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?

Immediate Goals

Consensus Recommendations

More consistent (and valid) public education message

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 (Mnemonic)

IS PATH IS PATH

WARM?WARM?

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?