present or not as extreme). Thus their activities may be less likely
to produce habituation and engage opponent processes. Among
women with bulimia, however, I would predict that those with purg-
ing behaviors (a provocative experience) would endorse more sui-
cidal symptoms than those with nonpurging behaviors (e.g., exces-
sive exercise, a relatively less provocative experience). In fact, a
history of suicide attempt is more prevalent in purging bulimic
women than in other bulimic women.72
As is the case for women with anorexia, women with bulimia have
198 ● WHY PEOPLE DIE BY SUICIDE
decreased pain sensitivity. In fact, their decreased sensitivity to pain
may persist even after their eating disorder resolves. One study com-
pared bulimic women who had recovered from bulimia at least a year
ago to fifteen healthy volunteer women.73 All women in the study re-
ceived two pain evaluations. The first was a thermal pain stimulation
test, which evaluates heat tolerance; the second was the submaximal
effort tourniquet test, which assesses tolerance to pain induced by in-
flation of a blood pressure cuff. In general, recovered bulimic pa-
tients showed higher pain tolerance on both tests as compared to
controls. To my knowledge, no study has examined the difference be-
tween purging and nonpurging women with bulimia regarding pain
tolerance. Since purging bulimics have been through more provoca-
tion than nonpurging bulimics, I would predict higher pain toler-
ance in the former group. If true, their higher pain tolerance may
play a role in their higher suicidality.
It is potentially important that high pain tolerance remains in
women with bulimia, even well after they recovered. High pain toler-
ance in particular and the acquired ability to enact serious self-injury
in general may be slow to fade. Once in place, these psychological
features likely endure for quite some time. As will be pointed out in
the next chapter, this has implications for prevention and treatment
of suicidal behavior. The acquired ability to enact lethal self-injury
may be resistant to change, more so than other aspects of the model
(like perceived burdensomeness and low belongingness). These latter
qualities thus may be more fruitful targets for treatment and preven-
tion programs.
It is interesting to recall that, in general, women have low rates of
completed suicide. Women who undergo an array of provocative ex-
periences, however, may be exceptions to the general rule. Patients
with borderline personality disorder, anorexia nervosa, and, perhaps
to a lesser degree, bulimia nervosa may represent examples of such
women.
Genetics, Neurobiology, and Mental Disorders ● 199
Of course, mood disorders deserve consideration in any discus-
sion of suicide. The rates of death by suicide in mood disorders are
substantial, and this is true for major depression, bipolar I disorder
(with clear manic and depressive phases), and bipolar II disorder
(hypomanic and pronounced, recurrent depressive phases).74 Viewed
through the lens of the model proposed here, high suicide rates
in mood disorders may be a function of the ability to enact lethal
self-injury, which is acquired through repeated past experience with
suicidality and through various provocative experiences associated
with manic symptoms. Indeed, manic episodes frequently land peo-
ple in jail, fights, or accidents. Moreover, mood disorders often
include acute feelings of ineffectiveness and social isolation, a promi-
nent symptom and associated feature, respectively, of major depres-
sion. Therefore, those suffering from mood disorders are vulnerable
on all three of the dimensions emphasized in my model—acquired
ability for lethality, perceived burdensomeness, and failed belong-
ingness.
There is a form of major depression called the atypical subtype.
This subtype’s symptoms include oversleeping, overeating, and ex-
treme interpersonal rejection sensitivity. The subtype is labeled
“atypical” because the symptoms of oversleeping and overeating are
unusual among depressed people; usually, depressed people lose
their appetite and have insomnia. With regard to the rejection sensi-
tivity symptom, it includes reactions to perceived criticisms or
rebuffs that are so intense that it is difficult to maintain long-term re-
lationships. New relationships are avoided for fear of potential rejec-
tion. Belongingness will therefore be a long-standing and vexed issue
for people with the atypical subtype of depression. There is mixed
evidence as to whether people with the atypical subtype experience
higher risk for suicidal behavior than do other depressed people.
One study found that people with the atypical subtype had more sui-
cidal ideas and suicide attempts than other depressed people; atypi-
200 ● WHY PEOPLE DIE BY SUICIDE
cal depressions also had earlier age of onset than other depressions.75
Early age of onset is one marker of severity of a disorder, and this
alone could explain why those with the atypical subtype had more
suicidality than others. But if it is established that atypicality is asso-
ciated with suicidal symptoms in a real way, my model would predict
that this occurs, in part, because people with this syndrome struggle
so intensely with rejection sensitivity and thus low belongingness.
