Disease, Pain, and Suicidal Behavior

Elsebeth Stenager

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781317721154
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Estimating the risk for suicidal behavior among patients is often a very complex challenge for psychiatrists, general practitioners, psychologists, surgeons, specialists in internal medicine, neurologists, nurses, and social workers. Disease, Pain, and Suicidal Behavior is designed to help you understand the methodological problems involved in the assessment of risk for suicidal behavior in patients with various somatic and psychiatric disorders so you can establish effective approaches to the psychosocial treatment of endangered patients. Through the book's comprehensive and insightful discussions, you will even learn specific strategies for improving the quality of life of such patients.Disease, Pain, and Suicidal Behavior discusses psychiatric disorders such as depression, schizophrenia, personality disorders, anxiety disorders, and alcohol and drug abuse as risk factors for suicidal behavior. From its helpful and clearly written pages, you will also learn about the role of social factors in suicidal behavior and the relationship between suicidal behavior and biological factors. Perhaps most important of all, you will learn which groups of patients and which disorders are associated with the highest risk of suicide through the book's critical discussions of:

• the lifetime risk of suicide in depressed patients
• the stages of diseases like multiple sclerosis and the strains placed on the patient
• young male schizophrenics and their vulnerability to self-destructive acts
• mortality in patients with spinal cord injuries
• forced reduction in daily activities for patients with heart and lung conditions and resulting emotional instability
• the high risk of suicide immediately after a cancer diagnosis is given
• identifying risk factors for a second attempt at suicide
• questions to ask those at risk for suicidal behaviorRecognizing which of your patients run the risk of committing suicide can be an overwhelming task because of the multiplicity of factors involved. Disease, Pain, and Suicidal Behavior, because it examines critically the existing literature and studies on suicide and suicide risk, can help you evaluate and prevent suicidal behavior in a timely manner. You will turn the last of its pages with a much improved understanding of which illnesses and sufferings present an increased risk of suicidal behavior.

Chapter 1
General Aspects of Suicidal Behavior

Suicides and suicide attempts are very frequent incidents in the Western hemisphere. Buzan and Weissberg (1992) estimate that in 1988, in the United States 30,407 deaths were due to suicide. This figure indicates that every eighth death in the United States is due to suicide, and every third death among those aged fifteen to twenty-four years is caused by suicide.

For years the suicide rate in the United States constantly has been 12.5 suicides per 100,000 persons per year. However, the frequency of suicide has increased among young people, whereas it has decreased among the elderly An increased suicide rate has also occurred among young black men. Thus, the frequency of suicide is now similar in young black and young Caucasian men. However, in general the frequency of suicide among blacks is 50 percent higher than in the Caucasian population. Furthermore, the mortality rate is higher among blacks due to homicide.

The research on mortality rates in other ethnic minorities in the United States has been minimal. Though, in general other ethnic minorities have a lower mortality rate to suicide compared to Caucasians. The mortality due to suicide in men is higher than in women, with a ratio of 3:1 to 4:1. The methods most frequently used are shooting, hanging, strangling, and poisoning with medication.

Especially among the young, a dramatic increase in the frequency of suicide has been seen within the last four decades. In certain areas, it has almost been like an epidemic. An increase from 4 per 100,000 per year in 1950 to 13.2 per 100,000 per year in 1988 in the fifteen- to twenty-four-year-old age group has been found. This increase has been seen not just in the United States, but also in a number of European countries.

However, the number of actual suicides is just the tip of the iceberg. It has been estimated that the number of suicide attempts is at least eight to ten times the number of suicides. Furthermore, the number of suicides probably is underestimated and uncertain due to methodological problems concerning registering suicides. Monk (1987) has described several factors contributing to this underregistration.

In the United States, information on mortality due to suicide is collected in each state separately. Consequently, geographic considerations, cultural influences, and varying time periods for the studies can cause great variation in which cases deaths are registered as suicide.

