A Detailed Overview of Suicide
Every year, more than one million people in the world lose their lives due to suicide, which ranks tenth among all causes of death. In addition, nearly 20 million suicide attempts occur every year. Suicide is an act of aggression and destruction directed against the self and is the voluntary ending of an individual’s life. In other words, the person who decides to end his/her life chooses the most effective method and kills himself/herself in a way that does not allow anyone to intervene. If he/she is still alive, this is a suicide attempt. It is also defined as a desperate escape from one’s problems. According to our laws, every suicide is a forensic case and needs to be examined thoroughly both medically and legally.
In contrast to the word “suicide” used in Western languages, the word “suicide” started to be used instead of “self-murder” in the works translated into Turkish with the Tanzimat, and it is a word of Arabic origin. The word suicide is defined as “killing oneself” in the dictionary. According to Ziyalar, suicide is a state of violent aggression directed against oneself. According to Herpertz, the most important factor leading to suicidal behavior is the desire to get rid of intolerable tension. The factor that creates this tension is the person’s aggression towards others. When a person identifies with one of these people, he/she directs his/her feelings of aggression against himself/herself. According to Arkun, suicidal ideation, attempt, and action are seen as contrary to the “life instinct” that exists in all living beings and suicide is when a person who decides to end his/her life chooses the most effective method and kills himself/herself in a way that does not allow anyone to intervene. If he or she is still alive, this is a suicide attempt. Freud also defines suicide as aggression directed against oneself. Freud explains this definition with the death instinct. According to Freud, suicide is the activation of the death instinct and turning it on oneself. Yörükoğlu defines suicide as “a desperate escape from the problems of a desperate person”. He explains this definition as follows. These problems may originate from the person himself/herself or his/her environment. As a result, the person falls into despair, helplessness, and pessimism because his/her hands are tied in the face of events, and it is seen that he/she lacks the power to evaluate the course of events. He/she feels oppressed and cornered and directs his/her anger towards himself/herself because he/she cannot vent it outward. Attempting suicide is an act of both self-punishment and revenge against those who caused him/her to be in this situation. The World Health Organization divides suicide into two categories: “completed suicides and suicide attempts”. Completed suicides result in death. Suicide attempts, on the other hand, are all voluntary, non-fatal attempts to commit suicide with the aim of self-destruction and harm. The International Institute of Mental Health classifies suicide under three headings: Completed suicide: The individual seeks death under the influence of aggressive instincts. This type of suicide has more of a masochistic aspect. Suicide results in death. Suicide attempt: Suicide attempts, which are life-threatening and involve any action directed at the individual, do not result in death. Suicidal ideation: It gives clues that the individual will make various attempts to end his/her life. According to Odağ, the dynamic approach to suicidal behavior, whether it results in death or not, shows the difficulty of distinguishing between suicide and suicide attempt. By suicide attempt, it is meant that the outcome is not death. However, the outcome alone is insufficient to distinguish between these two concepts and may lead to arbitrary determinations. This distinction may also have drawbacks in terms of treatment. In suicide attempts, the fact that the person is not as close to death as in suicide may prevent the attempt from being given the necessary importance. However, considering that 25% of suicide attempts are repeated and 30% of these repetitions result in death, the drawbacks of this distinction in treatment can be seen. Although there are some differences in the definitions of suicide, almost all of them refer to “aggression directed against oneself”. The complexity of the suicide phenomenon and the presence of multiple factors prevent a general definition valid for all suicides. According to current medical opinion, suicide is a symptom, not a disease, and like other symptoms, it can occur in different diseases. Suicide seems to be related to unmet needs, feelings of hopelessness and helplessness, conflict or ambiance between life and unbearable stress, the perception that one’s means of escape are exhausted, and the desire to escape.
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History of suicide
The attitudes of societies towards certain events and phenomena have changed throughout history. The approach of many societies to suicide bears traces of primitive fear behaviors. These fears are exacerbated by the lack of understanding and knowledge of the act and the helplessness it causes.
Suicide in Ancient Greece
In contrast to Plato and Aristotle, who condemned suicide, the followers of the Stoic School taught that suicide was not only permissible but also a virtuous act. The provision in the Attic Laws that a person who wishes to end his life must notify the state in advance for permission, stating his reasons, shows that the State controlled suicide rather than prohibiting it. In any case, suicide was not criminalized in Greece.
