Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part 1: Background, Rationale, and Methodology
Morton M. Silverman MD,
Alan L. Berman PhD,
Nels D. Sanddal MS,
Patrick W. O'Carroll MD, MPH,
Thomas E. Joiner Jr. PhD,
Corresponding Author
Morton M. Silverman MD
Clinical Associate Professor of Psychiatry at the University of Chicago, Senior Advisor to the Suicide Prevention Resource Center (Newton, MA), and Educational Consultant to the Denver VA VISN 19 MIRECC
4858 S. Dorchester Avenue, Chicago, IL. 601615–2012; E-mail: [email protected]Search for more papers by this authorAlan L. Berman PhD
Executive Director of the American Association of Suicidology
Search for more papers by this authorNels D. Sanddal MS
President and CEO of Critical Illness and Trauma Foundation, Inc., Bozeman, MT
Search for more papers by this authorPatrick W. O'Carroll MD, MPH
Regional Health Administrator, Public Health Region X
Search for more papers by this authorThomas E. Joiner Jr. PhD
Bright-Burton Professor of Psychology at The Florida State University.
Search for more papers by this authorMorton M. Silverman MD,
Alan L. Berman PhD,
Nels D. Sanddal MS,
Patrick W. O'Carroll MD, MPH,
Thomas E. Joiner Jr. PhD,
Corresponding Author
Morton M. Silverman MD
Clinical Associate Professor of Psychiatry at the University of Chicago, Senior Advisor to the Suicide Prevention Resource Center (Newton, MA), and Educational Consultant to the Denver VA VISN 19 MIRECC
4858 S. Dorchester Avenue, Chicago, IL. 601615–2012; E-mail: [email protected]Search for more papers by this authorAlan L. Berman PhD
Executive Director of the American Association of Suicidology
Search for more papers by this authorNels D. Sanddal MS
President and CEO of Critical Illness and Trauma Foundation, Inc., Bozeman, MT
Search for more papers by this authorPatrick W. O'Carroll MD, MPH
Regional Health Administrator, Public Health Region X
Search for more papers by this authorThomas E. Joiner Jr. PhD
Bright-Burton Professor of Psychology at The Florida State University.
Search for more papers by this authorThis effort was initially encouraged and supported, in part, by the Suicide Prevention Research Center (SPRC) at the University of Nevada School of Medicine, Las Vegas, Nevada. Principal investigators were G. Thomas Shires, MD, and John Fildes, MD. The Denver VA VISN 19 MIRECC sponsored a meeting of the MIRECC Nomenclature Workgroup in July, 2005, which resulted in the preparation of this revision. The Director of the Denver VA VISN 19 MIRECC is Lawrence E. Adler, MD. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Denver VA VISN 19 MIRECC.
Earlier drafts were read by David A. Jobes, PhD, Herbert Nagamoto, MD, and Pamela J. Staves, RN, MS, NP. The co-authors appreciate their contributions, critiques, and recommendations.
Abstract
Since the publication of the O'Carroll et al. (1996) nomenclature for suicidology, there have been a number of published letters and articles, as well as an active e-mail dialogue, in response to, and elaborating upon, this effort to establish a standard nomenclature for suicidology. This new nomenclature has been presented on a number of occasions at both national and international meetings. In this paper we provide the background, rationale, and methodology involved in the process of revising the O'Carroll et al. nomenclature, based on the feedback and discussions that have ensued over the past 10 years.
Those who have written and studied the phenomenon of suicide have not defined the term so simply … how the word is defined has implications and large effects for statistics that are compiled on the official number of suicides, and for researchers, so that there is clear communication regarding what and who is being studied.
Among writers in the field of suicidology there is no single common accepted definition … the term suicide refers not to a single action but more broadly to a great many varied behaviors. For example, one can speak of suicidal thoughts, intentions, ideation, gestures, attempts, completions, equivalents.
Thus far, no single term, definition, or taxonomy has served to sufficiently represent the complex set of behaviors that have been suggested as suicidal. A standard set of terms and definitions are greatly needed to advance the science of suicidology and aid communication and understanding of the field.
McIntosh (1985, pp. 18–19)
REFERENCES
- American Psychiatric Association. (2003). Practice guidelines for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(Suppl.), 1–60.
- Andriessen, K. (2006). On “intention” in the definition of suicide. Suicide and Life-Threatening Behavior, 36, 533–538.
- Arensman, E., & Kerkhof, A.J.F.M. (1996). Classification of attempted suicide: A review of empirical studies, 1963–1993. Suicide and Life-Threatening Behavior, 26, 46–67.
