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CHAPTER 1

Suicidal Behaviors in Adolescents Who Is Most at Risk?

THE EXTENT OF THE PROBLEM

Adolescent suicide is a major public health problem and accounts for at least 100,000 annual deaths in young people worldwide (WHO, 2002). In the United States, suicide accounts for more adolescent deaths than all natural causes combined, with more than 2,000 youth dying by suicide per year (Anderson, 2002). Suicide ranked as the third leading cause of death among the 10- to 14-year-old and 15- to 19-year-old age groups in the United States in 2000, preceded only by accidents and homicide (Anderson, 2002). Nearly 20 percent of adolescents in the middle school and high school age groups report having seriously considered attempting suicide during the past year (Grunbaum et al., 2002). In the United States, the Centers for Disease Control and Prevention's (CDC's) large Youth Risk Behavior Surveillance (YRBS) survey also found that nearly 15% of adolescents had made a specific plan to attempt suicide, and that 8.8% of adolescents reported a suicide attempt; this 8.8% represented over 1 million teenagers, of whom approximately 700,000 received medical attention for their attempts (Grunbaum et al., 2002). These results are consistent with those cited in other epidemiological studies in the United States (Gould, Wallenstein, Kleinman, O'Carroll, & Mercy, 1998; Reynolds & Mazza, 1992; Roberts, Chen, & Roberts, 1997; Wichstrom, 2000; Windle, Miller-Tutzauer, & Domenico, 1992).

Although suicide attempts are less common before adolescence, they increase significantly during adolescence, with a peak between 16 and 18 years of age (Lewinsohn, Rohde, & Seeley, 1996). After age 18, there is a marked decline in frequency of suicide attempts, especially for young women (Kessler, Borges, & Walters, 1999; Lewinsohn, Rohde, Seeley, & Baldwin, 2001). As a result, the highest prevalence rate of suicide attempts across the life span exists during adolescence. For each youth suicide, there are approximately 100–200 suicide attempts (American Association on Suicidology, 2003). Researchers have found that between 31% and 50% of adolescent suicide attempters reattempt suicide (Shaffer & Piacentini, 1994), with 27% (males) and 21% (females) reattempting within 3 months of their first attempt (Lewinsohn et al., 1996). These data have major treatment implications, including the need for rapid intervention following the first attempt, as well as the need for treatment that targets both the internal and external conditions contributing to multiple attempts.

As the research reviewed in this chapter will show, the adolescents most at risk for multiple suicide attempts have multiple problems and meet criteria for at least one mental disorder. In an analysis of the 1999 YRBS data, Miller and Taylor (2005) found that the more problem behaviors an adolescent has, the greater his or her risk of suicidal behavior. "Problem behaviors" were defined as including violent behavior, binge drinking, cigarette smoking, high-risk sexual behavior, disturbed eating behavior, and illicit drug use. Compared to adolescents with zero problem behaviors, the odds of a medically treated suicide attempt were 2.3 times greater among respondents with one, 8.8 with two, 18.3 with three, 30.8 with four, 50.0 with five, and 277.3 with six problem behaviors (Miller & Taylor, 2005).

In contrast to suicide attempts, what we are calling "nonsuicidal self-injurious behavior" (NSIB) involves intentionally injuring oneself in a manner that often results in damage to body tissue, but without any conscious suicidal intent. Incidence of NSIB is increasing, especially among adolescents (Hawton & Fagg, 1992; Hawton, Harriss, Simkin, Bale, & Bond, 2004). Although the prevalence estimates need to be interpreted with caution, due to the limited number of studies, adolescents in community studies are reporting that they engage in NSIB at extremely high rates — between 18% and 15.9% (Muehlenkamp & Gutierrez, 2004 and CDC, 2004). College student populations engage in NSIB at similar rates, ranging from 12% (Favazza, 1998) to 35% (Gratz, 2001). Youth who cut themselves, especially repeatedly, have a significant risk of suicide (Cooper et al., 2005).

In the next part of this chapter, we define adolescent suicidal behaviors in more detail. We then examine the existing research on risk factors, highlighting specific behavioral and environmental conditions that appear to increase suicidal risk in adolescents, and comparing those with risk factors for adults. In Chapter 2 we review the research on existing treatments, including preliminary findings on DBT adaptations for suicidal adolescents. We describe DBT, with those adaptations that we feel are most effective for multiproblem suicidal adolescents, in subsequent chapters.