In order to be sure that a death is due to suicide, ideally, it is necessary to perform a psychological autopsy, during which close relatives, friends, and others are queried about the indicators of suicide. Such a procedure is not possible because it is time-consuming and expensive.

A further problem in the United States is that persons with various types of training fill in the death certificates, and thereby decide the cause of death. No doubt, a medically trained person in cooperation with a forensic pathologist would be the most appropriate person to determine the cause of death as he or she would not be influenced by political or social pressure, and thus would not omit suicide as a cause of death. Additionally, a medically trained person is expected to register more suicides than, for example, a sheriff or mortician. Due to these factors, the validity of suicide statistics in the United States has to be taken with considerable reservation. These problems also have to be taken into account when reading the next chapters on methodological problems.

The frequency of suicide in Europe does not differ much from that of the United States. An increasing frequency of suicide has also been seen in Europe within the last few decades. This caused the World Health Organization (WHO) in Target for Health for All: The health policy for Europe in 1985 to adopt as their twelfth goal:

By the year 2000, there should be a sustained and continuing reduction in the prevalence of mental disorders, an improvement in the quality of life of all people with such disorders, and a reversal of the rising trends in suicide and attempted suicide.

At the same time, a large common European Project was planned, in which suicide attempts in certain representative areas in several European countries were registered, and interviews with representative suicide attempters were performed (Bille-Brahe, 1993; Sten ager, 1996). One of the purposes of the project was to identify risk factors for suicide and repetitive suicide attempts in a high-risk group such as suicide attempters. The suicide rates in different countries varied. In former Communist countries, such as Hungary, the frequency of suicide was 44 per 100,000 per year. Countries such as Finland, Denmark, Germany, France, Austria, and Switzerland also had high suicide rates, with rates above 20 per 100,000 per year. The lowest rates, comparable to the level in the United States, were found in Sweden, Norway, and the Netherlands.

Based on the common European registration study, it also has been possible to estimate the frequency of suicide attempts in the involved areas. The number of suicide attempts is low in the Netherlands and Italy while Finland, England, and Denmark have suicide attempt rates of 200 to 300 per 100,000 per year ( Bille-Brahe, 1993).

The primary goal in the research of risk factors in suicides and suicide attempts has been to reveal social and psychiatric characteristics in suicidal persons. Research has revealed that a number of psychiatric disorders such as depression, schizophrenia, personality disorders, anxiety disorders, and abuse of alcohol and drugs are risk factors for suicidal behavior.

Furthermore, a large number of social factors are thought to be of importance in suicidal behavior, such as recent divorce or dependence on public support, for example, financial support for the unemployed or welfare. Variation due to gender is also found. The risk of suicide is higher among men than women, while the frequency of suicide attempts is higher among women than men. Older people more frequently commit suicide than younger people, while younger people more frequently attempt suicide than older people.

Beyond the social and psychiatric factors, research groups also have examined the association between suicidal behavior and biological factors (Roy, DeJong, Linnoila, 1989). Traskman and colleagues (1992) examined the content of the metabolites 5-hydroxyindoleacetic acid (HIAA), homovanilin acid, and 3-methoxy 4-hydroxyphenylglycol in the cerebrospinal fluid of patients who had made suicide attempts. They found an association between a low level of HIAA and certain types of suicide attempts. Patients who made violent suicide attempts had a low level of HIAA. Other researchers have found the same association; however, all the studies are based on small populations. Therefore, final conclusions on the association of biological markers and suicidal behavior are not yet possible.

In connection with the prevention of suicide and the treatment of patients who have made suicide attempts, it is important to be able to predict which groups are at risk of either committing suicide or repeating a suicide attempt. A lot of suicide-threatened persons contact their practitioner or other health or social work personnel in the weeks or months just before they make their suicide attempt or commit suicide (Stenager and Jensen, 1994). However, if the warning signals or risk factors are not known and recognized, the chance of prevention is really small.

