What pre-suicidal syndrome is and how to recognise it?Suicide is a shocking phenomenon resulting from the dramatic decision of someone in suffering and desperation. According to WHO statistics, about 800 000 people commit suicide every year, which is 1 person every 40 seconds. It is indicated that for each person who commits suicide there might be more than 20 other people attempting suicide. In Poland, in 2016 the mortality rate was higher for suicide than for car accidents. Having said that, the horrible number of suicide attempts reached 9861, more than half of it (55%) was successful. Great number of those people directly or indirectly announced the intention to kill themselves. To compare in 2017 in UK the suicidal death rate was about 6.213, 17 families got terrible information that their family member or friend commit suicide. In the USA in 2017the estimated number of suicide attempts reaches almost 1,5 million, more than 47 000 Americans ended their lives. Those numbers point out the magnitude of the suicide problem scale and underline the necessity of evidence-based prevention interventions, including recognising pre suicidal symptoms and reacting appropriately.
Pre-suicidal syndromeErwin Riegel concept of the pre-suicidal syndrome is still known as impactful in recognising the suicidal risk. In 1994 mentioned Austrian psychiatrist and neurologist, published the result of research based on 745 participants who had experienced suicidal attempt. The analysis revealed a clear pattern of thinking and behaving common for all participants. That typical described by Riegel mental state was named pre-suicidal syndrome and it still constitutes the warning signs of the suicidal risk. When should we be warned that person is about to commit suicide? There are three crucial components described as constriction, inhibited aggression turned toward the self and suicidal fantasies. The specific behaviours appearing shortly before someone will take their own life indicate the attempt.
Constriction, which means narrowing perceived options – the person can`t see any options in life, much as they perceive suicide as the only option that remains for them. There is the vision of lack of the possibilities to change the current situation, finding solutions for problems, helplessness and hopeless defeat any attempt to take constructive actions or seeking help. Beside mentioned situational narrowing, there is an increase in negative thinking and self-judgement. The person is focused on experienced failures and losses, anticipate only negatives and misery in the future, constantly feel anxious and worthless. What comes next is narrowing the values system. There is a decline of beliefs, rational thinking collapses and person starts to perceive everything in a very subjective, negative way. The person feels a lack of understanding, worthlessness, loneliness which leads to social isolation.
Finally when the self-defence and control mechanisms collapse the only way to funnel the flustration became the self-aggression. The accumulation of a variety of negative emotions, aggression and perceived problems overwhelm the person to the extent that is not possible to deal with, what results with the final step toward the suicide. What is inseparable part of the pre-suicidal state, is fantasising about suicide. Feeling ever less adequate to cope with reality builds an illusory world in which only death become more purposeful.
Risk factorsThere are specific factors influencing the pre-suicidal syndrome occurrence, as follow:
- difficult life circumstances (breakup, recent job loss, chronic condition/disease, unemployment),
- traumatic events (being a victim of a crime or abuse, being a victim of natural disaster, death of a family member or a friend),
- toxic social relations (discrimination, experiencing abuse or neglect, social isolation) ,
- diseases and mental disorders (depression, schizophrenia, personality disorder, addictions, misuse of alcohol, chronic pain)
How to recognise the symptoms?Riegel analysis provides us with the knowledge that people who plan to commit suicide almost always announce it to someone in some way before the attempt (80-85%). It might be a direct statement (e.g. “I want to commit a suicide”), indirect (e.g. “My life doesn`t have any sense”) or non-verbal communication (e.g. abrupt last will and testament preparation). It all depends on ambivalent emotions that accompany pre-suicidal state. It is extremely important to treat every suicidal threat seriously and carefully. The immediate intervention is crucial for saving lives.
The pre-suicidal warning manifestation:
- hopelessness in finding problem solutions
- anxieties and helplessness in behaviour and activity
- expressing self-aggression or self-harm
- the feeling of meaninglessness and senselessness
- extremely low self-esteem
- passive or pessimistic attitude toward even simple challenges
- giving up rational thinking in favour of emotional reasoning
- social isolation, avoiding people
- the feeling of alienation, desolation, loneliness
- avoiding everyday challenges in favour of fantasising about death and planning suicide
- announcing suicidal plans and thought
- abrupt organising and ordering old matters e.g.cleaning the room, giving away belongings – searching for “the closing”
Suicide as a processThere is a misunderstanding of suicide as an unpredictable event committed impulsively. Given our current knowledge, we should be aware of the dynamic process of suicide starting with thinking about death, through preparing it and taking final measures to complete the plan. By being perceptive we can recognise the warning signs and support person in need of urgent saving-life help.
The aim of suicide prophylaxis is to support a person to combat the crisis and release from the mental disease, getting back to the state of a satisfying life. Saving life is not a sufficient aim but we should take all the measures to preserve the person from being left back alone after the helping intervention.The most impactful factor for saving a life is the psychoeducation of society as well as professional training for mental health specialists and health care professionals. Knowledge about all the stages of person who plan to take their own life (starting with pre-suicidal symptoms, ending up with post-attempt support plan) is the key for effective recognition and prevention of risky mental states and saying straight forward – saving lives.
– H. Bortnowska , Sens Choroby. Sens śmierci. Sens życia.
- Erwin Ringel – “Gdy życie traci sens.”, 1987
- Mariusz Sobkowiak – “Przeciwdziałanie zachowaniom suicydalnym w pracy socjalnej.” , 2011
- 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention.