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Chronically suicidal?

Øivind Ekeberg, Erlend Hem About the authors

“Chronically suicidal” and “chronic suicidality” are unclear terms which in our opinion should not be used.

Both these terms are relatively new. The late psychiatrist Professor Nils Retterstøl offered the following definition in his book Selvmord (Suicide) from 1995: “The ‘chronically suicidal’ are a group of people who over a long period of time take their own lives by dint of their lifestyles: the daredevils who repeatedly take risks and survive one accident after another (‛accident proneness’), alcohol and drug abusers who in the long run shorten their lives by many years, and also people who neglect to have themselves treated for their physical disorders. The category of the ‛chronically suicidal’ also includes those people who resolve their conflicts and crises by suicide attempts and who are admitted to hospital and to some degree test the patience of their therapists” (1). This definition is broad, covers many groups and is thus rather imprecise.

“Chronic suicidality” is also described in the Norwegian national guidelines for prevention of suicide in mental health care: “In some few patients, suicidal thoughts and plans can be more or less constant. They may also have repetitive self-destructive patterns of behaviour, often with self-harming and/or suicide attempts” (2, p. 25). These people form a different group to those described by Retterstøl.

According to the national guidelines, “chronic suicidality” most frequently occurs in individuals with borderline personality disorder. At the same time, suicidal behaviour is one of the criteria for this diagnosis. The term “chronic suicidality” can be part of a circular definition.

Many individuals suffering from severe depression probably have equally persistent suicidal thoughts as patients with borderline personality disorder, but our impression is that the term “chronically suicidal” is rarely used to describe patients who are depressed.

International literature

A search in PubMed (27 July 2017) produced 32 hits on “chronic suicidality”, with the first hit dating from 1989. Six of the articles were written by the Canadian psychiatrist Joel Paris. In scarcely any of the articles was the term defined.

“Chronic suicidality” is often referred to in tandem with dialectical behaviour therapy (DBT). In the first studies, the authors used the term “chronically parasuicidal borderline patients”. Among the inclusion criteria was borderline personality disorder and “at least two incidents of parasuicide in the last 5 years, with one during the last 8 weeks” (3). However, the term “chronically parasuicidal borderline patients” only produced hits on these two articles in PubMed.

Patients with “chronic suicidality” often attempt suicide, and with low mortality rates, usually by taking small overdoses or by superficial cutting that represents no serious risk, according to Paris (4). In our opinion, it is difficult to see how patients acting in this way could have intended to take their lives, in other words been suicidal.

“Chronic suicidality” is, again according to Paris, not related to periods of depression, but to personality disorder. It is a pattern of behaviour that is continual, repetitive and that performs an interpersonal function. Suicidality is a trait that cannot be removed easily since it is rooted in the structure of the personality (4).

Suicidal

We have no common understanding of what is meant by the term “suicidal”. According to Paris it is used of thoughts and behaviours in patients who think about suicide, who cut themselves, who take small overdoses or who carry out life-threatening acts (4). He points out that it can be confusing to have a word that covers so many and different phenomena (5). Some mental health professionals advise against its use (6).

In our view, the word should be reserved for conditions where an individual has thoughts and plans about ending their life, and where those plans entail a belief that the act of suicide will be fatal.

Chronic

In medicine, the duration limit between acute and chronic is usually fixed at six months. However, a number of mental health professionals believe that there is no clear delimitation between acute and “chronic suicidality” (7). If we are going to use “chronic” in connection with suicidal behaviour, we must in our opinion clarify whether we mean it is the thoughts, plans, preparations or suicide attempts that are chronic.

What does it mean?

As we have seen, it is unclear what “chronically suicidal” and “chronic suicidality” imply. Unclear terms will often cause ambiguity and confusion. The national guidelines refer to the risk of suicide being raised in the long term (2). Does this mean that the criterion is that there are recurrent suicidal impulses? Or that an individual has a certain number of risk factors?

It surely cannot mean that an individual who has several known risk factors, such as being male, misusing alcohol, and being divorced and unemployed, and thus having a raised suicide risk, should be classified as “chronically suicidal”? Patients admitted to hospital after acute self-inflicted poisoning have a raised risk of suicide for at least 20 years after the event (8), but it would also be wrong to classify them as “chronically suicidal”.

For most individuals struggling with suicide problems, their suicidal impulses fluctuate. For long periods of time they have no specific plans to take their lives, even if the thoughts may be there. That they should then be referred to as “chronically suicidal” can easily mask the true situation. It is difficult to imagine how someone can be “chronically suicidal” without also being suicidal at a specific point in time, in other words “acutely suicidal”. One can undoubtedly have a chronically raised suicide risk in the form of several risk factors being present, without being acutely suicidal.

Suicidal thoughts and suicide plans

Suicidal behaviour usually means suicidal thoughts and suicidal acts (Table 1). Suicidal thoughts may possibly be chronic, or at least recurrent. This may be because the individual is in a constant state of despair and struggles to keep such thoughts at bay.

Table 1

Suicidal behaviour and time perspectives



Behaviour

Chronic?

