Psychiatric Diagnoses - Therapeutic Management of the Suicidal Patient

Psychiatric Diagnoses

A number of psychiatric diagnoses are linked with suicidality. While patients with mood disorders (major depression and bi-polar disorder) are commonly assessed for suicidality, anxiety disorders are also associated with significant suicide risk. Psy-chosis, in both mood disorders and schizophrenia, can heighten risk. Although borderline personality disorder has a high prevalence of suicidal ideation, impulsivity and self-injurious behavior, these patients are at risk for unexpected intentional and accidental death.

Bipolar Disorder

Oquendo and colleagues (2000) evaluated the applicability of their stress-diathesis model to a sample of bipolar patients. As with their other sample of psychiatric patients (Mann et al., 1999), objective illness severity was not a differentiating fac-tor between bipolar attempters and nonattempters, although the symptoms were more severe at the index hospitalization via self-report and research clinician depression ratings. Similarly, bipolar attempters had increased suicidal ideation, hopelessness and decreased reasons for living. In contrast, there were no dif-ferences in impulsivity, although bipolar attempters had higher lifetime aggression. Oquendo and Mann (2001) include gender (men more likely to attempt than women, in contrast with other studies); white race; age (no difference in their study); suicidal ideation, hopelessness, fewer reasons for living; life time aggres-sion and impulsivity; smoking, alcoholism and substance abuse, and family history of suicide as possible diathesis-related suicide risk factors for bipolar patients. Stress-related risk factors in bipolar patients may include depressed or mixed state (Oquendo and Mann, 2001).

Anxiety Disorders

A frequently overlooked risk factor for suicidal behavior is anxi-ety. The clinical history features that are most predictive of seri-ous suicide attempt in a study of patients with suicide attempts (Hall et al., 1999) are severe anxiety (92%) and panic attacks (80%), partial insomnia (difficulty falling asleep, middle insom-nia, early morning awakening) (92%), depressed mood (80%), relationship disruption (78%), substance abuse (68%), pessimism (hopelessness 64%, helplessness 62% and worthlessness 29%), global insomnia (46%) and anhedonia (43%). Severe anxiety and agitation may be an important risk factor for an acute suicide at-tempt. These “modifiable risk factors” may be responsive to early intervention. Evidence accumulated argues for the assessment of severe anxiety/agitation and aggressive anxiolytic treatment in the management of suicide risk.

Psychosis

Grunebaum and colleagues (2001) reported that about half of the reviewed articles published since 1982 reported a positive asso-ciation between delusions and suicidal ideation or behavior and about half found a negative association. Approximately half of the subset of studies of delusional depression and suicide risk were negative. Half of the studies of delusions and suicide risk in schizophrenia were negative. A study of delusions and suicidal ideation in bipolar patients was negative.

Although the best predictors of suicidal behavior are past history of suicide attempts, substance abuse, and chronic and/or deteriorating clinical course, clinicians should consider new onset psychosis as a significant risk factor (Verdoux et al., 2001).

Borderline Personality Disorder

Suicidal behavior is frequently associated with affective lability, anger, impulsivity and disruption in interpersonal relationships. Suicidal ideation and suicide attempts are part of the diagnos-tic criteria for borderline personality disorder. The recurrence and/or chronicity of suicidal ideation, combined with multiple low lethality attempts, have assigned some of these episodes to communicative idioms of distress or suicidal gestures. How-ever, there is evidence (Soloff et al., 2000) that suggests bor-derline personality disorder may be predictive of the number of attempts, but does not differentiate attempt characteristics, for example intent to die, planning, or lethality. Assumptions about the seriousness of suicidal behavior based on diagnosis alone may be flawed. Comorbid substance abuse and interpersonal disruption/abandonment issues heighten the risk (Soloff et al., 2000).