Tag: suicide attempt

My Thoughts on the Language of Suicidology and the Tower of Babel

by Midnight Demon, posted in suicide, suicide attempt

My Thoughts on the Language of Suicidology and the Tower of Babel

I finally read the “Language of Suicidology” by Morton Silverman (Silverman, 2006). Silverman has been in the suicide field for years. He has written countless books and articles on the subject of suicide. In this article, I found a few interesting things. One is there is no such thing as the language of suicide that encompasses the whole discipline or even the different disciplines that suicide falls into. Things like suicide attempt or suicide gesture mean completely different things to different people. There is no forward definition on the subject. In O’Carroll et al. work (O’Carroll et al., 1996), the Tower of Babel, state that “’attempted suicide’ is meaningless”. Does it mean someone intended to die with an act that put their life in danger, hurt themselves without the intent to die, or just thought about the intent to die? Everyone has their own opinion on what this term means. Dr. Silverman pointed out that there was a study with expert suicidologists and then general mental health clinicians to find out if they could identify among ten vignettes which were deemed an attempted suicide. There was no consensus among either the suicidologists or the clinicians!! How is this term used so frequently yet has no definitive markers or insights is beyond my thoughts. I am sure you, as a reader of my blog, has your own opinion as to what is deemed a suicide attempt. But is it what the next person will think? Even among self-reports, there are no guidelines as to what makes a suicide attempt. Is it a few extra pills of Tylenol? A deep slash on the wrist that required stitches and a hospital stay? Or an overdose that didn’t require medical attention at all?

The one thing that I can take away from this paper is that his idea of “died by suicide” is golden. It is gaining ground in the suicide community to replace “committed suicide” or completed suicide. Other than that, there is no other message in the paper to help the understanding of the terms of suicide or even suicidality, a term that he wanted to get rid of all together. I use suicidality a lot in my blog. It encompasses the whole suicidal thoughts, behaviors, cognition, and emotion that I feel when I want to end my life. It might not mean anything to anyone else, but it means something to me. But he states that this word is not going away anytime soon.

If the experts can’t figure out what is meant by attempted suicide, how can the rest of the world? It means so much to different people yet in the clinical world it hardly means anything if there isn’t a nomenclature about it. What I found interesting was the synonyms for suicide attempt (SA): cry for help, courting death, life threatening behavior, near fatal SA, suicidal manipulation, near lethal suicide, risk taking behavior. And what is meant by suicidality? There is no clear definition of it. To me, it encompasses the cognition, behavior, and emotion of suicide, but it might not be the same to someone else. Does it mean someone is suicidal? What is meant by that? There were fifteen different definitions of suicide. Fifteen! All were mostly similar. The shortest one was “self-initiated, intentional death”. There was a definition by the father of suicidology, Edwin Shneidman, but I found that the definition to be confusing and wordy. The author of this article also had a definition, “suicide is, by definition, not a disease, but a death that is caused by self-inflicted intentional action or behavior”. If so many people define suicide differently than someone else, how can there be any consensus?

The one take away from this article was “committed suicide” should be taken away and “died by suicide” should be used. I was happy to see that. Also was glad to see possible terms to be removed: nonfatal suicide, committed suicide, completed suicide, failed attempt, failed completion, and fatal suicide attempt.

Part 1 and 2 of Revisiting the Tower of Babel

Since O’Carroll’s paper in 1996, there have been no definitive terms for suicide, suicide attempt, suicide gesture, self harm, or suicide threat. Efforts have been made but no two researchers have consistently used the same term. In the following, I will give the background of what has been used and what was “taken away”.

Silverman et al. (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007a) have stated “’suicide’ refers not to a single action but more broadly to a great many varied behaviors” (p248). And as such, no single term defines the complex set of behaviors that suggests someone being suicidal. Here are my thoughts on this paper and the outcome of their process that was made to be simple in mind but proved difficult.

The background for this is as follows:

“Measures of suicide and nonfatal suicidal behavior continue to be hindered by the lack of 1) standard nomenclature; 2) clear operational definitions; 3) standardized lethality measures” (p249). While this is true, my feeling is that if a researcher/clinician defines what is meant by these terms in their measurement in their study, it will be defined as such so no confusion exists in that paper. Though I understand the complexity it will have among different studies, there are no set guidelines. In the many papers I have read in over the past 11 years since this paper has come into print, O’Carroll (1996) has been cited as the standard definition of the terms of suicide and suicide attempt. He distinguished suicidal behaviors by three characteristic features: intent to die, evidence of self-injury, and outcome (injury, no injury, death). A number of researchers have adopted this nomenclature in their studies (see article for the list). Even the American Psychiatric Association has acknowledged and adopted the definitions set by O’Carroll et al. in their implementation of practice guidelines for the assessment and treatment of patients with suicidal behaviors. The only reason why this hasn’t been formally adopted is because of the new terms they have proposed. It should stop here but let us continue with their insight into the definitions of suicidal behaviors.

