It takes two years to get healthy, proposes the American Psychiatric Association in its newly published revised text of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This is the time it takes to shed the diagnosis of the re-defined ‘suicidal behaviour disorder’, which the text pushes forward towards recognition as a fully-fledged illness. I would like to comment on the text of the DSM, and also on the idea itself. Some might find this blog controversial and difficult.

Here is the first of the proposed criteria:

1. Within the last 24 months, the individual has made a suicide attempt.

Note: A suicide attempt is a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death. (The “time of initiation” is the time when a behavior took place that involved applying the method.)

The criteria start in an interesting way, explicitly focusing on the individual. The sentence is in active voice, underscoring the action taken by the individual. The verb ‘make’ (for linguists: referring to the Hallidayan material process) constructs the individual as an agent (a doer) in the action undertaken. I think this is a welcome phrasing, as suicides don’t just happen. Unfortunately, this doesn’t stop the APA from using the phrase ‘die by suicide’ in other parts of the book, which does precisely the opposite.

Also the focus on the individual rather than on ‘the act’ is welcome, it is a minute sign that psychiatry wants to focus on the person and not on things.

It gets even more interesting when the APA describes the suicide attempt as ‘is a self-initiated sequence of behaviors’. I think it is high time that psychiatry started understanding that a suicide attempt doesn’t just happen, it is a process, over time (Justyna Ziółkowska and I wrote an entire book about it).  People don’t just drop off, it takes time.

It is perhaps worth noting that the ICD11 still has the suicide attempt as a single point in time, as if it just happens

MB23.R. A specific episode of self-harming behaviour undertaken with the conscious intention of ending one’s life.

Alas, the initial focus on the active person quickly disappears. In its definition the DSM initially talks about behaviour. It is a strange choice, I would think, given that behaviour can be unconscious, and a suicide attempt is anything but unconscious, given that it is defined through expectation in the definition. You can’t expect unconsciously, can you? It gets even stranger when behaviours are replaced with actions, only to revert to behaviour again. That’s quite confusing, actually.

It seems that the authors of the DSM can’t make up their minds whether they want to talk about actions, with intent, or whether they want to make it way more ambiguous and talk about behaviour. Suicide or the suicide attempt are not behaviours, they are actions and it should be acknowledged in the text of the DSM.

What defines a suicide attempt is intent (indeed, the authors speak about intent later in the text). Yet, interestingly, the DSM renders it in terms of expectation. The individual expects their actions to result in death, says the DSM. But there is a difference between intent and expectation. It seems to me that intent refers to the pre-condition of the act, the entry condition, so to say, while expectation focuses more on the outcome. Expectation, it seems to me, is more than intent, it introduces premeditation and rationality. How this squares with ‘behaviour’, it’s anyone’s guess.

Problems continue when we go further. The criteria stipulate:

The diagnosis is not applied to suicidal ideation or to preparatory acts.

Suicide ideation seems quite easy – thinking of suicide does not constitute a suicide attempt. But preparations are considerably more difficult. I really would like to know what constitutes preparation. If a person makes a noose, literally seconds between hanging themselves, that’s still preparation? If they put a noose on their neck, is it still preparation or is it already initiation of the ‘behaviour’? Do you have to jump off the stool to stop the preparation?

Things get more complicated when you read on. The authors say:

Suicide attempts can include behaviors in which, after initiating the suicide attempt, the individual changed his or her mind or someone intervened.

So, you can stop or change your mind (suicide ideation seems quite relevant here). Again though, is putting the noose on the neck enough? There is so much ambiguity here and I find quite unhelpful. But the authors offer an example of starting to take pills with the intent to kill yourself and stopping, say, halfway through, but stopping you just before you start wouldn’t count as a suicide attempt. Again, potentially, we are talking seconds here. Preparing a rope and standing on a stool is not yet enough, I think. And I must admit that I find this quite bizarre.

On a more general note. Suicidology is largely uninterested in the process. Ziółkowska and I were the first to ask what a person killing themselves does an hour before their death, or a few hours, or 10 minutes before. Suicide notes, which we used in order to answer some of the questions (we also used interviews with people who attempted to kill themselves), suggest that the time in which you take your life can be long and is certainly not emptiness. Sometimes much is happening. The question when suicide starts is exceedingly significant, and far from obvious. Indeed, the text of the DSM would confirm this.

So, what does the DSM tell us? Well, it tells us that the APA still hasn’t decided what they are talking about. The criteria are confusing and subject to much interpretation. Not only is there no clarity, but the criteria and the text that follows are inconsistent. Things are way too complex for the DSM.

But before I finish, I would like to offer a more general, social comment on the idea of medicalising ‘suicidal behaviour’. In a nutshell, I find it extraordinarily problematic, counteruseful, potentially leading to more concealment and secrecy. It’s probably not as bad as making suicide illegal (have the APA noticed that in Cyprus, where suicide continues to be illegal, suicide statistics are very very low?), but not far. People will hide suicide even more, think.

There are several reasons why the decision to medicalise is so bad. First, I find it extraordinary that one event (which in itself is subject to interpretation, which I will come to below) sets off an ‘entire’ illness. One event, nothing else, and you are ill. Moreover, it’s, I think, the only illness (disorder) which is has a time limit. If you behave well for two years, you will no longer be ill.

It looks like sentencing, doesn’t? And if you ask why two years. I doubt there is a sensible answer, the text of the DSM doesn’t provide one.

The second problem is interpretation. Difficulties in differentiating between a suicide attempt and self-injury are well-known and there is much literature on this. Will the introduction of a new disorder encourage change in interpretation trends? Moreover, several Golden-Gate studies describe situations in which people change their minds after initiating the ‘behaviour’. In other words, some people who did jump off the bridge regretted it immediately. Were such cases instances of suicide attempts? It seems that the DSM authors would say yes, I am not so sure at all.

And finally, the third issue – rational suicide. There is enough literature to suggest that suicide is not only an act commonly described in suicidology as resulting from ‘unbearable pain’. People kill themselves for a variety of reasons, and some of them can be thought of as rational. Are those people also ill with the suicidal behaviour disorder? Re-casting every suicide attempt as mental illness is not only at odds with reality, but, I think, it might have significant consequences for how suicide and people killing themselves are perceived.

One obvious issue is that of assisted suicide. If suicide is illness, how can we possibly even talk about assisted suicide? Regardless of what one might think about assisted suicide, it should be discussed without prejudging it as problematic, wrong, or indeed related to illness. And yet, this is precisely what the DSM does.

Suicide is a rare and extremely complex set of actions which so far has escaped clear and obvious descriptions, let alone prediction. As we can’t speak to those who did commit suicide, our insight into their actions is limited. And so, we make many assumptions about the reasons, the state of mind, emotions, suicidology is full of such assumptions. For example, when a famous British suicidologist speaks on TV about this ‘tunnel vision’ in people about to kill themselves, how exactly does he know what happens to those who killed themselves? He actually doesn’t, he only assumes, probably on the basis of accounts of those who didn’t kill themselves.

In my view, the assumptions simplify things for the most part, but people making them, for the most part, understand the limitations of their knowledge, attempting to offer some nuance to research.

The DSM-5-TR proposal treats the nuance with an axe. By medicalisation of suicide, the APA has gone out of its way to ignore the individual in their complex social, personal, psychological contexts. Badly done, indeed!