Warning Signs of Suicide

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					Warning Signs of

     Lanny Berman, Ph.D., ABPP
          Executive director
  American Association of Suicidology

    Screening for Mental Health
        September 24, 2007
Risk Factors for Suicidal

 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

Perpetuating risk
   Family history (violence,
    suicide, mental disorder
    requiring hospitalization)
   Skill deficits (social,
   Multiple/chronic personal
   Early trauma/abuse
   Prior suicidal behavior
Risk Factors for Suicidal

 Predisposing risk
  Poor self-esteem/Self-
  Psychiatric illness
    e.g. depression
  Chemical dependency
  Physical illness
  Exposure to suicidal
Risk Factors for Suicidal
 Precipitating risk factors
   Loss of social support (friends,
   Loss of identity/meaning (job,
    career); loss of attachments
   Threat of/actual loss of
    job/financial loss
   Acute psychiatric symptoms
    (psychosis, depression,
   Loss of hope/Sense of failure
   Acute disappointments
   Embarrassments, humiliations,
    threat to status
   Threat of legal
   Availability of means
   Anniversary reaction
Warning Signs
 Early detection, referral,
  treatment model
   Health care workers
   Mental health providers
   First responders

 Public health awareness
   To lay public
   To gatekeepers, etc.
Suicide Prevention
Case Finding

  Suicide awareness
 Gatekeeper training
 Screening
 Crisis centers and
 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
    • 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 JASON AAS SFSP DMDA NAMI AFSP SAVE YELLOW RIB.       BI
Family History
suicide (3)                                        X                                   X                          X
substance abuse (1)                                X
physical or sexual abuse (2)                       X                                                              X
Suicidal/Death Ideation (2)                                                                           X           X
writing about death and suicide (1)                                                                               X
talking about suicide and plans (7)                X          X    X    X        X          X                     X
giving prized possessions away (7)                            X    X    X        X          X         X           X
attraction to death (4)                            X          X    X                        X
making arrangements (4)                                       X    X        X               X
making out wills (4)                                               X    X   X               X
unusual visiting or calling loved ones (2)                    X                             X
obsession with guns/knives (1)                                                              X
Behavior Changes (4); marked changes                          X         X        X                                X
substance abuse (9)                                X    X          X    X   X    X          X         X           X
withdrawal from friends/family (4)                      X     X    X                        X
personality changes (4)                                 X               X        X                    X
physical symptoms (3)                              X    X                                   X
withdrawal from regular activities (4)                  X          X                        X                     X
neglect of personal appearance (3)                      X          X                                  X
unnecessary risks (3); behaving recklessly (1)                X    X                        X                     X
agitation (3)                                                           X        X          X
restlessness (3)                                                        X        X                    X
fear of losing control (3)                                              X   X    X
running away (2)                                        X                                             X
self-destructive behavior (2);self-mutilation (1)             X                             X                     X
hyperactivity (2)                                                       X        X
accident-prone (2)                                                                          X         X
boredom (2); daydreaming (1)                            X                                             X           X
decline in quality of schoolwork (2)                    X                                             X
rebellious behavior (2)                                 X                                             X
not tolerating praise or rewards (1)                    X
violent actions (1)                                     X
extravagant spending (1)                                                X
lethargy (1)                                                            X
nightmares (1)                                                                   X
worry about money (1)                                                            X
worry about illness (real or imaginary) (1)                                      X
fear of hurting oneself or others (1)                                            X
increased crying (2)                                                                        X                     X
increased anxiety (1)                                                                       X
increased panic attacks (1)                                                                 X
perfectionism (1)                                                                                     X
fighting                                                                                                          X
unwillingness or inablity to communicate (1)                                                          X
impulsiveness (1)                                                                                                 X
helplessness (1)                                                                                                  X
chronic pain, panic, anxiety (1)                                                                      X
loss of interest in appearance (1)                                                                                X
Stressful Events
severe loss/separation (loved one, job,            X               X    X        X     X              X           X
         money, status, self-esteem) (7)
rejection - feeling marginalized                                                                                  X
failing in school (2)                                                                                 X           X
loss of physical funtioning (1)                    X
loss of body parts/physical integrity (1)          X
serious illness or injury to oneself (1)                                                              X
causing serious injury or death to another (1)                                                        X
terminal illness (1)                               X
HIV/AIDS (1)                                       X
chronic emotional/physical pain (2)                X                                                  X
dependence on others for health care (1)           X
stressful family life (1)                                                                             X
loss of religious faith (1)                                                      X
panic, anxiety (2)                                                                                    X           X
loss of security (1)                                                                                  X
recent imprisonment or upcoming release                                                                           X
problems with school/law (2)                                                                          X           X
increase in minor illnesses (1)                                                                                   X
depressed mood (4)                                 X          X                             X         X           X
loss of interest in pleasurable activities (5)                X    X    X        X          X
change in eating habits (6)                             X          X    X        X          X         X
sudden weight gain or loss (1)                                                                                    X
change in sleeping habits (7)                           X          X    X        X          X         X           X
feelings of worthlessness or guilt (8)             X          X         X   X    X          X         X           X
difficulty concentrating, remembering (2)               X                                   X
recurrent thoughts of death (7)                    X          X    X    X        X          X         X
lack of energy (1)                                                                                                X
change of sexual interest (1)                                                                                     X
deep sadness or guilt (1)                                                                                         X
Past Suicide Attempts (7)                          X                    X        X     X    X         X           X
seriousness of attempts (1)                        X
rehearsing suicide (1)                                                      X
comorbidity (2)                                    X                                   X
beginning to feel better (2)                                                X               X
contagion (1)                                                                          X
loneliness - lack of support from fam/friends (1)                                                                 X
unable to see beyond a narrow focus (1)                                                                           X
neurotransmitters (1)                                                                  X
Web Site Warning
 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;

     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
Babson College, Wellesley, MA

 M. David Rudd, Ph.D.
      Baylor University
 Lanny Berman, Ph.D.
      American Association of


  Matthew Nock, Ph.D.
      Harvard University
    Gregory Brown, Ph.D.
      University of Pennsylvania
    Dana Carr, Ph.D.
      U. S. Department of Education
    David Chambers, Ph.D.
    Yeates Conwell, M.D.
      University of Rochester Medical Center
    Jan Fawcett, M.D.
      University of New Mexico
    Keith Hawton, M.D.
    University of Oxf ord, 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 Center
    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

 What time-frame best
  defines imminent or acute
   Is this a reasonable
     definition of a “warning
Essential Questions
 How are warning signs to be
  differentiated from risk

 Do we have empirically-
  based warning signs of
  suicide and, if so, are there
  different signs for different
  outcomes (suicide, nonfatal
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.,
Essential Questions
 Can we agree on how such a
  common set or list should be

 Can we identify future
  research needs/questions to
  address areas of insufficient
  knowledge regarding warning
Immediate Goals
 Consensus

 More consistent (and valid)
  public education message
   Warning Signs
                                     Key Messages

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

□ Someone talking or writing about death, dying or
suicide, when these actions are out of the ordinary for
the person.
Warning Signs

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
 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
 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

Red Flags
   I Ideation/threatened or
   S Substance Abuse/excessive or

   P Purposeless/no reasons for
   A Anxiety, Agitation/Insomnia
   T Trapped/feeling no way out
   H Hopelessness

   W Withdrawal from friends, family,
   A Anger (uncontrolled)/rage/seeking
   R Recklessness/risky acts -
   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?

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