DEFINING ADOLESCENT SUICIDAL BEHAVIORS

"Suicidal behaviors" include completed suicide, suicide attempts, and suicidal ideation. Because it can often be extremely difficult to assess the degree of suicide intent accompanying intentional self-injury, many suicidologists also consider NSIB as falling into the larger spectrum of adolescent suicidal behaviors, even though NSIB by definition involves no suicidal intent (Berman & Jobes, 1991; Brent et al., 1988; Lewinsohn et al., 1996; Reynolds & Mazza, 1994). We include NSIB within the general category of suicidal behaviors for a number of reasons. First, although some intentional self-injury is clearly without any suicide intent, intentional self-injury often occurs with enormous ambivalence or with swiftly changing intent, such that retrospective analyses of intent may be exceptionally difficult. Second, a behavior that starts as suicidal can evolve into a nonsuicidal act and vice versa. Third, intentional but nonsuicidal self-injury can itself be lethal. That is, it can unintentionally become a suicidal act. Some behaviors categorized as suicide may in fact have been nonsuicidal but none-the-less lethal self-injuries. Finally, and most important clinically, intentional self-injury even without suicide intent is a potent predictor of eventual suicide. It is a behavior with important overlapping characteristics. By excluding this behavior from the general category of suicidal behaviors it is extremely easy for both client and clinician to marginalize or trivialize the behavior. Indeed, many adolescent clients do engage in both suicide attempts and NSIB (Linehan, 1993a). Clearly, however, some youth engage only in NSIB and never in suicidal behavior, while others engage only in suicidal behavior and never in NSIB (Jacobson et al., 2006). Thus, the term "NSIB" helps distinguish not only those teens who deliberately self-injure with no intent to die from those who do have suicidal intent, but also the two types of self-injurious behavior in the same person. This can be critical when precipitants and consequences are very different for the two types of behavior. In this book, we define "completed suicide" as an intentional, self-inflicted death. A "suicide attempt" is self-injurious behavior with ambivalent or certain intent to die. "NSIB" is defined by the lack of an intent to die in the context of deliberate self-injury. "Suicidal ideation" consists of thoughts about being dead or killing oneself and can vary widely in clinical significance, depending on its qualities and context. To a large extent, these definitions hinge on the determination of an intent to die — but in the real world, intent is not always clear or easy to assess.

What Is a Suicide Attempt?

Suicidologists' disagreements about how to define a suicide attempt generally revolve around the degree of intent necessary for a behavior to be considered suicidal (Linehan & Shearin, 1988; Farmer, 1988; Bille-Brahe et al., 2004). Some investigators infer or assume intent rather than measure it, and label all intentional self-injurious behavior not resulting in death as "suicide attempt." Yet not all self-injury is intended to result in death. Brent, Perper, and Allman (1987) and Lewinsohn, Rohde, Seeley, and Klein (1997) reported that among adolescents who acted to self-inflict harm, approximately one-fourth reported no intent to die, and only about one-third of those seen in emergency rooms stated that they had wanted to die. Some investigators have attempted to provide a nomenclature for suicidal behavior that incorporates information about intent to die. O'Carroll et al. (1996), for example, classify a self-injurious behavior in which there is no intent to die but rather intent to communicate distress to someone else as "instrumental suicide-related behavior." As we have noted in the Introduction, the WHO currently uses the term "suicide attempt" any time an individual does not die, regardless of whether suicidal intent is present (Bille-Brahe et al., 2004).

In addition to the definitional confusion across research studies internationally, clinical assessment of suicidal intent in adolescents and adults remains a challenge because self-reports of suicidal ideation, intent, and behavior are unreliable. For example, one study using both pencil-and-paper questionnaires and a semistructured interview format to evaluate adolescents' self-reports of suicidality reported discrepancies between assessment modalities in 50% of the 48 adolescents (Velting, Rathus, & Asnis, 1998). Moreover, adolescents' reports of attempts often indicate ambivalence, further complicating their accurate assessment (King et al., 1995). However, when interviewers are reliably trained and use a structured interview format, they can be reliable judges of suicidal intent with older adolescents and adults (Linehan, Heard, & Armstrong, 1993b).

What Is NSIB?

In a recent review article on NSIB, Gratz (2003) offered the following definition: "Deliberate self-harm may be defined as the deliberate, direct destruction or alteration of body tissue, without conscious suicidal intent but resulting in injury severe enough for tissue damage to occur" (p. 192). NSIB has been associated with a number of mental disorders, including schizophrenia (Herpertz, 1995), trichotillomania, personality disorders, eating disorders, substance use disorders, PTSD, and intermittent explosive disorder (Favazza & Rosenthal, 1990; Zlotnick, Mattia, & Zimmerman, 1999), as well as mental retardation and a variety of neurological, developmental, and genetic disorders (Schroeder, Oster-Granite, & Thompson, 2002). In particular, these researchers and others have found impulsive NSIB to occur in up to 80% of clients with BPD, as compared to prevalence estimates of approximately 4% in the general population of mental health treatment seekers (Shearer, Peter, Quaytman, & Wadman, 1988). Among clients diagnosed with BPD, the onset is usually reported during early adolescence, whereas onset appears later during young adulthood among individuals without BPD (Symons, 2002).

There is growing evidence that suicidal behaviors and NSIB have different phenomenological pathways (Muehlenkamp & Gutierrez, 2004), functions (Brown, Comtois, & Linehan, 2002), and correlates (Boergers, Spirito, & Donaldson, 1998; Herpertz, 1995; Pattison & Kahan, 1983). As Groholt, Ekeberg, Wichstrom, and Haldorsen (2000) point out, suicidal acts pose greater risks and may require different interventions than repetitive NSIB. Furthermore, a client who repeatedly cuts one's arm to temporarily relieve anger may have difficulty developing a therapeutic alliance with a therapist who focuses primarily on reasons for living instead of alternative methods of managing anger. Therefore, assessing intent allows us to discriminate behaviors that are suicide attempts (i.e., self-injurious behavior with varying levels of intent to die) from self-harming acts that involve no intent to die.