Within recent decades, several studies have been performed in order to identify risk factors. The studies have concentrated on social and psychiatric characteristics of suicidal persons. Despite this vast number of studies, almost none have dealt with the association of physical disorders and suicidal behavior. A reason may be that suicidal behavior in many countries is considered to be a psychiatric problem, and therefore, such behavior rarely catches the attention of somatically interested doctors—neither from the point of view of research nor treatment.

Neurological disorders and cancer are the only sufferings in which suicidal behavior has been studied carefully. Such studies have been of fair quality, judged from a methodological point of view. As a contrast, studies on much more frequent somatic disorders and suicidal behavior usually are either nonexistent or outdated and inconclusive due to methodological flaws.

Some Danish studies (Nielsen, Wang, and Bille-Brahe, 1990; Nielsen, 1994; Stenager and Benjaminsen, 1991) have been performed specifically in order to understand the importance of somatic disorders as risk factors in suicide attempts, but the number is few.

From the point of view of both prevention and treatment, it would be of utmost importance if not only health personal in psychiatric wards but also health personnel in somatic wards were aware of both general risk factors for suicidal behavior and somatic disorders associated with an increased risk of suicide. Using this knowledge, such personnel could establish a better psychosocial treatment of the endangered groups of patients, thereby increasing their quality of life while decreasing the acknowledged increased risk of suicidal behavior.

Suicidal behavior could be regarded as the ultimate consequence of a life that for a number of reasons is unbearable. Therefore, in certain cases, the circumstances will be such that no treatment can be expected to be helpful, and prevention may be difficult or even impossible. Consequently, not all suicides can be prevented. However, a large number of physical, psychological, medical, and psychosocial conditions can be changed, which may alleviate the life of a severely strained person, and thus with proper treatment and support, make the life bearable. Then, the question is whether we today have the necessary knowledge and resources to provide this help, especially to patients with chronic somatic disorders.

The purpose of this book is to give a review of the psychosocial problems associated with a chronic somatic disorder, methodological problems in suicide research especially regarding somatic disorders and suicidal behavior, and our present knowledge on the association of specific somatic disorders, pains, and suicidal behavior. Finally, based on this review, proposals for prevention and treatment of this group of patients will be presented.

Chapter 2
Psychosocial Aspects of Chronic Somatic Disorders

Traditionally, the task of doctors has been to diagnose and treat disorders, while the more delicate problems of how a disorder affects the patient and his or her surroundings have either been neglected or dealt with by relatives, nurses, social workers, and others. Consequently, almost nothing can be found in medical literature on this aspect. However, in the context of suicide and chronic somatic disorders, the effects of a disorder are important in order to understand why people with, for example, a neurological disorder may have an increased risk of suicide. Therefore, in this chapter the present knowledge on the psychosocial aspect of one neurological disorder, i.e., multiple sclerosis, is presented.

Some of the findings are unique to multiple sclerosis, but most are common not only in dealing with neurological disorders but also with other disorders.

Multiple sclerosis is fully described in Chapter 5. Here, however, only disease courses and prognosis are mentioned, which is intended to give a basis for understanding the following descriptions.

Course and Prognosis

An important concept in multiple sclerosis is an attack or relapse, which means a usually transient deterioration, i.e., an outbreak of the disorder. This could be a paralysis, sensory disturbances, visual disturbances, or other problems lasting from a few days up to several months. A remission, i.e., a disappearance of the symptoms, may then occur. A new relapse may or may not happen again in the future with varying intervals of time between such attacks.

The course of the disease can be described in different ways, but the following terms are often used.

1. Relapsing/remitting course. The course is characterized by repeating relapses and remissions, usually lasting weeks to months. At the onset, the relapses often occur frequently. Later on the course may change to a secondary progressive course.
2. The secondary progressive course. This course is characterized by a gradual, and usually slow, deterioration with no remissions.
3. The primary progressive course. The deterioration occurs gradually from the onset with no remission.
4. Benign multiple sclerosis. Only few relapses are seen and the symptoms are mild. (Confavreux, Aimard, and Devic, 1980; Weinshenker et al., 1989; Thompson et al., 1990)

The onset of multiple sclerosis may be acute, so that a stroke or brain tumor is suspected, but usually a long period passes from the time the first symptom occurs until the diagnosis is made (Stenager and Jensen, 1993). The period from onset to diagnosis is frequently five to six years (Confavreux, Aimard, and Devic, 1980; Stenager, Knudsen, and Jensen, 1989). New diagnostic procedures may reduce this period in the years to come. At the time of diagnosis, roughly 20 percent of the patients have a primary progressive course.

