and competence to die by suicide, as research indicates that these are important indicators of suicide risk (Joiner et al., 1997). A comprehensive assessment of suicidal intent is imperative, as the imminence of suicide risk will have implications for the action taken.
Suicide Risk Assessments with Children
Conducting a suicide risk assessment with children may require the consideration of additional factors. Not all young children understand that suicide, and death in general, is irreversible, and understanding of death and suicide may depend on the child’s developmental level and experiences of illness and death, including information from home or school (American Academy of Child & Adolescent Psychiatry, 2001). Clinicians working with children should also assess the child’s understanding of death and suicide. Understanding of death and lethality in children may be limited; therefore, the child’s belief in the lethality of a particular method is more indicative of suicide risk than actual lethality of the method. Collateral information from family members may be particularly important; family engagement in treatment is also particularly important (Berman, 2006).
Suicide Risk Assessment Disposition
A difficult reality clinicians face in assessment of suicide risk is that despite the best efforts of researchers, suicide and suicidal behavior cannot be reliably predicted (Berman, 2006; Rudd & Joiner, 1998). For example, researchers have estimated that among 15–19 year olds, the suicide attempt to death ratio is 400:1 for boys and 3,000:1 for girls (Mann et al., 2006). Conducting a suicide risk assessment and intervening can rely heavily on clinical judgment. Once a suicide risk assessment has been conducted and suicidal ideation, plan, and intent have been established, a disposition must be decided upon. This decision must incorporate legal and ethical responsibilities and organizational guidelines. The following recommendations are based on the protocol suggested by Joiner, Walker, Rudd, and Jobes (1999) and the experience of the authors. An appropriate disposition for an individual who indicates suicidal ideation, but not a suicide plan or intent, may include continued assessment, such as a phone call a few days later to assess suicide risk, or focus in treatment. A crisis plan should also be established, including plans to call a clinician, suicide hotline, or friend or family member if the suicidal ideation worsens or the patient feels unsafe. Depending on the clinician’s judgment, he or she might suggest that if the feelings do not lessen after seeking social support, or if the patient develops more suicidal plans or intent, that the patient go to the nearest emergency room or call emergency services. Clinicians may wish to use a detailed emergency coping card with a step-by-step plan of what a patient can do in the event of an emergency.
If a clinician feels that a patient is at elevated risk, such as a suicide plan or intent that is not imminent, the clinician may consider increased frequency or duration of therapy sessions to attempt to resolve current symptoms, address stressors, and reevaluate treatment goals such as reducing feelings of hopelessness, increasing social support, and improving self-soothing, self-control, coping, or problem-solving skills (Joiner et al., 1999). If a patient is in imminent danger of attempting suicide, the clinician should closely monitor the patient and may consider voluntary hospitalization or even involuntary hospitalization if necessary. Documentation of all risk evaluation, assessment, and treatment goals and progress is essential when treating patients who report any suicidal ideation, plan, or intent. All clinical activities and decisions should be regularly recorded in a clinician’s progress notes (Berman, 2006; Joiner et al., 1999).
Associated Factors to Assess
In addition to assessment of suicidal ideation, suicide plan, and suicide intent, assessment of other suicide risk factors may provide additional information important in determining suicide risk. In addition to the assessment of suicide risk, these associated factors may be important in treatment planning.
History of Suicide Attempts
History of previous suicide attempts is an important factor to consider when assessing risk for future suicide attempts. History of attempted suicide is the single strongest predictor of a future attempt (Joiner et al., 2005). Number of previous attempts is also an important factor to consider; an individual with multiple past attempts is at a greater risk for future suicide attempts than an individual with a single past attempt (Joiner et al., 1999). It is important that the clinician gather as much information as possible about past attempts, including to what extent a suicide attempt was planned versus impulsive by asking how long he or she had been thinking about it and any indicators about planning such as leaving a suicide note or making preparations for what would happen after her or she died (Joiner et al., 2005). Information about history of suicide attempts can also inform the clinician about the extent to which the patient has begun to habituate to the physical and emotional pain inherent in suicide, which may increase risk for future suicide death (Van Orden et al., 2010).
Demographic Factors
In the United States, men are almost four times more likely to die by suicide than women, but women are three times more likely to attempt suicide than men (Joiner et al., 2005; Kessler et al., 1999). Rates of suicide differ among age groups, with the highest rate of suicide among the elderly over age 80 (APA, 2003; CDC, 2007). Caucasians are more than twice as likely to die by suicide as members of racial minority groups in the United States, with the exception of Native Americans (APA, 2003; CDC, 2007). Single adults are twice as likely as those who are married to die by suicide but those who are divorced, separated, or widowed are more likely to die by suicide than married individuals (APA, 2003). Lower levels of education are associated with increased likelihood to attempt suicide (Kessler et al., 1999).
Comorbid Mood Disorders
While research has demonstrated an association between anxiety disorders and suicidal thoughts and behaviors, mood disorders may play an important role in this association. Comorbid mood and anxiety disorders are associated with a higher likelihood of suicide attempts than mood disorders alone (Sareen, Cox et al., 2005), and an increased risk for suicide in depressive disorders has been noted for individuals reporting higher levels of anxious symptoms (Chioqueta & Stiles, 2003). In addition, severe anxiety or agitation—independent of an anxiety disorder—may precede suicidal behaviors among individuals with mood disorders (Fawcett, 2007). Therefore, it is particularly important to assess suicide risk among anxious individuals presenting with a comorbid mood disorder or depressive symptoms.
Precipitant Stressors
Assessment of relatively recent life stressors, particularly those involving interpersonal loss or disruption, is important in understanding suicide risk. The clinician should determine if the stressor continues to be significant for the patient. For any patient, the existence of notable stress combined with suicidal symptoms may be considered riskier than suicidal symptoms alone (APA, 2003; Joiner et al., 1999).
Hopelessness
Hopelessness is a psychological symptom that can exacerbate risk for suicide and can be considered a major risk factor for suicide (Beck, Steer, Beck, & Newman, 1993; Chance, Kaslow, & Baldwin, 1994). Joiner et al. (2005) described hopelessness as one of the most important risk factors for suicide. Hopelessness can be assessed as a risk factor for suicide, and if present, can be targeted as a part of treatment (APA, 2003).
Social Support
Lack of social support is associated with an increased risk for suicide (APA, 2003; Joiner et al., 1999). In addition, feeling of being disconnected from or not belonging to any social network may increase risk for suicide (Van Orden et al., 2010). Perceived social support is important to assess as a risk factor for suicide, but also as a protective factor. In addition, knowing the level of social support available to an individual may be helpful in treatment planning and disposition.
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