Pathways to Suicide: An Integrative Approach
Van Heeringen K., Hawton K., Williams JMG.
© 2000 John Wiley & Sons, Ltd. All rights reserved. It may have become apparent from the chapters in Part I of this Handbook that suicidal behaviour is to be regarded as the consequence of a complex interaction between psychological, biological and social characteristics. Recent findings from research in apparently divergent areas such as ethology, psychology, biology and sociology tend to converge to such an extent that earlier questions, like whether suicidal behaviour is primarily a psychologically defined problem or mainly due to biological characteristics, no longer appear to be relevant. A central issue in the development of suicidal behaviour concerns the reciprocal effects of the individual and hidher environment upon each other. These include exposure to specific stressors, which may be in part under genetic control; a sensitivity to such environmental influences, which can be defined in perceptual or cognitive terms; and the behavioural reaction to them. Recent advances in our understanding of the functioning of the brain's prefontal cortex suggest an important role of the latter two phenomena. An important issue in the interpretation of the meaning of findings from the epidemiological, biological, psychological and social areas concerns the specificity of such findings, which influences their power in predicting suicidal behaviour to a great extent. The effect of identified risk factors on the occurrence should therefore be regarded as probabilistic rather than deterministic. Epidemiological research has shown that attempted suicide is the strongest clinical predictor of suicide and indicates that suicide is commonly preceded by a process that may start with fleeting suicidal thoughts, then evolve through more concrete plans and suicide attempts to completed suicide. The biological, psychological and psychopathological underpinnings of this process are in need of further study, but it has become clear that while in early phases of the process anger and anxiety may be predominant, later stages may be characterized by high levels of depression and especially hopelessness. Findings like these have important implications for our understanding of suicidal behaviour, and for its treatment and prevention. Based on our current knowledge we can thus build a model in which psychological, biological and social characteristics are grouped according to their effects on the development of hopelessness and suicidal behaviour, and according to their risk-increasing or protective properties. Elements of this model will be exemplified in Part II of this Handbook by means of an examination of specific populations and circumstances in which suicidal behaviour may occur. Implications for treatment and prevention will be addressed in Parts III and IV.