Warning Signs of Suicide
Lanny Berman, Ph.D., ABPPExecutive director
American Association of Suicidology
Screening for Mental Health Teleconference
September 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 Behavior
Perpetuating risk factors Family history (violence,
suicide, mental disorder requiring hospitalization)
Skill deficits (social, cognitive…)
Multiple/chronic personal losses
Early trauma/abuse Prior suicidal behavior
Risk Factors for Suicidal Behavior
Predisposing risk factors Poor self-esteem/Self-
concept Psychiatric illness
e.g. depression Co-morbidity
Chemical dependency Physical illness Exposure to suicidal
behavior Impulsivity/aggression
Risk Factors for Suicidal Behavior
Precipitating risk factors Loss of social support (friends,
family) Loss of identity/meaning (job,
career); loss of attachments Threat of/actual loss of
job/financial loss Acute psychiatric symptoms
(psychosis, depression, panic…)
Loss of hope/Sense of failure Acute disappointments Embarrassments, humiliations,
threat to status Threat of legal
action/incarceration Availability of means Anniversary reaction
Warning Signs
Early detection, referral, treatment model Health care workers Mental health providers First responders
Public health awareness model To lay public To gatekeepers, etc.
Evidence-based Suicide Prevention Programs
Case 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 “suicide”– 183,000 hits
• Tabulation of 1st 50 of randomly selected 200 sites– 138 distinct warning signs– 18 signs posted on > 30% of
sites• 63 were unique to one site
• Of 200 web sites sampled– 3266 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.APA AACAP JASONAAS SFSP DMDA NAMI AFSP SAVE YELLOW RIB. BI
Family History suicide (3) X X Xsubstance abuse (1) Xphysical or sexual abuse (2) X XSuicidal/Death Ideation (2) X Xwriting about death and suicide (1) Xtalking about suicide and plans (7) X X X X X X Xgiving prized possessions away (7) X X X X X X Xattraction to death (4) X X X Xmaking arrangements (4) X X X Xmaking out wills (4) X X X Xunusual visiting or calling loved ones (2) X Xobsession with guns/knives (1) XBehavior Changes (4); marked changes X X X Xsubstance abuse (9) X X X X X X X X Xwithdrawal from friends/family (4) X X X Xpersonality changes (4) X X X Xphysical symptoms (3) X X Xwithdrawal from regular activities (4) X X X Xneglect of personal appearance (3) X X Xunnecessary risks (3); behaving recklessly (1) X X X Xagitation (3) X X Xrestlessness (3) X X Xfear of losing control (3) X X Xrunning away (2) X Xself-destructive behavior (2);self-mutilation (1) X X Xhyperactivity (2) X Xaccident-prone (2) X Xboredom (2); daydreaming (1) X X Xdecline in quality of schoolwork (2) X Xrebellious behavior (2) X Xnot tolerating praise or rewards (1) Xviolent actions (1) Xextravagant spending (1) Xlethargy (1) Xnightmares (1) Xworry about money (1) Xworry about illness (real or imaginary) (1) Xfear of hurting oneself or others (1) Xincreased crying (2) X Xincreased anxiety (1) Xincreased panic attacks (1) Xperfectionism (1) Xfighting Xunwillingness or inablity to communicate (1) Ximpulsiveness (1) Xhelplessness (1) Xchronic pain, panic, anxiety (1) Xloss of interest in appearance (1) XStressful Eventssevere loss/separation (loved one, job, X X X X X X X money, status, self-esteem) (7)rejection - feeling marginalized Xfailing in school (2) X Xloss of physical funtioning (1) Xloss of body parts/physical integrity (1) Xserious illness or injury to oneself (1) Xcausing serious injury or death to another (1) Xterminal illness (1) XHIV/AIDS (1) Xchronic emotional/physical pain (2) X Xdependence on others for health care (1) Xstressful family life (1) Xloss of religious faith (1) Xpanic, anxiety (2) X Xloss of security (1) Xrecent imprisonment or upcoming release Xproblems with school/law (2) X Xincrease in minor illnesses (1) XDepression depressed mood (4) X X X X Xloss of interest in pleasurable activities (5) X X X X Xchange in eating habits (6) X X X X X Xsudden weight gain or loss (1) Xchange in sleeping habits (7) X X X X X X Xfeelings of worthlessness or guilt (8) X X X X X X X Xdifficulty concentrating, remembering (2) X Xrecurrent thoughts of death (7) X X X X X X Xlack of energy (1) Xchange of sexual interest (1) Xdeep sadness or guilt (1) XPast Suicide Attempts (7) X X X X X X Xseriousness of attempts (1) Xrehearsing suicide (1) XOthercomorbidity (2) X Xbeginning to feel better (2) X Xcontagion (1) Xloneliness - lack of support from fam/friends (1) Xunable to see beyond a narrow focus (1) Xneurotransmitters (1) X
Web Site Warning Signs
Messages: Lack consensus Are 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 WARNING SIGNS FOR SIGNS FOR SUICIDESUICIDE
A 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 Education
Babson College, Wellesley, MA
Chairs/Facilitator
Co-Chairs:
M. David Rudd, Ph.D. Baylor University Lanny Berman, Ph.D. American Association of
Suicidology
Facilitator
Matthew Nock, Ph.D. Harvard University
Participants
Gregory Brown, Ph.D. University of Pennsylvania Dana Carr, Ph.D. U. S. Department of Education David Chambers, Ph.D. NIMH Yeates Conwell, M.D. University of Rochester Medical Center Jan Fawcett, M.D. University of New Mexico Keith Hawton, M.D. University of Oxford, UK Thomas Joiner, Ph.D. Florida State University Karen Clapper Morris American Heart Association James Overholser, Ph.D. Case Western Reserve University Mitch Prinstein, Ph.D Yale University David Shaffer, M.D. Columbia University College of Physicians and Surgeons Peter Sheras, Ph.D. University of Virginia Morton M. Silverman, M.D. Education Development CenterCo-chairs: M. David Rudd, Ph.D.Lanny Berman, Ph.D.
Baylor University American Association of Suicidology Facilitator: Matthew Nock, Ph.D., Harvard University
Essential Questions What defines a “warning
sign”?
What time-frame best defines imminent or acute risk?
Is this a reasonable definition of a “warning sign”?
Essential Questions
How 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 (cont’d)
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 Questions
Can 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?
Are 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 Key Messages
Warning Signs continued
Seek 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:
Hopelessness Rage, uncontrolled anger, seeking
revenge Acting reckless or engaging in risky
activities, seemingly without thinking Feeling trapped – like there’s no way out Increasing alcohol or drug use Withdrawing from friends, family and
society Anxiety, agitation, unable to sleep or
sleeping all the time Dramatic mood changes No reason for living; no sense of purpose
in life
Red Flags I Ideation/threatened or
communicated S Substance Abuse/excessive
or increased
P Purposeless/no reasons for living
A Anxiety, Agitation/Insomnia T Trapped/feeling no way out H Hopelessness
W Withdrawal from friends, family, society
A Anger (uncontrolled)/rage/seeking revenge
R Recklessness/risky acts - unthinking
M Mood changes (dramatic)
Evaluating Warning Signs: 1st Stages Suicide and Life-Threatening Behavior, Summer 2006
Public education Is this information harmful,
upsetting to people? vs. WS for heart attack and
diabetes, no difference in emotional impact
Is it retainable? vs. WS for heart attack and
diabetes, as easy to recall after exposure
Will it change behavior?
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