- Aschkenasy, J. R., Clark, D. C., Zinn, D., & Richtsmeier, A. J. (1992). The non-psychiatric physician's responsibilities for the suicidal adolescent. NY State Journal of Medicine, 92, 97–104.
- Barber, M. E., Marzuk, P. M., Leon, A.A.C., & Portera, L. (1998). Aborted suicide attempts: A new classification of suicidal behavior. American Journal of Psychiatry, 155, 385–389.
- Beautrais, A. L. (2001). Suicide and serious suicide attempts: Two populations or one? Psychological Medicine, 31, 837–845.
- Beautrais, A., Joyce, P., & Mulder, R. (1999). Personality traits and cognitive styles as risk factors for serious attempts among young people. Suicide and Life-Threatening Behavior, 29, 37–47.
- Beck, A. T., Davis, J. H., Frederick, C. J., Perlin, S., Pokorny, A. D., Schulman, R. E., et al (1973). Classification and nomenclature. In H.L.P. Resnik & B. C. Hawthorne, (Eds.), Suicide prevention in the seventies (pp. 7–12). Washington, DC: U.S. Government Printing Office.
- Beck, A. T., Schuyler, D., & Herman, I. (1974). Development of suicide intent scales. In A. T. Beck, H.C.P. Resnick, & D. Lettieri, (Eds.), The prediction of suicide (pp. 45–69). Bowie, MD: Charles Press.
- Beck, A., Steer, R., & Brown, G. (1993). Dysfunctional attitudes and suicidal ideation in psychiatric outpatients. Suicide and Life-Threatening Behavior, 23, 11–20.
- Berman, A. L. (1993). Forensic suicidology and the psychological autopsy. In A. A. Leenaars, A. L. Berman, P. Cantor, R. E. Litman, & R. W. Maris, (Eds.), Suicidology: Essays in honor of Edwin S. Shneidman (pp. 248–266). Northvale, NJ: Jason Aronson.
- Berman, A. L., & Cohen-Sandler, R. (1982). Childhood and adolescent suicide research: A critique. Crisis, 3, 3–15.
- Berman, A. L., Shepherd, G., & Silverman, M. M. (2003). The LSARS-II: Lethality of suicide attempt rating scale—updated. Suicide and Life-Threatening Behavior, 33, 261–276.
- Bridge, J., Barbe, R., Birmaher, B., Kolko, D., & Brent, D. (2005). Emergent suicidality in a clinical psychotherapy trial for adolescent depression. American Journal of Psychiatry, 162, 2173–2175.
- Brown, G. K. (2001). A review of suicide assessment measures for intervention research with adults and older adults. Rockville, MD: U.S. Department of Health and Human Services.
- Brown, G. K., Henriques, G. R., Sosdjan, D., & Beck, A. T. (2004). Suicide intent and accurate expectations of lethality: Predictors of medical lethality of suicide attempts. Journal of Consulting and Clinical Psychology, 72, 1170–1174.
-
Brown, G. K.,
Jeglic, E.,
Henriques, G. R., &
Beck, A. T. (2006). Cognitive therapy, cognition, and suicidal behavior. In T. E. Ellis, (Ed.), Cognition and suicide: Theory, research, and therapy (pp. 53–74). Washington, DC: American Psychological Association.
10.1037/11377-003 Google Scholar
- Bryan, C. J., & Rudd, M. D. (2006). Advances in the assessment of suicide risk. Journal Clinical Psychology/In Session, 62, 185–200.
- Centers for Disease Control and Prevention. (2005). Youth risk behavior surveillance system. Retrieved November 23, 2005, from http://www.cdc.gov/HealthyYouth/yrbs/index.htm.
- Compton, J., Daniel, S. S., & Goldston, D. B. (in press). Suicidal behaviors in DSM: A need for clarity. American Journal of Psychiatry..
- Daigle, M. S., & Cote, G. (2006). Nonfatal suicide-related behavior among inmates: Testing for gender and type differences. Suicide and Life-Threatening Behavior, 36, 670–681.
- Dear, G. E. (1997). Writing this was instrumental, whatever my intent: A comment. Suicide and Life-Threatening Behavior, 27, 408–410.
- Dear, G. E. (2001). Further comments on the nomenclature for suicide-related thoughts and behavior. Suicide and Life-Threatening Behavior, 31, 234–235.
- De Leo, D., Burgis, S., Bertolote, J., Kerkhof, A.D.M., & Bille-Brahe, U. (2004). Definitions of suicidal behavior. In D. DeLeo, U. Bille-Brahe, A.D.M. Kerkhof, & A. Schmidtke, (Eds.), Suicidal behavior: Theories and research findings (pp. 17–39). Washington: Hogrefe & Huber.