Interestingly, rates of suicide are lower for people suffering from
dysthymia (a low-grade but very chronic form of depression)76 than
from other depressions. Again viewed from the present perspective,
this stands to reason, in that the feelings of ineffectiveness and social
isolation in dysthymia may not reach the level of severity necessary
to fully instill the desire for death.
Antisocial personality disorder is interesting to consider in light of
the model proposed here. The disorder is characterized in the cur-
rent psychiatric nomenclature as a long-standing pattern of aggres-
sive behavior and reckless and impulsive disregard for others and for
rules and norms. However, recent research, informed by classic work
by the psychiatrist Hervey Cleckley,77 suggests that there are two dif-
ferent kinds of antisocial personality. One type is characterized by
emotional detachment (i.e., low anxiety; fake or shallow emotions;
immunity to guilt and shame; callousness; and incapacity for love,
intimacy, and loyalty). The other type is characterized by impulsive,
reckless, and under-controlled behaviors.
Cleckley reserved the term “psychopath” for those with the cardi-
nal feature of emotional detachment. Research has demonstrated
that the two types of antisociality are separable.78 One factor is cur-
rently emphasized by DSM and prioritizes antisocial behavior. The
other factor was formerly emphasized in DSM to some degree and
corresponds to Cleckley’s emphasis on “emotional detachment.” Ac-
cording to this research, there are two kinds of people with antisocial
personality—those who are emotion
ally detached (and who are also
Genetics, Neurobiology, and Mental Disorders ● 201
prone to poor behavioral control, in part because of their emotional
detachment), and those who are primarily impulsive, aggressive, and
irresponsible but who are not emotionally detached (and actually
may be especially emotionally reactive).
My colleagues and I predicted that this latter type of individual
would be prone to suicidal behavior (due to the combination of
impulsivity and emotional reactivity), but that emotionally detached,
“Cleckley psychopaths” would not be, due in part to low emo-
tional reactivity. Our study of 313 inmates supported this predic-
tion: “antisocial behavior” was associated with history of suicide at-
tempts; “emotional detachment” was not, and in fact, was negatively
associated with suicide history, although to a nonsignificant degree.
Moreover, we found that the link between “antisocial behavior” and
suicidality occurred in part because antisocial characters were prone
to the combination of negative emotionality and impulsivity.79
According to the model of suicidality described here, emotionally
detached antisocial personalities may not be prone to suicide, be-
cause their callousness and incapacity for intimacy and loyalty would
insulate them from perceived burdensomeness and disconnection
from others. By contrast, antisocial personalities characterized by
under-controlled behaviors would be at higher risk, because their
recklessness gives them an opportunity to habituate to pain and in-
jury, and because their negative emotionality increases the likelihood
of a sense of burdensomeness and low belongingness.
Virtually everyone who dies by suicide experienced one or more
mental disorders at the time of their death. Certain disorders are
more associated with suicidal behaviors than others, and it is impor-
tant to recall that relatively few people with a mental disorder die by
suicide. My model explains these facts by arguing that some mental
disorders are more likely than others to lay down the ability to enact
suicide and to instill perceived burdensomeness and failed belong-
ingness. Those with one of these suicide-related disorders who do
202 ● WHY PEOPLE DIE BY SUICIDE
not die by suicide have managed to avoid perceived burdensomeness,
low belongingness, or acquiring the ability to seriously harm them-
selves, despite their mental disorder. Certain mental disorders sub-
stantially increase the likelihood but do not guarantee that the three
conditions will be present that I propose are required for serious
suicidality.
At the moment of conception, a baby’s future is not fully plotted,
but some of its general trajectories can be discerned. Genes influence
neurobiology, including the serotonin system. Genes also influence
personality traits like impulsivity, and this influence may occur
mostly through genes’ impact on the serotonin system. Genetics,
neurobiology, and personality all interact in complex ways with an
individual’s life experience. Early adverse experience, including
childhood abuse and neglect, heightens the risk for later problems,
especially in vulnerable people. One set of such problems is men-
tal disorders, which, in addition to the agony and impairment they
cause, clearly confer risk to suicidal behavior. Genes, neurobiology,
impulsivity, childhood adversity, and mental disorders are inter-
connected strands that converge and can influence whether people
acquire the ability for lethal self-injury, feel a burden on others, and
fail to feel that they belong. This lethal endpoint is the culmination
of processes started at conception and furthered, biologically and
through experience, over a person’s lifetime.
