Suicidality in a broad sense can be viewed as a self-deletion (apoptosis) of the organism due to a perception of suffering, being damaged, hopelessly/irreversibly so, and a burden to its extended kin. While there is an evolutionary rationale for such a mechanism and behavior to exist and persist in the population at large, in most cases an affective and cognitive distortion occurs, leading to psychotic thinking in the perisuicidal period- either manic/positive symptoms (delusions, paranoia), or depressed/negative symptoms (avolition, lack of interest in living). The former can be labeled as “hot” suicide (impulsive, externalizing), the later as “cold” suicide (planned, internalizing).
Particular, psychologically and culturally influenced, forms of suicidality are: 1. passive-aggressive suicide, when the act is meant to distress or induce guilt in somebody else, 2. copycat suicides, where precedents in the environment demystify and lower the fear of committing the act in people who were vacillating, and 3. atonement suicide, prompted by overwhelming guilt at something one has done and possible ostracism consequences. The passive-aggressive suicide is more towards the psychotic side of the spectrum, whereas the atonement suicide is more towards the evolutionarily normal side of the spectrum, with copycat suicides somewhere in between.
Identification of people at risk for hot or cold suicide due to psychiatric and medical illnesses, chronic and acute social stressors, and alcohol/drug use, can be enhanced by developing blood tests. More subtle factors such as existential crises and isolation, like for single cells, tip the balance to apoptosis. They should be probed for and included in any risk prediction score and algorithm.
Treatment should be individualized and multifaceted, based on reversing the panel of causes and risk factors each individual has. The opposites of the risk factors for suicide are protective factors for suicide, in a yin-yang fashion, and should be enhanced. For example, a strong sense of spirituality and social support may compensate for and overcome other risk factors. Medications like lithium and clozapine, that prevent cellular apoptosis by increasing BCL-2, have also been shown to prevent organismal apoptosis, i.e. suicide. Other anti-apoptotic and neurotrophic medications should be considered and studied for suicidality treatment, perhaps distinguishing between the two broad categories- hot and cold.
Alexander B. Niculescu, III, MD, PhD