Lucas inspired me to write about suicidal behaviour disorder which is now a separate diagnosis in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). The DSM is a diagnostic tool, published by the American Psychiatric Association (APA), used by psychiatric professionals.
Sadly, having learned in hindsight the DSM diagnostic criteria, it’s clear Lucas was a predictable candidate for suicide, given his multiple mental illness conditions and environmental stressors.
And given Lucas would have fit Eli’s Place 18 to 35 target age range, I can predict the holistic treatment and recovery model proposed by Eli’s Place will treat those with similar multiple conditions and reduce the risks of suicide.
Some Suicide Background …
Suicide is a comorbid condition, a term which indicates a patient has more than one medical condition simultaneously present. Prevention treatment strategies are more effective when recognizing suicidal behaviour disorder occurs simultaneously with a range of psychiatric conditions. These include borderline personality disorder, major depressive disorder, and schizophrenia. Studies reveal that of those with bipolar disorder alone, 29% report a history of suicide attempts. Other comorbid conditions would raise those risks.
Identifying suicidal behaviour disorder as a mental illness linked to varying sets of comorbid illnesses is a breakthrough. It enables the systematic and proactive treatment of the root psychological causes.
Finding ways to identify those with comorbid conditions at risk of suicide is critical, since to date “researchers and clinicians alike have been stumped in the quest to decrease suicide rates…” according to Maria A. Quendo and Enrique Baca-Garcia. We require comorbid strategies to treat the underlying mental illnesses in order to prevent suicide. By directing attention to the suicidal patterns associated with a range of diagnoses, DSM-5 helps provide strategic patient care —and save lives.
Suicidal Behaviour Disorder
Suicidal behaviour disorder is a new DSM-5 diagnosis. It defines suicidal behaviour disorder as a separate diagnosis and provides clearly defined criteria, validators, and risk factors.
Criteria
According to the DSM-5, there are five criteria for a suicidal behaviour disorder diagnosis.
- a suicide attempt within the past twenty-four months
- attempt was not actually the result of chronic self-injurious behaviour
- attempt was not actually preparation for a suicide attempt, or suicidal ideation
- attempt was not made during an altered mental state, such as delirium or “confusion”
- attempt was not ideologically motivated e.g., religious or political
Three Types of Validators
To satisfy suicidal behaviour disorder criteria three types of validators must be present: antecedent (or pre-existing), concurrent and predictive validators.
Regarding antecedent validators, a psychiatric condition is the most commonly recognized risk factor for suicidal behaviour. In addition, environmental risk factors such as unemployment, marital disruptions and financial crises are also linked to the psychiatric condition risk. In addition to his psychiatric conditions, Lucas had his relationship breakup, coupled with precarious employment and income environmental factors.
In addition, familial and twin studies show a suicidal behaviour propensity in families, independent of other psychiatric disorders.
As for concurrent validators, these are factors present which are unrelated to the diagnostic criteria, that indicate risk for suicidal behaviour. Factors include “cognitive (problem-solving difficulties, cognitive rigidity), emotional (hopelessness, agitation, depressed mood), temperament (aggression, impulsivity), and personality (borderline, narcissistic or antisocial personality disorders) domains.” Lucas suffered from hopelessness, a depressed mood and ADHD impulsivity.
The clearest predictive validator of suicidal behaviour is a history of attempts. Some individuals only make one suicide attempt in their life, others may make many attempts. To our knowledge, Lucas had not attempted suicide before.
Risk Factors
The DSM-5 identifies specific mental illnesses that are risk factors for suicidal behaviour disorder. They include bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders, panic disorder, PTSD, substance use disorders (especially alcohol use disorder), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. Lucas suffered from depression, anxiety and substance use disorders.
Treatment
The DSM-5 does not specify treatment options for suicidal behaviour disorder itself. Instead, it proscribes the treatment of the underlying disorders to either alleviate suicidal impulses or to improve coping with the source of distress. “Instillation of hope is essential, as the individual must find reasons to continue living, rather than seeking self-destruction.”
Conclusions …
It is believed that the increased emphasis on suicide throughout DSM-5’s underlying mental illnesses will enable the systematic diagnosis and treatment of underlying causes of suicide. That will lead to more effective recognition of individuals with symptoms and behaviours that put them at risk. With improved diagnosis and treatment strategies, we may be able to stem the tide of suicide losses.
Too late for our dear Lucas, it is clear to see that the future Eli’s Place long-term, rural, residential treatment program for serious mental illness, when combined with suicidal behaviour disorder, will prevent others’ suicide attempts.
To explore further:
Oquendo, M. A., & Baca-Garcia, E. (2014). Suicidal behaviour disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry, 13(2), 128–130. https://doi.org/10.1002/wps.20116
Oquendo, M. A., Baca-García, E., Mann, J. J., & Giner, J. (2008b). Issues for DSM-V: Suicidal Behavior as a Separate Diagnosis on a Separate Axis. American Journal of Psychiatry, 165(11), 1383–1384. https://doi.org/10.1176/appi.ajp.2008.08020281
Richard Childs: Father of the late Lucas, outdoors person, haiku and technical writer, and facilitator of organizational change. Grateful volunteer helping Eli’s Place come into fruition to save and enable young adult lives.
Eli’s Place will be a farm-based residential treatment centre helping adults aged 18-35 who have been diagnosed with serious mental illness. As we envision Eli’s Place, we anticipate that yoga will play an important role supporting the journey from mental illness to hopeful futures.