One of the new terms proposed was “instrumental suicide-related behavior (ISRB)”. O’Carroll et al. thought this would be a better term than suicidality. However, as we will see, suicidality has been used more frequently to describe the whole of suicide, suicide attempts, behaviors relating to suicide, and self-harm (NSSI).

As stated above with Silverman’s paper, there is still confusion about the terms suicidal behavior, deliberate self-harm, suicide-related behavior, parasuicide, and suicidality. It is important to recognize that suicide and its subsequent behaviors are not a disorder or diagnosis. The motivation to die and prepare to die by self-jury do not necessarily place an individual at either acute or high risk for suicide. There has been much debate about what constitutes intent. It has been suggested that “intent implies an action to change the future while “motivation” implies an effort to affect interpersonal relations and a change in social milieu”(p254). Their position is that “intent refers to the aim, purpose, or goal of the behavior” (p254). I believe the latter to be the simpler definition of intent and “connote a conscious desire or wish to leave (or escape from) life as we know it” (p254). We also need to bear in mind that intent is fluid and changes from minute to minute.

The authors also explored the relationship between intent and lethality. They concluded “the presence of intent assumes 1) a desire or wish to die as a conscious experience; 2) knowledge of risk associated with a behavior; 3) some perception that means or methods are available to achieve the desired outcome (suicide attempt); 4) some knowledge about how to use means or method” (p255). Without knowing intent, it becomes impossible to know the different types of suicide related behaviors and self-injurious behaviors. The end result of this was to reorganize to three categories: no intent, uncertain intent, and intent. Regarding lethality, most clinicians think that high medical lethality suggests high intent even though high intent doesn’t always suggest high lethality.

Another term they deemed not to include in their nomenclature was “suicide gesture”. It’s ambiguity about it being a threat with low intent or behavior that is self-inflicted but not suicidal in nature makes it a precursor to suicide attempt but not with intention (p256). The common theory is ultimately that it simply means an action was taken with the intent to die not withstanding. It implies a suicidal act but because the intent was low, it doesn’t mean it. It can just be termed as self-harm behavior.

The term suicidality is used to encompass a wide range of thoughts, behaviors, and ideation of suicide and related behaviors. The authors chose not to avoid the term even though some authors use the term to describe the “totality of suicide-related ideation and behaviors” (P257). It has become a popular term even though it is not yet in the dictionary. Therefore the authors decided to stick with suicide-related ideations, suicide-related behaviors, and added the ridiculous term, suicide-related communication. Now that is simplifying things!

Even though the term “suicide attempt” was chosen to be extinguished from the vocabulary but still remains in the literature, it still does not have a clear definition though it has been suggested to mean “a high likelihood of death as a well as a true intent to kill oneself” (p258). As there can be varying degrees of attempts, part 2 of this article suggests typifying them into categories of type I and type II. Suicide Attempt, Type I is when no injury occurs. Type II is when injury occurs. Suicide is when death occurs.

Part 2 of (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007b) is utter nonsense and had no meaning in defining anymore than what is already known. The term they tried to typify are the behavior, threat, plan, and ideation of suicide. For example, terms such as accidental suicide becomes self-inflicted unintentional death, completed suicide becomes suicide, intentional self harm or injury becomes self harm type I and II. And the term instrumental self-related behavior becomes suicide threat type I-III. (see the exhaustive list in the paper for definition).

A suicide plan is a proposed method of carrying out a method that leads to a self-injurious outcome (p268). That is something that I can agree on.

In closing, the authors quote Dr. Jamison (Jamison, 1999) as stating “all suicide classification and nomenclature systems are to a greater or lesser extent, flawed; and all or most all will have points that are well or uniquely taken” (p27;275). I take that to interpret that people will take what they will as it suits them and leave the rest as it lies.

Jamison, K. R. (1999). Night Falls Fast: Understanding Suicide: Alfred Knopf.

O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the Tower of Babel: A Nomenclature for Suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.

Silverman, M. M. (2006). The Language of Suicidology. Suicide and Life-Threatening Behavior, 36(5), 519-532. doi: 10.1521/suli.2006.36.5.519

Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007a). Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 1: Background, Rationale, and Methodology. Suicide and Life Threatening Behavior, 37(3), 248-276.

Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007b). Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 2: Suicide-Related Ideations, Communications, and Behaviors. Suicide and Life Threatening Behavior, 37(3), 264-277.