Suicidal thoughts

Possibly

Suicide plans

Probably not

Preparation for suicide

No

Suicide attempt

No

Suicide

No

Some individuals experience suicidal thoughts as a way of helping them keep going, because they may regard suicide as a possible solution should the situation become completely unbearable, so that they have a way out and thus greater latitude. Only the fewest individuals with suicidal thoughts make plans for how to carry through a suicide.

Where there are suicide plans the individual will have come further in the suicide process, such as planning how to execute the suicide attempt, perhaps envisaging the time, place, method, and so on. This is quite certainly not a chronic condition. Preparations for suicide may for example consist of getting hold of what is assumed to be a fatal dose of medication from the pharmacy, or taking out a gun and concealing oneself so as not to be stopped. This is not the sort of behaviour either that occurs often enough to be characterised as chronic.

Some individuals make several attempts to take their lives. However, not many have made more than five serious attempts, and almost none have made more than ten. Hardly anyone will take the view that making serious suicide attempts is a chronic condition.

Who gets help?

In some cases, the label “chronically suicidal” can probably be used as a means of not deciding whether there is an acutely raised risk of suicide. There is no final answer to whether one should discharge or admit a patient who talks about suicidal thoughts. One must assess whether the patient is acutely suicidal or not. This can be difficult and depends on whether the patient has suicide plans, how concrete they are, whether they are present all the time, whether the patient hears voices telling her what to do, and whether the patient is agitated, has access to the means of suicide (weapon, medication, etc.) and has no plans for the future (9).

It is well known that patients displaying suicidal behaviour are capable of arousing negative reactions among their therapists. Maybe it is easier to treat the patient as “chronically suicidal” than to deal with the acute risk of suicide and the challenges that can entail. We have seen several examples of patients making serious suicide attempts or taking their lives after being assessed as “chronically suicidal”, despite making it known that they had clear suicide plans.

The term “chronically suicidal” has also been problematised by others (10). A girl had taken her life after being discharged from a psychiatric institution. She was described as chronically suicidal and emotionally unstable. Two practice consultants wrote that many people react negatively to the label “chronically suicidal”. In their view, the label was a dangerous one, because it enabled acute risk of suicide to be overlooked. They concluded with an appeal: that perhaps the mental health community could look with fresh eyes at how it deals with patients with suicide problems and raised suicide risk, instead of staring blindly at the label “chronically suicidal” (10).

Conclusion

In our opinion, the terms “chronically suicidal” and “chronic suicidality” are so imprecise and unclear that they should not be used. Some individuals struggle with suicidal behaviour over a long period of time. But this should not be described as “chronic suicidality”, because it can easily appear template-like and make assistive measures more difficult.

An individual’s suicidal behaviour should be described as precisely as possible on the basis of the current situation and be treated accordingly. There should always be an effort to concretise the characteristic features of the suicidal behaviour. Only suicidal thoughts can be chronic. Suicide plans, preparations and attempts occur only a few times and must be treated with the requisite seriousness.

One of the authors is an editor of the Journal of the Norwegian Medical Association. The manuscript has accordingly been processed externally by external editor Pål Gulbrandsen.

1

Retterstøl N. Selvmord. 5. utg. Oslo: Universitetsforlaget, 1995: 16-8.

2

Nasjonale retningslinjer for forebygging av selvmord i psykisk helsevern. IS-1511. Oslo: Sosial- og helsedirektoratet, 2008. https://helsedirektoratet.no/Lists/Publikasjoner/Attachments/3/Nasjonal-faglig-retningslinjefor-forebygging-av-selvmord-i-psykisk-helsevern-IS-1511.pdf (13.7.2017).

3

Linehan MM, Armstrong HE, Suarez A et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48: 1060 - 4. [PubMed][CrossRef]

4

Paris J. Kronisk suicidalitet ved ustabil personlighetsforstyrrelse: Hvorfor det er behov for særskilte tilnærminger i behandlingen. Suicidologi 2010; 15: 3 - 7.

5

Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder. Harv Rev Psychiatry 2004; 12: 42 - 8  [PubMed].. [PubMed]

6

Meyer RE, Salzman C, Youngstrom EA et al. Suicidality and risk of suicide–definition, drug safety concerns, and a necessary target for drug development: a brief report. J Clin Psychiatry 2010; 71: 1040 - 6. [PubMed][CrossRef]

7

Yager J, Feinstein RE. General psychiatric management for suicidal patients, with remarks on chronicity: contending with the angel of death. J Nerv Ment Dis 2017; 205: 419 - 26. [PubMed][CrossRef]

8

Bjørnaas MA, Jacobsen D, Haldorsen T et al. Mortality and causes of death after hospital-treated self-poisoning in Oslo: a 20-year follow-up. Clin Toxicol (Phila) 2009; 47: 116 - 23. [PubMed][CrossRef]

9

Ekeberg Ø. Vurdering av selvmordsfare. I: Ekeberg Ø, Hem E, red. Praktisk selvmordsforebygging. Oslo: Gyldendal Akademisk, 2016: 117-34.

10

Weber A, Jensen MJF. Hvorfor? Hvorfor vil Veronica dø? Nordlys 16.6.2015. http://nordnorskdebatt.no/article/ hvorfor-hvorfor-vil-veronica-do (13.7.2017).

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