- De Leo, D., Burgis, S., Bertolote, J. M., Kerkhof, A.J.F.M., & Bille-Brahe, U. (2006). Definitions of suicidal behavior: Lessons learned from the WHO/EURO Multicentre Study. Crisis, 27, 4–15.
- De Moore, G. M., & Robertson, A. R. (1999). Suicide attempts by firearms and by leaping from heights: A comparative study of survivors. American Journal of Psychiatry, 9, 1425–1431.
- Denning, D. G., Conwell, Y., King, D., & Cox, C. (2000). Method choice, intent and gender in completed suicide. Suicide and Life-Threatening Behavior, 30, 282–288.
- Duberstein, P. R., & Conwell, Y. (1997). Personality disorders and completed suicides: A methodological and conceptual review. Clinical Psychology: Science and Practice, 4, 359–376.
- Egel, L. (1999). On the need for a new term for suicide. Suicide and Life-Threatening Behavior, 29, 393–394.
- Ellis, T. E. (1988). Classification of suicidal behavior: A review and step toward integration. Suicide and Life-Threatening Behavior, 18, 358–371.
- N. L. Farberow (Ed.). (1980). Indirect self-destructive behavior: Classification and characteristics. In N. L. Farberow, (Ed.), The many faces of suicide: Indirect self-destructive behavior (pp. 15–27). New York: McGraw-Hill.
- Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C. (1990). Time-related predictors of suicide in major affective disorder. American Journal of Psychiatry, 147, 1189–1194.
- Fischer, E., Comstock, G., Monk, M., & Spencer, D. (1993). Characteristics of completed suicides: Implications of differences among methods. Suicide and Life-Threatening Behavior, 23, 91–100.
- Freeman, D. J., Wilson, K., Thigpen, J., & McGee, R. F. (1974). Assessing intention to die in self-injury behavior. In C. Neuringer, (Ed.), Psychological assessment of suicide risk (pp. 18–42). Springfield, IL: Charles C. Thomas.
- Garrison, C. Z., McKeown, R. E., Valois, R. F., et al. (1993). Aggression, substance abuse, and suicidal behaviors in high school students. American Journal of Public Health, 83, 179–184.
- Goldney, R. D. (1998). Variation in suicide rates: The “Tipping Point.” Crisis, 19, 136–138.
-
Goldston, D. B. (2003). Measuring suicidal behavior and risk in children and adolescents. Washington, DC: American Psychological Association.
10.1037/10609-000 Google Scholar
- Hammad, T. A., Laughren, T., & Racoosin, J. (2006). Suicidality in pediatric patients treated with antidepressant drugs. Archives of General Psychiatry, 63, 332–339.
- Hjelmeland, H., & Hawton, K. (2004). Intentional aspects of non-fatal suicidal behavior. In D. De Leo, U. Bille-Brahe, A. Kerkhof, & A. Schmidtke, (Eds.), Suicidal behavior: Theories and research findings (pp. 67–78). Cambridge, MA: Hogrefe & Huber.
- Hjelmeland, H., & Knizek, B. L. (1999). Conceptual confusion about intentions and motives of nonfatal suicidal behavior: A discussion of terms employed in the literature of suicidology. Archives of Suicide Research, 5, 275–281.
-
Jenkins, R., &
Singh, B. (2000). General population strategies of suicide prevention. In K. Hawton &
K. van Heeringen, (Eds.), The international handbook of suicide and attempted suicide (pp. 597–615). Chichester, England: John Wiley.
10.1002/9780470698976.ch34 Google Scholar
- Jobes, D. A., Berman, A. L., & Josselson, A. R. (1987). Improving the validity and reliability of medical-legal certifications of suicide. Suicide and Life-Threatening Behavior, 17, 310–325.
- Jobes, D. A., Casey, J. O., Berman, A. L., & Wright, D. G. (1991). Empirical criteria for the determination of suicide. Journal of Forensic Sciences, 36, 244–256.
- Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. Archives of General Psychiatry, 56, 617–626.
- Kessler, R., Berglund, P., Borges, G., Nock, M., & Wang, P. S. (2005). Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990–1992 to 2001–2003. Journal of the American Medical Association, 293, 2487–2495.
- Kidd, S. A. (2003). The need for improved operational definition of suicide attempts: Illustrations from the case of street youth. Death Studies, 27, 449–455.
- Kjoller, M., Norlev, J., & Davidsen, M. (2004). Recall bias and suicidal behavior in a six year follow-up study. 10th European Symposium on Suicide and Suicdal Behaviour (p. 118). Copenhagen, Denmark: National Institute of Public Health.