Preview of the nomenclature of suicide

by Midnight Demon, posted in suicide, suicide attempt

Preview of Tower of Babel, Part 2 article

I just finished reading this ridiculous article that is supposed to clarify terms but instead complicates them more than anything. I know I am not a clinician, but if I were, I doubt I would use their terms that state and I quote “self-harm type I, II, III, suicide attempt type I, II, III” etc. I have read research articles that have been written after this article and NO WHERE do they define their terms as such. I am appalled. I just had to write about this. It will be in my paper when I write it this weekend, once I calm down a bit.

What was interested was they omitted the term suicidality altogether. Instead they called it “suicide-related communications”. I am glad I have short hair, otherwise I would be pulling mine out right now. Obviously, this article is not meant to be reviewed by someone with lived experience. It was blatantly obvious this was for a clinician, researcher, or other type of professional in the suicide field (e.g., medical examiner, coroner, or public health person). I probably shouldn’t stick my nose in it but I am going to anyways because, like I said, no one has yet to use these terms in the literature so I am going to go to town on this. I am just glad they didn’t have subtypes to the self-harm or suicide attempt. And by the way, suicide attempt type III is suicide! I will have the definitions in the paper this weekend. I just wanted to blow off some steam about this now so I could be a little bit more clear headed while writing.

In the conclusion, the authors wrote that there should be studies, international and multi-centered nationally, to try and see if these terms fit. That would take some doing, though how to classify a death by suicide after it was indeed a suicide, I am clueless. And the authors did write that it would be difficult to ascertain intent with individuals who were intoxicated by drugs/alcohol or who were psychotic, delusional, or dissociated. They did mention the word “demented” but I am not sure I have ever heard that term in a clinical setting. The authors didn’t speculate on that term, which I guess means it is implied that what it is meant by.

Also in the closing paragraph, Dr. Kay Redfield Jamison was quoted about nomenclature being essentially rubbish when it concerns suicide classification. I fricken was laughing at that. I remember the line because I read the book so many times. The whole article is rubbish. More to follow…

An Oxymoron

by Midnight Demon, posted in Bipolar Disorder, blogging, chronic physical pain, depression, mood disorders, suicide attempt

I had an interesting conversation with my psychiatrist tonight. She confirmed I am on the right meds and that comforted me. I told her I was a little hypo and she said to let her know how things go. She wasn’t going to make any changes and I wasn’t asking for one. These things need to ride themselves out, as I have learned over the years. Medication isn’t always the answer to every problem that you face.

My mood was all over the place today. I got really irritable and angry over someone’s comment that they left on my blog today. I don’t know why it bothered me so. I had a long conversation with the voices over this. It helped to air it out and once I did, I wasn’t as agitated. Then I got a stupid migraine and that made me scared. My face went numb within minutes and my eye felt like it was going to pop. I took my migraine pill and waited anxiously for the pain to subside. I had just started to read a research article when my eyes went blurry and the migraine started. I guess I will read that article tomorrow. I am not in the same mood I was in before the migraine hit. After the migraine subsided and I was feeling better, I read some more of Harry Potter. Hogwarts got me the escape I was looking for. Reading has been suggested by a doctor who does man therapy. If you look it up, it is pretty dumb. But men need something stupid to be able to laugh at themselves and break up their manliness. I know I do at times. I don’t know if his particular therapy has helped men but I took his suggestion of reading a book to escape to relax.

I also told my pdoc about my sleeping habits as of late. Three to four hours a night I have been getting, which doesn’t help someone with Bipolar illness. I am lucky I can sleep during the day to try and catch up but I don’t always. Sometimes napping causes more trouble. I never feel rested unless I have a six hour nap. I usually am able to get one over the weekends usually. I don’t know why that is. I tend to sleep better during day time hours than at night anyways. I am a night owl. The funny thing is, I was never really able to work a night shift. By 4 or 5, I was so tired that I needed sleep. And if I got it on my break, I usually slept for an hour, which was against the rules. One time I think I slept for two hours and my supervisor wasn’t happy. But I no longer work so I can stay up till whatever time and sleep all day if I want to.

Today is my therapist’s birthday so I will be texting her a lot. I will stop once she texts back a “thank you”. I can be a pain in the ass, too! She always makes a big deal out of my birthday so it’s payback.

My ankle is really hurting me for all the walking I did today. I have a bum ankle due to nerve damage that I got when a disc exploded in my back. The disc compressed the nerve that controls the muscles in my ankle and foot. I never was able to regain the strength in my foot after surgery. That was 14 years ago. If I didn’t get strength back in the first two years, I am certainly not going to now. What I am left with is pain due to a pain syndrome no one can identify. Some have called it complex regional pain syndrome, others have just called it tendonitis. But if it was tendonitis, rest and ice should have cured it by now and I have been resting it for three years. The pain has gotten a little better but on days like today where I was walking too much, it flares up and is hard to settle down without pain medication. I don’t know why they call it pain medication when the meds are supposed to relieve your pain, not cause it. Just an oxymoron, I suppose.

