Warning Signs of Suicide
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Warning Signs of SuicideLanny Berman, Ph.D., ABPPExecutive directorAmerican Association of Suicidology
Screening for Mental Health TeleconferenceSeptember 24, 2007
Risk Factors for Suicidal Behavior
A measurable characteristic, variable, or hazard that increases the likelihood of development of an adverse outcome.
A risk factor precedes the outcome in time.
Risk Factors for Suicidal BehaviorPerpetuating risk factorsFamily history (violence, suicide, mental disorder requiring hospitalization)Skill deficits (social, cognitive)Multiple/chronic personal lossesEarly trauma/abusePrior suicidal behavior
Risk Factors for Suicidal Behavior Predisposing risk factorsPoor self-esteem/Self-conceptPsychiatric illnesse.g. depressionCo-morbidityChemical dependencyPhysical illnessExposure to suicidal behaviorImpulsivity/aggression
Risk Factors for Suicidal BehaviorPrecipitating risk factorsLoss of social support (friends, family)Loss of identity/meaning (job, career); loss of attachmentsThreat of/actual loss of job/financial lossAcute psychiatric symptoms (psychosis, depression, panic)Loss of hope/Sense of failureAcute disappointmentsEmbarrassments, humiliations, threat to statusThreat of legal action/incarcerationAvailability of meansAnniversary reaction
Warning SignsEarly detection, referral, treatment modelHealth care workersMental health providersFirst responders
Public health awareness modelTo lay publicTo gatekeepers, etc.
Evidence-based Suicide Prevention ProgramsCase Finding Strategies:
Suicide awareness curricula Gatekeeper training Screening Crisis centers and hotlines
Warning Signs on the Internet (Mandrusiak et al, 2006)Google search: warning signs and suicide183,000 hitsTabulation of 1st 50 of randomly selected 200 sites138 distinct warning signs18 signs posted on > 30% of sites63 were unique to one siteOf 200 web sites sampled3266 warning signs categorized from all 200 sites
Appendix 1. List of Warning Signs and Risk Factors Published By Various Organizations and Number of Times Listed.
substance abuse (1)X
physical or sexual abuse (2)XX
Suicidal/Death Ideation (2)XX
writing about death and suicide (1)X
talking about suicide and plans (7)XXXXXXX
giving prized possessions away (7)XXXXXXX
attraction to death (4)XXXX
making arrangements (4)XXXX
making out wills (4)XXXX
unusual visiting or calling loved ones (2)XX
obsession with guns/knives (1)X
Behavior Changes (4); marked changesXXXX
substance abuse (9)XXXXXXXXX
withdrawal from friends/family (4)XXXX
personality changes (4)XXXX
physical symptoms (3)XXX
withdrawal from regular activities (4)XXXX
neglect of personal appearance (3)XXX
unnecessary risks (3); behaving recklessly (1)XXXX
fear of losing control (3)XXX
running away (2)XX
self-destructive behavior (2);self-mutilation (1)XXX
boredom (2); daydreaming (1)XXX
decline in quality of schoolwork (2)XX
rebellious behavior (2)XX
not tolerating praise or rewards (1)X
violent actions (1)X
extravagant spending (1)X
worry about money (1)X
worry about illness (real or imaginary) (1)X
fear of hurting oneself or others (1)X
increased crying (2)XX
increased anxiety (1)X
increased panic attacks (1)X
unwillingness or inablity to communicate (1)X
chronic pain, panic, anxiety (1)X
loss of interest in appearance (1)X
severe loss/separation (loved one, job,XXXXXXX
money, status, self-esteem) (7)
rejection - feeling marginalizedX
failing in school (2)XX
loss of physical funtioning (1)X
loss of body parts/physical integrity (1)X
serious illness or injury to oneself (1)X
causing serious injury or death to another (1)X
terminal illness (1)X
chronic emotional/physical pain (2)XX
dependence on others for health care (1)X
stressful family life (1)X
loss of religious faith (1)X
panic, anxiety (2)XX
loss of security (1)X
recent imprisonment or upcoming releaseX
problems with school/law (2)XX
increase in minor illnesses (1)X
depressed mood (4)XXXXX
loss of interest in pleasurable activities (5)XXXXX
change in eating habits (6)XXXXXX
sudden weight gain or loss (1)X
change in sleeping habits (7)XXXXXXX
feelings of worthlessness or guilt (8)XXXXXXXX
difficulty concentrating, remembering (2)XX