Patients with a relapsing/remitting course who progress to a secondary progressive course will on the average do so after approximately seven years. Expressed differently, ten to twelve years after diagnosis, 40 to 50 percent of patients with relapsing/remitting course will have changed to a secondary progressive course (Confavreux, Aimard, and Devic, 1980; Weinshenker et al., 1989; Lauer and Firnhaber, 1987).

Prognosis can be measured in different ways. In this context a very simplistic model will be used: slight, moderate, and severe impairment. A slightly impaired patient will be able to take care of him- or herself without aids while a moderately impaired patient typically will use a cane, and a severely impaired patient will use a wheelchair or be bedridden.

Five years after the diagnosis has been made, approximately 25 percent will be moderately impaired and approximately 50 to 60 percent after fifteen years. Generally, 30 percent have a benign course, and 10 to 15 percent a severe course. Finally, a study found that 60 percent were alive thirty-five years after the diagnosis was made (Poser et al., 1989).

Prediagnostic Period

The prediagnostic period is defined as the period between the first symptom of multiple sclerosis and when the diagnosis is made. The patient experiences this period as a time of searching for an explanation of the symptoms and experiencing uncertainty. This is reflected by the fact that approximately 10 percent of the patients are admitted to a psychiatric ward in this period, and a further 10 percent have their symptoms of multiple sclerosis misinterpreted as a surgical disorder (Stenager and Jensen, 1988; 1993).

Relatives also find this period characterized by uncertainty, due to both anxiety regarding the cause of the symptoms and doubt over whether the patient suffers from a somatic or a psychiatric disorder. Finally, the family physician also may be uncertain of the nature of the symptoms.

This period may last for years (Marteux, 1991; Burnfield and Burnfield, 1978, 1982; Duval, 1984).

The Diagnostic Period

Obviously, the diagnostic period is associated with much anxiety both for the patient and relatives due to fear of what diagnosis may be reached, treatment possibilities, and prognosis. The treating physician may have doubts regarding how to inform the patient and relatives and how much is to be told. Frequently, little or nothing is told (Stenager, Knudsen, and Jensen, 1989; Burnfield, 1984; Elian and Dean, 1985; Spencer, 1988; Stewart and Sullivans, 1982).

Some of the patients will experience a crisis reaction. Of course, this can also occur at other stages of the disorder, such as a relapse or transition to a secondary progressive course.

Crisis Reaction

The first stage in the crisis reaction is the denial. In denial, the patient refuses to accept the diagnosis. He will consult other authorities in order to have the diagnosis rejected. He will not meet other patients with multiple sclerosis, and he will try to hide the diagnosis. Trying to maintain previous activities and refusing to accept help from others also characterize this stage of behavior.

The next stage is the resistance phase, in which the patient anxiously seeks information on multiple sclerosis and tries to control the disease. Reluctantly, he will accept help from others. He may accept meeting other patients with multiple sclerosis a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Chapter 1. General Aspects of Suicidal Behavior
• Chapter 2. Psychosocial Aspects of Chronic Somatic Disorders
• Chapter 3. Suicidal Behavior and Mental Disorders
• Chapter 4. Methodological Problems
• Chapter 5. Suicide in Patients with Neurological Disorders
• Chapter 6. Cancer and Suicide
• Chapter 7. Suicide in Patients with Other Somatic Disorders
• Chapter 8. Suicide Attempts and Somatic Disorders
• Chapter 9. Pain and Suicidal Behavior
• Chapter 10. General Aspects of Suicidal Behavior, Pain, and Somatic Disorders
• Bibliography
• Index