The article I was going to read before my migraine made it impossible was on the language of suicide. I am a suicidologist from the inside out. I love studying about suicide and read everything I can about the subject. I have the experience to go with it as I have attempted more than a few times. That is why I write this blog. It helps to write out my suicidal thoughts and feelings I am having in the moment. I know that if I don’t write about them, I am as good as dead. After I write my morose feelings, I usually send them to my pdoc and therapist, well sometimes just my therapist as I am afraid of sending them to my psychiatrist. I sent her a goodbye email once and that ended poorly. She sectioned me and I spent the next three weeks in the hospital. It wasn’t fun. The police came and when they couldn’t find me because the ambulance had already taken me to the hospital, they broke into my house by smashing a window. I was very upset. So I am hesitant to send my pdoc my suicidal writings.

It has been at least a month since my last writings. I haven’t really felt suicidal since I gave up the day I was going to kill myself. My therapist and psychiatrist were against the idea of me dying. Go figure. I still am angry with them for keeping me here. I had everything planned out, sort of. I knew how I was going to die, but I just didn’t know where. I didn’t want a family member to find me so that sort of kept me here. But the writing that I was doing before I gave up my date were my one outlet. Now they are gone and I don’t know if I will be that productive ever again.

Random 548

by Midnight Demon, posted in Bipolar Disorder, blogging, chronic physical pain, depression, mood disorders, suicide attempt

I think I am a little hypomanic. I only had three hours of sleep last night despite taking 600 mg of Neurontin to help me sleep. I am wired but tired at the same time. I just walked to the post office to drop off some letters that I wrote to my therapist and my hip and ankle are having a tug of war as to who is going to hurt me more. I am not happy.

I keep thinking today is a holiday and it’s not. I called my physiatrist’s office and found out he is on fucking vacation so I can’t talk to him about how the new NSAID is working out. It is working out. I am finding that there is less pressure on my ankle than it was before. It’s still swollen but I think in time, the NSAID will help ease it, as long as I remember to take it every day. I just got to make sure that I eat something or I can’t take it.

Been getting reports that the MBTA, our public transportation system, has been having major problems today and then there was an accident in Sully Sq that caused the ramp on the major highway to be closed while it got cleared up. It was closed for at least two hours so I am sure traffic is a bitch. I can only imagine the trouble on the highway and the mess in Sully Sq. I tweeted the mess and then a news reporter wanted me to send photos. I am not going to take pictures of people, without their consent, and then send it to a news station! Plus, I wasn’t there. HEHEHE. I think the reporter was like, “no pic or it didn’t happen” bullshit. I also am not going out till this afternoon because the bus I need to take to the Square is severely delayed, which probably means that there is no service to where I want to go. So I am staying home, again. I might go back out and get pizza when the place opens. I don’t know if my hip and ankle are going to want to do it again. I don’t know why, but it felt like someone was grabbing my hip as I was walking down the street. It was very uncomfortable. I always have problems with my hip. I know I should probably go back to PT to get it strengthened. I think the muscles are weak because of my stupid back problems. It has been hurting me for some time now, almost 9 months. But usually if I continue to walk, the pain goes away. This time it didn’t and I am still hurting. I was walking with my cane because I needed extra support with my ankle. I didn’t want to put added pressure on it.

I would really love Red Baron’s single deep dish pizza right now. But I can’t go to the grocery store. I am going to do a big shopping at the end of the month when I get paid. Because I bought my glasses, I couldn’t do food shopping this month. It’s the sacrifices you got to make when you are on a limited budget.
I bought cookies yesterday, which I should not have done. I am eating them instead of meals. I will have like 8 cookies and call it my dinner or lunch. I am wicked bad with cookies. They are my nemesis and I am the cookie monster.

I woke up from a nap about an hour ago and found that my glasses have been delivered. I was just expecting one pair of glasses but got three. As I was about to check out, the next screen asked if I wanted single vision and distance lenses. I thought I had to order them separately with the multifocal lenses so I ordered them, not realizing they are separate. So I got three glasses but no instructions as to which pair was which. I had to call them and tell them I wanted to cancel my order. They told me that I could get 100% refund (store credit) or 50% on my credit card. I opted to return the two pairs that I didn’t need and get the 100% store credit. This way when I need new glasses, I have a credit and it will be easier to afford my glasses as I won’t be getting the LTD payments anymore.

I was going through some old mail when I came across a notepad. I took it to my room and found that it had suicide notes for my nieces and nephew and my psychiatrist. It had other suicide related items in it as well. I forgot that I wrote these things and judging by the other writings, I must have been in serious pain when I wrote this. It was in Nov. 2013. I had just finished an article about suicide attempters and their “longevity”. Turns out, they don’t live as long because they attempt again and succeed. I blogged about this and I guess this was my saving grace because I am still here.