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Behavioral Emergencies Update

Fall/Winter 2004-5

Section on Clinical Emergencies and Crises
American Psychological Assn.
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In this issue...

The President's Column

Ethical Issues in Research on Behavioral Emergencies and Crises

Subtle Differences between Self-Injury and Suicide in Adolescents

Section VII in Hawaii

Conference Photos

What is Suicidal Behavior? Definitional Problems in Research and Practice

Congratulations to Our Newly Elected Members


A Message from the Treasurer

Notes from the Editor

Extras

 

What is Suicidal Behavior? Definitional Problems in Research and Practice

Jennifer J. Muehlenkamp & Alec L. Miller
Montefiore Medical Center/Albert Einstein College of Medicine
Bronx, NY

The ability to clearly and operationally define a behavior is critical to advancing a field of research and to designing effective treatments for problematic behaviors. Despite valiant efforts to create a consistent nomenclature for the study of suicidal and non-suicidal self-injurious behaviors based on terms of outcome and intent to die (O’Carroll et al., 1996), the field has stagnated. One critique against a nomenclature incorporating motives such as the wish to die is that it may be difficult if not impossible posthumously to prove any motive behind the act or any clear presence of the wish to die (Bille-Brahe, Kerkhof, DeLeo, & Schmidtke, 2004).  A review of the literature finds that researchers employ a variety of idiosyncratic terms and definitions across studies rather than relying on a unified nomenclature. Within the past year, an expert panel of suicidologists consulting to the FDA on the adverse events from the SSRI and pediatric depression studies resorted to creating its own classification system to differentiate accidents, from suicidal ideation, from non-suicidal self-injurious behavior with intent to change emotional state, from preparatory actions toward suicide, from suicide attempt, etc.   In Europe, where the term parasuicide originated (Kreitman, 1977) in order to refer to behavior with and without intent to die, researchers decided to drop the term parasuicide.   The proposed ICD-10 definition, which was selected for the WHO/Euro Multicentre study on Suicidal Behavior, required all sites to use the following definition for “suicide attempt”:  “An act with nonfatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences” (Schmidtke, Bille-  Brahe, DeLeo, & Kerkhof, 2004, p. 8).   Interestingly, however, this “new” definition does not differentiate behaviors on the basis of intent thus begging the question of whether they are clarifying or confusing the field of suicidologists. Within the United States, some researchers continue to use vague terms such as parasuicide, which refers to both suicide and non-suicidal self-injury; self-harm, which often refers to a conglomerate of suicidal behaviors, non-suicidal self-injury, and other risky behaviors (e.g., promiscuity, binge drinking, anorexic behavior); self-mutilation/self-cutting, which are specific to the action being performed; and suicide attempt, which can mean a full range of behaviors depending on how the authors define it. The assortment of available terms is mind-boggling and creates numerous problems for the advancement of our field.

The inability to use consistent terminology makes comparing findings across studies near impossible, and means clinicians are not speaking the same language. Confusion regarding suicidal or non-suicidal self-injurious behavior is problematic because it reduces confidence in results from research since findings can differ depending on what behaviors are or are not grouped together. Confusion regarding the behavior under study also impairs clinicians’ ability to select the best treatment options. Forward progress within the field of suicidology is contingent on the use of a universal language that shares a common definition of the behavior(s) being examined. Utilizing a nomenclature that differentiates suicidal and non-suicidal self-injury is important because research is demonstrating that although they share comorbidities, there are reliable distinctions between the two and they are separate behaviors that may warrant different interventions.

O’Carroll and colleagues (1996) laid forth a solid classification system for the field, providing operationally defined terms for a range of suicidal and non-suicidal self-injurious behaviors. The critical differentiating feature of whether a particular behavior is to be considered a suicide attempt or non-suicidal self-injury is based on the intent underlying the action. While we must acknowledge difficulties in retrospectively assessing intent of a behavior, our experience has been for those individuals who have not died by suicide, they can often identify their intent or their ambivalence of intent. Linehan (1997) highlights that much of the ambiguity and confusion in terminology regarding suicidal/non-suicidal self-injury results from inadequate attention to and assessment of intent. As professionals with expertise in the field of suicidology, we are all sensitive to and vigilant in assessing suicidal intent with our patients. We need to bring this vigilance to our research efforts so that specific behaviors can be clarified and adequately studied.

It is possible that our failure to systematically use the taxonomy delineated by O’Carroll and colleagues is due to our tendency to remain with what is familiar, using the terms we have always used. It is also possible that the nomenclature created is insufficient and in need of revision. In either case, we need to address the problem. As leaders in the area of suicidology we, as a whole, are perpetuating the problem of definitional obfuscation (Linehan, 1997). It is up to us to correct the problem and move the field forward with greater precision. Consequently, we are placing a call for a consensus meeting to review the current state of affairs and come to an agreed upon nomenclature that will be implemented by all. We welcome your thoughts and comments regarding this matter (including letters to the Editor of Behavioral Emergencies Update). Efforts are needed to ensure we are speaking a similar language, studying the same behaviors, and using the correct treatment approaches for the targeted behavior. It is our hope that we all begin to take purposeful action toward improving our work in suicidology by using an agreed upon language.

References
Bille-Brahe, U., Kerkhof, A, DeLeo, D. & Schmidtke, A. (2004).Definitions and terminology used in the WHO/EURO multicentre study (Chapter 3).  In, Suicidal Behavior in Europe, (Eds.) Schmidtke, Bille-Brahe, DeLeo, Kerkhof.  Hogrefe & Huber.

Linehan, MM. (1997). Behavioral treatments of suicidal behaviors: Definitional obfuscation and treatment outcomes. In Stoff, David M, Mann, J. John (Eds), The neurobiology of suicide: From the bench to the clinic. Annals of The New York Academy of Sciences, Vol. 836. (pp. 302-328). New York, NY, US: New York Academy of Sciences.

O’Carroll, PW, Berman, AL, Maris, EW, Moscicki, E. Tanney, BL, & Silverman, M. (1996).  Beyond the tower of Babel.  Suicide and Life-Threatening Behavior, 26, 237-252.

 Schmidtke, A, Bille-Brahe, U, DeLeo, D, & Kerkhof, A. (2004).  The WHO/EURO multicentre study on suicidal behavior (Chapter 2).  In, Suicidal Behavior in Europe, (Eds.) Schmidtke, Bille-Brahe, DeLeo, Kerkhof.  Hogrefe & Huber.

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