While the evidence to support the relationship between impulsivity and NSIB is mixed, the empirical research suggests that childhood sexual and physical abuse and emotional neglect account for significant variance in the risk for NSIB in adulthood (Gratz, 2003). Moreover, the function of NSIB is commonly conceptualized as a means of regulating emotions (Linehan, 1993a). Both clinical and empirical research suggests that NSIB functions as a form of emotional avoidance and escape from unwanted emotions (Gratz, 2003).

Although suicidal behaviors and NSIB should be considered clinically distinct entities, it is also important to remember that individuals can engage in both types of behaviors at different points in their lives. Lipschitz et al. (1999) found that adolescents hospitalized for suicidal behaviors were more likely also to exhibit NSIB than adolescents hospitalized for other problems were. In one study of adults, 37% of those with self-injury had histories of suicide attempts (Herpertz, 1995). Other studies have found that 10–27% of self-injuring adults eventually die from suicide (Stanley, Gameroff, Michalsen, & Mann, 2001; Cowmeadow, 1995).

What Is Suicidal Ideation?

As with the other terms discussed here, researchers have been unable to reach a consensus on a definition of "suicidal ideation," and so comparing findings from different studies has been difficult (King, 1997). More recently, researchers have suggested conceptualizing suicidal ideation as occurring on a continuum of increasing clinical significance, and some have begun to operationalize definitions that help to overcome the difficulties (Lewinsohn et al., 1996; Roberts et al., 1997). Members of the Oregon Adolescent Depression Project (Lewinsohn et al., 1996) put forth the following categories to operationalize suicidal ideation, in order of increasing severity: "thoughts of death or dying," "wishing to be dead," "thought of hurting (or killing) self," and "suicidal plan."

Suicidal ideation most generally involves current thoughts of death, of killing oneself, or of being killed. Some adolescents may present with passive suicidal ideation (e.g., "I wish I were dead") but report having no plan or intent to kill themselves. For a subgroup of these adolescents, the idea of actively taking their own lives is unfathomable. In contrast, some adolescents report active suicidal ideation that is more alarming to the clinician (e.g., "I feel like killing myself"). When asked, these clients may report having a specific plan to kill themselves. A suicidal plan involves identifying a specific method, and possibly a given time frame, in which an adolescent plans to kill him- or herself. Once an adolescent reports having a plan, the clinician must assess for suicidal intent. "Intent" characterizes the adolescent's level of commitment in carrying out the plan. For some adolescents, suicidal intent may be clear and definite; however, many report ambivalence or minimal intent to die (Brent et al., 1993b; King et al., 1995). Hence adolescents may report having a specific plan but have no intent to die (e.g., "I thought about jumping off a bridge, but I would never do it"). Others may describe their intent as ambivalent (e.g., "I am thinking about taking an overdose, but I am not sure if I can go through with it"). Still others may have full intent to kill themselves (e.g., "I intend to shoot myself with my own gun this Sunday when my parents leave town"). Further complicating matters is the inconsistency across assessments in adolescents' reports of their own suicidal behavior, as noted earlier (Velting et al., 1998).

Suicidal ideation is a strong predictor, if not one of the best predictors, of suicide attempts (Andrews & Lewinsohn, 1992; Kienhorst, DeWilde, van den Bout, Diekstra, & Wolters, 1990). Lewinsohn et al. (1996) found in their prospective study that two dimensions of suicidal ideation were highly correlated: severity and duration. Specifically, adolescents who spent more time thinking about suicide also tended to have more serious thoughts about suicide. More importantly, adolescents who indicated a greater intensity of suicidal ideation (i.e., by endorsing a greater number of items during the past week) were more likely to attempt suicide (Lewinsohn et al., 1996). In sum, as suicidal ideation becomes more frequent and intense, the risk of suicide attempts increases. Researchers have discovered that suicidal ideation is commonly associated with an Axis I disorder in adolescents; it is most strongly associated with depression, but also occurs in anxiety, disruptive behavior, and substance use disorders (Lewinsohn et al., 1996).

CHALLENGES IN DETERMINING RISK FACTORS FOR ADOLESCENT SUICIDAL BEHAVIORS

One of the greatest frustrations for clinicians, researchers, and family members is the inability to predict in advance which individual adolescents will attempt or complete suicide. It is unlikely that the state of the art will improve dramatically in the near future. Research is limited by both ethical problems and recording errors in determining whether predictions are accurate. There is also the more general problem of predicting infrequent events. The best that can be done is to describe the characteristics of subpopulations in which rates of suicide are higher than in the general population. Such a description can then be used to determine whether or not a given adolescent is at high risk for suicide.

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Excerpted from "Dialectical Behavior Therapy with Suicidal Adolescents"
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Copyright © 2007 The Guilford Press.
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