recurrent thoughts of death (7)XXXXXXX
lack of energy (1)X
change of sexual interest (1)X
deep sadness or guilt (1)X
Past Suicide Attempts (7)XXXXXXX
seriousness of attempts (1)X
rehearsing suicide (1)X
beginning to feel better (2)XX
loneliness - lack of support from fam/friends (1)X
unable to see beyond a narrow focus (1)X
Web Site Warning Signs Messages:Lack consensusAre inconsistent Lack empirical support (e.g. giving away prized possessions on 86% of 50 sites)Are non-specific (e.g., visiting or calling people one cares about; neurotransmitters)
WARNING SIGNS FOR SUICIDEA Working Conference Sponsored by the American Association of Suicidology
With generous support from the Annenberg Sunnylands Trust, the Suicide Prevention Resource Center, and the National Institutes of Mental Health
November 9-11, 2003
The Center for Executive EducationBabson College, Wellesley, MA
M. David Rudd, Ph.D. Baylor UniversityLanny Berman, Ph.D. American Association of Suicidology
Matthew Nock, Ph.D. Harvard University
Gregory Brown, Ph.D. University of PennsylvaniaDana Carr, Ph.D. U. S. Department of EducationDavid Chambers, Ph.D. NIMHYeates Conwell, M.D. University of Rochester Medical Center Jan Fawcett, M.D. University of New Mexico Keith Hawton, M.D. University of Oxford, UKThomas Joiner, Ph.D. Florida State UniversityKaren Clapper Morris American Heart AssociationJames Overholser, Ph.D. Case Western Reserve UniversityMitch Prinstein, Ph.D Yale UniversityDavid Shaffer, M.D. Columbia University College of Physicians and SurgeonsPeter Sheras, Ph.D. University of VirginiaMorton M. Silverman, M.D. Education Development CenterCo-chairs:M. David Rudd, Ph.D.Lanny Berman, Ph.D. Baylor UniversityAmerican Association of SuicidologyFacilitator: Matthew Nock, Ph.D., Harvard University
Essential QuestionsWhat defines a warning sign?
What time-frame best defines imminent or acute risk?Is this a reasonable definition of a warning sign?
Essential QuestionsHow are warning signs to be differentiated from risk factors?
Do we have empirically-based warning signs of suicide and, if so, are there different signs for different outcomes (suicide, nonfatal attempts?)
Essential Questions (contd)Can we consensually agree on a list of warning signs most appropriate for public information campaigns?
If not, should we produce public education information that defines something other than warning signs, e.g., guidelines?
Essential QuestionsCan we agree on how such a common set or list should be disseminated?
Can we identify future research needs/questions to address areas of insufficient knowledge regarding warning signs?
Immediate GoalsConsensus Recommendations
More consistent (and valid) public education message
Warning Signs Key MessagesAre you or someone you love at risk of suicide? Get the facts and take appropriate action. Get help now by contacting a mental health professional or calling 1-800-273-TALK for a referral should you witness, hear, or see anyone exhibiting any one or more of the following:
Someone threatening to hurt or kill him/herself, or talking of wanting to hurt or kill him/herself.
Someone looking for ways to kill him/herself by seeking access to firearms, available pills, or other means.
Someone talking or writing about death, dying or suicide, when these actions are out of the ordinary for the person.
Warning Signs continuedSeek help by contacting a mental health professional or calling 1-800-273-TALK for a referral should you witness, hear, or see anyone exhibiting any one or more of the following:
HopelessnessRage, uncontrolled anger, seeking revengeActing reckless or engaging in risky activities, seemingly without thinkingFeeling trapped like theres no way outIncreasing alcohol or drug useWithdrawing from friends, family and societyAnxiety, agitation, unable to sleep or sleeping all the timeDramatic mood changesNo reason for living; no sense of purpose in life
Red Flags (Mnemonic) IS PATH WARM?
Red FlagsIIdeation/threatened or communicatedSSubstance Abuse/excessive or increased
PPurposeless/no reasons for livingAAnxiety, Agitation/InsomniaTTrapped/feeling no way outHHopelessness
WWithdrawal from friends, family, societyAA