Usually, suicide has no single cause. It is the endpoint of an individual process, in which several interacting determinants or risk factors can be identified ( Table...!, and TableJ). Risk factors are by their nature cultural, social, situational, psychological, biological, and even genetic.
Table 1 Risk factors for suicide: sociodemographic variables
Table 2 Clinical determinants of suicide
Culture defines basic attitudes towards life and death, and also towards suicide in society. A hundred years ago suicide was illegal in many European countries. Similarly, most churches overtly opposed suicide and allowed suicide victims to be buried only outside the cemetery. Religion was also a major integrating force between individuals and the community. In a modern secularized society, religion is still a meaningful and protective factor for many individuals in a suicidal crisis. Church plays an important role in suicide prevention in many countries, by arranging crisis services for suicidal people and support for survivors. Western culture has had a tendency to emphasize the individuals's free will and the shouldering of responsibility for one's life, while egoistic and anomic trends in society have intensified and altruism has almost disappeared. Such changes may have increased the incidence of suicide in society. The cultural background of suicide is a deep structure inhereted over the generations. Cultural factors also prevent rapid changes in suicidal behaviour, which is evident among immigrants, whose mode and rate of suicide usually lie somewhere between the original and the host cultures.
Classic sociology views suicide as a social, not an individual, phenomenon. The suicide victim's moral predisposition to commit suicide, not his or her individual experiences, is felt to be the crucial factor. Moral predisposition means the degree to which the victim is involved in more or less integrated groups and in the values of those groups. Suicides are seen as a disturbance or symptom of a relationship between society and individuals. In 1897 Durkheim published his famous work on suicide and described four basic types. Anomic suicide reflects a situation where an individual is no longer guided by the society due to its weakness, like the suicide of an unemployed and rejected alcoholic without any support from society. Altruistic suicide is illustrated by a society which can exert a strong influence on an individual's decision to sacrifice his or her life, as did the captain of the Titanic, for example. Egoistic suicide is an individualistic decision of a person no longer dependent on others' control or opinion such as a person who has arranged an assisted suicide. Fatalistic suicide is seen as a result of strict rules in a society which have proved decisive for the destiny of an individual, for example the suicide of a person held as a slave. (15) There are also newer social theories of suicide which stress more the joint effects of social factors. The concept of social isolation has been clinically useful in understanding the socio-ecological and social-psychiatric background of suicide.(1 Ji) Some sociologists have underlined the individual meanings associated with suicide.
The life situation preceding suicide is typically characterized by an excess of adverse life events and recent stressors. Usually, the sum effect of events is overwhelming and more important than a single life event. Job problems, family discord, somatic illness, financial trouble, unemployment, separation, and death and illness in the family are the most common life events preceding suicide. Somatic illness and retirement are age-specifically connected with the suicides of elderly men, while separation, financial troubles, job problems, and unemployment are more common among younger men. Severely disabling somatic illness is a very important risk factor for suicide in elderly male patients, especially when associated with signs of distress and depression. In general, suicide among men is more often related to recent stressors than it is among women. The excess of specific stressors among men implies a subjective lack of success or failures in achievements expected in the social roles of adult life.
In most cases life events are not accidental, but are usually also dependent on the individual's own behaviour. Personality features, even mental disorders, often explain the difficulties the victim has had. Among male alcoholics life stress is connected with family discord and separations in all age groups. Other sources of stress in alcoholic male suicides are unemployment and financial troubles, whereas in depressive non-alcoholic male victims life stress is associated more with somatic illness. Among alcoholic males, adverse life events and living alone clearly have an enhancing effect on suicidality, which should be taken into account when treating alcohol misuse. In the extreme case of a rejected suicidal alcoholic husband of a divorcing wife, all available social support should be mobilized for both sides. Among females life events as psychosocial stress are less strongly connected with suicide. Depression and adverse interpersonal life events are more frequent contributors to female than male suicides. (1M9)
Early psychological theories of suicide focused on the concept of the self. A classical example is Freud's theory assuming that self-destructive behaviour in depression represents aggression directed against a part of the self that has incorporated a loss or rejection of a love object. In his later theory of suicide Freud presented the construction of the dual instincts, where Eros is a life-sustaining and life-enhancing drive in constant interaction with Thanatos, the aggressive death instinct.
Later psychodynamic thinking on suicide focused more on the self in relation to others. Suicide was seen as an aggressive attack against the 'bad mother', a failure of the separation-individuation transition, a failure to achieve adaptation in situations of confusion and loss of control, an expression of narcissistic rage and an inability to tolerate feelings of shame, an effort to re-establish control over a chaotic inner world, or as a need to regain feelings of self-esteem by merging with a lost loved object through death. Failures in the developmental and adaptational processes are reflected in negative self-images and distorted cognitive schemas, leading to such feelings as depression, hopelessness, rage, shame, guilt, and anxiety. It is widely held that psychological pain is found as a common element at the core of all suicidal behaviours; suicide occurs when the individual can no longer endure the pain. Most recent psychological theories of suicide accept a multiaxial causation of suicide resulting from an interaction of predisposing and precipitating factors. A person moves towards a suicidal crisis depending on the stressors and precence or absence of protective factors in his or her life.
Suicide often aggregates in families. Relatives of patients who commit suicide are themselves more likely to commit suicide than relatives of patients who do not commit suicide. Liability to suicidal behaviour may be a familially transmitted trait which is independent on the specific mental disorders.
Results of adoption studies suggest that genetic factors rather than familial environmental factors are the determinants of familial concordance for suicidal behaviour. Among biological relatives of adopted suicide victims there is a higher incidence of suicide than among the relatives of non-suicide controls or among the adoptive relatives of the suicide victims. Also identical twins have a higher concordance for suicide, attempted suicide, and suicide ideation compared with non-identical twins.(.2.1)
Patients who have seriously attempted suicide by violent means have low levels of the serotonin metabolite 5-hydroxyindole acetic acid in their cerebrospinal fluid. ^i2 These and other biochemical changes are discussed in Chapter.4.15.3.
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