RISK ASSESSMENT,
CRISIS INTER VENTION,
TREATMENT,
AND PREVENTION
6
Time and again, psychopathology theorists and researchers go to
great lengths to develop theories and models of psychopathology, but
then when it comes time to talk about applications like assessment,
treatment, and prevention, there is a great disconnect between the-
ory and application. I think this occurs in part because applications
are often developed without theory in the clinic—on the fly, as it
were. This is not all bad, because many treatments that are discon-
nected from theory are very good—and, it must be added, some
treatments that are awash in theory are not very good at all.
Some examples of good treatments are interesting to consider.
A first is called Interpersonal Psychotherapy (IPT) and it was devel-
oped in the 1970s by the late psychiatrist Gerald Klerman and
colleagues. IPT is a down-to-earth, here-and-now kind of psycho-
therapy originally developed for depression but now used for other
conditions too. Its central idea is that if a major interpersonal issue
connected to symptom onset is worked out—say, a grief problem or
a hostile standoff in a marriage—then that is bound to help relieve
symptoms. IPT also recommends the sensible strategy of staying fo-
203
204 ● WHY PEOPLE DIE BY SUICIDE
cused on one interpersonal issue, trusting that progress made on it
will generalize to improve other areas too.
That IPT relieves symptoms is beyond doubt; randomized, con-
trolled clinical trials have attested to the fact. In an intriguing study,
IPT was assessed in rural Uganda.1 Thirty Ugandan villages were
studied. In each village, men or women who were self-identified
and viewed by other villagers to have symptoms of depression were
interviewed. In the local language, there is no single term to de-
scribe depression. Instead the interviewers asked for persons with
Yo’kwekyawa or Okwekubazida, two depression-like syndromes well known to villagers. These two syndromes together include all the
major depression symptom criteria in the DSM-IV. Approximately
eight per village of the most depressed people were selected for par-
ticipation, totaling around 250. Eight of fifteen male villagers and
seven of fifteen female villagers were randomly assigned to the ther-
apy and the remainder to a control group. People in the control vil-
lages did not receive the therapy; however, people in both control
and intervention villages were free to seek whatever other interven-
tions they wished throughout the study. The intervention villages
received the depression therapy in group meetings for weekly ninety-
minute sessions for sixteen weeks. Groups were led by a local per-
son, of the same sex as the group, who had received brief training in
the therapy. During each session, the group leader reviewed each
participant’s depressive symptoms, and participants described recent
events and linked the events to his or her mood. The group leader
then facilitated supportive statements and suggestions for change
from other group members. The therapy was very effective. Among
those who received the treatment, rates of severe depression went
from around
90 percent before treatment to around 6 percent after
treatment; by contrast, among those in the control groups, rates of
severe depression went from around 90 percent before treatment to
around 55 percent after treatment.
Assessment, Intervention, Treatment, and Prevention ● 205
This and other studies show that IPT is effective. But it is remark-
ably theory-free. As IPT was being developed in the 1970s and there-
after, a scientific and theoretical literature on the interpersonal as-
pects of depression was developing too.2 Strangely, these two strands
of work rarely if ever intersected. IPT’s relative lack of theory has not
hamstrung it; it works, and additionally, no theoretical errors or
obfuscations were introduced as part of the treatment description.
A second example of a good treatment being disconnected from
theory is the Cognitive Behavioral Analysis System of Psychotherapy
(CBASP).3 This treatment relies heavily on past work by people like
Aaron T. Beck and Albert Ellis on cognitive therapy, as well as on the
field of applied behavior analysis. The gist of CBASP is, in ways, sim-
ilar to IPT. The idea is to repeatedly focus on specific, discrete situa-
tions and then to mould one’s thoughts and behaviors so that those
situations tend to produce one’s goals. Like IPT, the idea is down-to-
earth, and like IPT, impressive clinical trial data support the treat-
ment’s effectiveness.4
The theory behind the treatment, however, is both flawed and
largely irrelevant to the treatment. The theory makes unfortunate
and unsubstantiated claims about the nature of depressed people—
for example, that the chronically depressed individual is “a cognitive-
emotionally retarded adult child who brings a negative ‘snapshot’
view of the world to the session. The chronic patient functions, at
least in the social-interpersonal arena, with the structural mindset of
a 4–6-year-old preoperational child.”5 I find this a ludicrous claim,
and would feel even more strongly, I’m sure, if I were a chronically
depressed adult. Moreover, the claim is not necessary or even very
relevant to the treatment, which, far from being ludicrous, has been
shown to be effective and useful.
The cognitive theorizing and treatment recommendations of Beck
Why People Die By Suicide Page 26