- Kraemer, H. C., Kazdin, A. E., Offord, D. R., Kessler, R. C., Jensen, P. S., & Kupfer, D. J. (1997). Coming to terms with the terms of risk. Archives of General Psychiatry, 54, 337–343.
- Kreitman, N. (1977). Parasuicide. London: John Wiley.
- Leenaars, A. A., DeLeo, D., Diekstra, R.F.W., Goldney, R. D., Kelleher, M. J., Lester, D., et al (1997). Consultations for research in suicidology. Archives of Suicide Research, 3, 139–151.
- Lester, D. (1990). A classification of acts of attempted suicide. Perceptual and Motor Skills, 70, 1245–1246.
-
Linehan, M. M. (1997). Behavioral treatments of suicidal behaviors. Definitional obfuscation and treatment outcomes. In D. Stoff &
J. J. Mann, (Eds.), The neurobiology of suicide: From the bench to the clinic (pp. 302–328). New York: Annals of the New York Academy of Sciences.
10.1111/j.1749-6632.1997.tb52367.x Google Scholar
- Linehan, M. M. (2000). Behavioral treatments of suicidal behavior: Definitional obfuscation and treatment outcomes. In R. W. Maris, S. S. Canetto, J. L. McIntosh, & M. M. Silverman, (Eds.), Review of suicidology 2000 (pp. 84–111). New York: Guilford.
- Mann, J. J., Waternaux, C., Haas, G. L., & Malone, K. M. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156, 181–189.
- Maris, R. W. (1992). Overview of the study of suicide assessment and prediction. In R. W. Maris, A. L. Berman, J. T. Maltsberger, R. Yufit, (Eds.), Assessment and prediction of suicide (pp. 3–22). New York: Guilford.
- Maris, R. W., Berman, A. L., & Silverman, M. M. (2000). The theoretical component in suicidology. In R. W. Maris, A. L. Berman, & M. M. Silverman, Comprehensive textbook of suicidology (pp. 26–61). New York: Guilford.
- Marusic, A. (2004). Toward a new definition of suicidality? Are we prone to Fregoli's illusion? Crisis, 25, 145–146.
- Mayo, D. J. (1992). What is being predicted? The definition of “suicide.” In R. W. Maris, A. L. Berman, J. T. Maltsberger, & R. I. Yufit, (Eds.), Assessment and prediction of suicide (pp. 88–101). New York: Guilford.
- McIntosh, J. L. (1985). Research on suicidology: A bibliography. Westport, CT: Greenwood Press.
- McIntosh, J. L. (1992). Methods of suicide. In R. W. Maris, A. L. Berman, J. T. Maltsberger, & R. I. Yufit, (Eds.), Assessment and prediction of suicide (pp. 381–417). New York: Guilford Press.
- McKeown, R., Garrison, C. Z., Cuffe, S. P., Waller, J. L., Jackson, K. L., & Addy, C. L. (1998). Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 612–619.
- Meehan, P. J., Lamb, J. A., Saltzman, L. E., & O'Carroll, P. W. (1992). Attempted suicide among young adults: Progress toward a meaningful estimate of prevalence. American Journal of Psychiatry, 149, 41–44.
- Moller, J. (1997). Suicide and self harm: What do we mean and what do we measure? Paper presented at the International Association for Suicide Prevention Conference, Adelaide, Australia, 1997.
- Moscicki, E. K. (1989). Epidemiological surveys as tools for studying suicidal behavior: A review. Suicide and Life-Threatening Behavior, 19, 131–146.
- Moscicki, E. K. (1995). Epidemiology of suicidal behavior. Suicide and Life-Threatening Behavior, 25, 22–35.
- O'Carroll, P. W. (1989). A consideration of the validity and reliability of suicide mortality data. Suicide and Life-Threatening Behavior, 19, 1–16.
- O'Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26, 237–252.
- O'Carroll, P. W., Berman, A. L., Maris, R., Moscicki, E., Tanney, B., & Silverman, M. M. (1997). Beyond the Tower of Babel: A nomenclature for suicidology. In R. J. Kosky, H. S. Eshkevari, R. D. Goldney, & R. Hazzan, (Eds.), Suicide prevention: The global context (pp. 23–39). New York: Plenum Press.
- Orbach, I. (1997). A taxonomy of factors related to suicidal behavior. Clinical Psychology: Science and Practice, 4, 208–224.
- Phillips, D. P., & Ruth, T. E. (1993). Adequacy of official suicide statistics for scientific research and public policy. Suicide and Life-Threatening Behavior, 23, 307–319.
- Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21, 25–58.
- Rosenbaum, J. E. (2006). Reborn a virgin: Adolescents' retracting of virginity pledges and sexual histories. American Journal of Public Health, 96, 1098–1103.
- Rosenberg, M. L., Davidson, L. E., Smith, J. C., Berman, A. L., Buzbee, H., Gantner, G., et al (1988). Operational criteria for the determination of suicide. Journal of Forensic Sciences, 32, 1445–1455.
- Rudd, M. D. (1997). “What is in a Name …” Suicide and Life-Threatening Behavior, 27, 326–327.
- Rudd, M. D. (2000). Integrating science into the practice of clinical suicidology: A review of the psychotherapy literature and a research agenda for the future. In R. W. Maris, S. S. Canetto, J. L. McIntosh, & M. M. Silverman, (Eds.), Review of suicidology 2000 (pp. 49–83). New York: Guilford.
- Rudd, M. D. (2006a). Suicidality in clinical practice: Anxieties and answers. Journal of Clinical Psychology: In Session, 62, 157–159.
- Rudd, M. D. (2006b). The assessment and management of suicidology. Sarasota, FL: Professional Resource Press.
- Rudd, M. D., & Joiner, T. E., Jr. (1998). The assessment, management and treatment of suicidality: Towards clinically informed and balanced standards of care. Clinical Psychology: Science and Practice, 5, 135–150.
- Rudd, M. D., Joiner, T. E., Jr., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30, 437–446.
- Rudd, M. D., Joiner, T. E., & Rajab, M. H. (1999). Treating suicidal behavior: An effective time-limited approach. New York: Guilford.
- Santa Mina, E. E., & Gallop, R. M. (1998). Childhood sexual and physical abuse and adult self-harm and suicidal behavior: A literature review. Canadian Journal of Psychiatry, 43, 793–800.
- Shea, S. C. (1999). The practical art of suicide assessment: A guide for mental health professionals and substance abuse counselors. New York: Wiley.
- Shneidman, E. (1968). Classificationn of suicidal phenomena. Bulletin of Suicidology, 2, 1–9.
- Shneidman, E. (1985). Definition of suicide. Northvale, NJ: Jason Aronson.
- Silverman, M. M. (2006). The language of suicidology. Suicide and Life-Threatening Behavior, 36, 519–532.
- Silverman, M. M., Berman, A. L., Sanddal, N. D., O'Carroll, P. W., & Joiner, T. E., Jr. (this issue). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part II: Suicide-related ideations, communications, and behaviors. Suicide and Life-Threatening Behavior, 37.
- Silverman, M. M., & Maris, R. W. (1995). The prevention of suicidal behaviors: An overview. Suicide and Life-Threatening Behavior, 25, 10–21.
- Silverman, M. M., & Simon, T. (Eds.). (2001). The Houston case-control study of nearly lethal suicide attempts. Suicide and Life-Threatening Behavior, 31(Suppl.), 1–84.
- Simon, R. I. (2006). Imminent suicide: The illusion of short-term prediction. Suicide and Life-Threatening Behavior, 36, 296–301.
- Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M-J, & O'Carroll, P. W. (2001). Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior, 31(Suppl.), 49–59.
- Smith, K., Conroy, R. W., & Ehler, B. D. (1984). Lethality of suicide attempt rating scale. Suicide and Life-Threatening Behavior, 14, 215–243.
- Sommer-Rotenberg, D. (1998). Suicide and language. Canadian Medical Association Journal, 159, 239–240.
- U.S. Department of Health and Human Services. (2006). Research on the reduction and prevention of suicidality (R01). Retrieved May 20, 2006, from http://grants.nih.gov/grants/guide/pafiles/PA-06-438.html.
- U.S. Department of Health and Human Services, Public Health Service. (2001). National strategy for suicide prevention: Goals and objectives for action. Rockville, MD: Author.
- Wagner, B. M., Wong, S. A., & Jobes, D. A. (2002). Mental health professionals' determinations of adolescent suicide attempts. Suicide and Life-Threatening Behavior, 32, 284–300.
- Westefeld, J. S., Range, L., Rogers, J. R., Maples, M. R., Bromley, J. L., & Alcorn, J. (2000). Suicide: An overview. The Counseling Psychologist, 28, 445–510.
- World Health Organization. (1968): Prevention of suicide (Public Health Paper No. 35). Geneva: Author.
- World Health Organization. (1986). Summary report: Working group on preventive practices in suicide and attempted suicide. Copenhagen: WHO Regional Office for Europe.
