Suicidal ideation

Suicidality, also known as suicidal risk or colloquially as tiredness of life, describes a mental state in which thoughts, fantasies, impulses and actions are directed persistently, repeatedly or in certain crisis-like peaks towards deliberately bringing about one's own death. Suicidology is a scientific discipline concerned with the study of suicidality and suicidal events.

There is a gradual differentiation between suicidal thoughts without the desire to commit suicide - which also count as suicidality - and urgent suicidal thoughts with concrete intentions, plans and even preparations for suicide.

Suicidality is not a disease, but a symptom of an underlying problem. It can be the culmination of an emotional development in which despair and hopelessness have gained the upper hand. Suicidal people often experience themselves as internally torn and are often ambivalent about their wish to die. On the one hand, they feel that their life is unbearably painful and therefore want to end it; on the other hand, many feel a kind of self-preservation instinct, fear of severe pain in the context of a suicide attempt, and generally great uncertainty about the consequences of their actions. A possibility to change their current life, to start it anew, is not apparent in acute suicidal tendencies; suicide appears to this group of persons as the only way out.

Since suicidality can manifest itself - or not manifest itself - in very different ways, trying to assess how acute a person's suicidality is or how pronounced his or her suicidal tendency is often turns into a difficult, sometimes even hopeless undertaking, especially for those people who - for whatever reason - are hostile to offers of help. In cases of acute suicidality, in which the person concerned may already have made concrete plans and preparations, is unable to distance himself from his intentions and cannot enter into any agreements (e.g. assuring that he will call the therapist the next day), there is an indication for compulsory admission to a psychiatric hospital within the framework of the duty of care.

In the assessment or diagnosis of suicidality, the following aspects are important:

• Presuicidal syndrome: constriction, aggression reversal, suicidal fantasies
• Risk factors: Mental illness (especially depression, addiction or schizophrenia in the acute phase), psychosocial crises (separation, death of a close person), few social relationships, previous suicide attempts, suicides in the family.
• Current state of mind: hopelessness, anxiety, sleeplessness, joylessness, impulsivity and acute life stresses: disturbed processing of illness, unbearable memories, negative assessment of life circumstances, resignation
• Separation experiences: failed partnership, death of a relative, mortification, developmental crises, discharge from inpatient psychiatric and psychotherapeutic treatment

A special group of suicidality can be seen as the wish to die of people who wish to die in the face of old age, old age complaints or a terminal incurable disease. It is not uncommon for such people to refuse to take in food and/or fluids; their relatives and doctors are then faced with the question of whether such a person is sane (see also presumed will, living will, artificial feeding).

Questionnaires for the assessment of suicidality

There are several questionnaires for self and external assessment:

• NGASR - Nurses Global Assessment of Suicide Risk (16 questions)
• SSF-II - Suicide Status Form
• BSSI - (19 questions)
• Beck Scale for Suicidal Ideation (SBQ-R|SBQ-R, Questionnaire for the Assessment of Suicidal Behavior (4 questions))
• Reasons for Living Inventory (RFL)
• Beck Hopelessness Scale (BHS)
• INQ - Interpersonal Needs Questionnaire
• ACSS - Acquired Capability for Suicide Scale
• TASR - Tool for Assessment of Suicide Risk
• SSI - Scale for Suicidal Ideation (19 questions)
• SIS - Suicide Intent Scale (15 questions)
• LSARS - Lethality of Suicide Attempt Rating Scale
• LASPC - Los Angeles Suicide Prevention Scale
• SDPS - Suicidal Death Prediction Scale
• SD - SAD Persons Scale
• SIQ - Suicidal Ideation Questionnaire
• SRAS - Suicide Risk Assessment Scale
• SASR - Scale for Assessing Suicidal Risk
• SPS - Suicide Probability Scale

Etiology Models

There are several models of the origin of suicidal thoughts or behavior:

• Phase model of suicidal development (Pöldinger 1968)
• Cubic Model of Suicide (Shneidman, 1989)
• Escape theory (Baumeister, 1990)
• Cry of Pain model (Williams 2001)
• Fluid Vulnerability Theory of Suicide (Rudd, 2006).
• Cognitive model of suicidal acts (Wenzel and Beck, 2008).
• Interpersonal theory of suicidal behavior (Joiner 2005): Passive suicidal desires could arise either from the lack of a sense of belonging to a group or the assumption of being a burden for others. If both components were present at the same time, active suicidal desires could develop. The decisive factor for whether a suicide attempt is made is whether there is a third component, a fearlessness of pain, dying and death. This fearlessness of pain and death could possibly result from habituation to repeated painful or frightening experiences, such as self-harm, trauma or drug abuse.
• Integrative motivational-volitional model of suicidal behavior (O'Connor, 2011).