Suicide in Rome
One of the characteristics of Roman society was that it was composed of various classes. Each class was bound by its laws. For this reason, the legislation applied to free people, slaves and soldiers differed from each other in terms of suicide. Suicide of free people In the early period of the Roman Empire, which was characterized by wars, suicide was very rare. Since human life was very precious in a society oriented towards conquest and strong family ties, it was unthinkable for people to end their lives unnecessarily and in the face of a momentary difficulty. Therefore, those who attempted suicide were severely punished. During the decline of the Romans, towards the end of the Republic (509–27 BC), there was an increase in suicides. Having learned the maxims of the Stoics and Greek philosophy, the Romans accepted suicide as a pleasant way of ending life. The philosophers considered suicide a sign of courage and wisdom. Indeed, all Stoics, including Cicero, perceived ending one’s life by one’s hand as the act of a virtuous person.
Suicide of slaves
As in all ancient societies, slaves in Rome were deprived of all rights. Slaves were treated as property like movable and immovable property in terms of Roman Law. It is seen that the number of slaves who committed suicide was high among the slaves who were uneasy with the hard work and the behavior of their masters. A slave who attempted suicide was regarded as an immoral person.
Suicide of soldiers
While the suicide of a free person due to suffering or boredom with life was tolerated, the suicide of a soldier was punishable in any case. A soldier who ends his life out of fear or laziness has his will annulled and is considered a dishonorable person. Since the soldier, who had the duty to protect his country, was obliged to serve his state in this capacity, suicide was considered to be a desertion. According to the Christian understanding of suicide in ancient European law and church law, a person does not have the right to take any action on his/her life that does not belong to him/her. It was thought that what God gave belonged to God. Suicide was considered one of the forbidden acts because of the view that “only God can end human life”. The prosecution of suicide, which was not tolerated and severely punished, decreased towards the end of the 18th century, especially under the influence of Beccaria, Montesquieu, and Voltaire.
Suicide and assisted suicide in Islamic law
Islamic Law, which prohibits killing, also prohibits suicide. While the muntaheer who dies cannot be punished, the person who wants to commit suicide is punished for attempting suicide if he does not die. Since suicide is forbidden, anyone who persuades or assists a person who commits suicide will also be punished.
Theories to explain suicide
One of the main characteristics of suicidology today is the ever-increasing collaboration and interaction between biomedical and social sciences in the research and prevention of suicidal behavior. One of the most important results of this interaction is the growing recognition that suicidal behavior is not the product of an individual or social pathology alone, but rather the result of a combination of biological, psychological, and social factors. In line with this view, suicide has become a biopsychosocial phenomenon and a focus of social interest that requires the participation of both individual human values and the whole of society, together with many professional groups. In contemporary societies, the factors leading to suicide are too strong to be eliminated or neutralized by preventive measures. Every suicidal behavior has psychological and sociological causes and social and individual impact factors:
1. Sociological theories
Sociologists have looked for the cause of suicide outside the individual, in society. Durkheim attributed suicidal behavior to social factors such as age, gender, upbringing, education, marital status beliefs and disbeliefs, religious beliefs and disbeliefs, urban life or social isolation, civil or military occupation, race and nationality, economic and political conditions and described three types of suicide: egoistic, altruistic and anomic: In particular, periods of economic or political depression lead to social turmoil and a weakening of social values. It is noteworthy that suicide graphs increase during these periods. Durkheim emphasizes that people should attach themselves to a cause or an ideal to withstand the difficulties of life and advises people to commit themselves to a social group such as religion, family, or nation and to give themselves to it. According to this theory, the rate of egoistic suicide is inversely proportional to the individual’s commitment to religion, family, state, and nation. The main reason for the increase in suicides is the changes in the structure of society. It does not matter whether these changes are beneficial or harmful to society. Changes upset a person’s living conditions and ethical values. The main reason for suicides is difficulties in adapting to new situations. Schneidman and Farberovv see suicide as a social event and classify suicides into 5 groups.
- Those who accept suicide as a transition to a better condition than the one they are still living in. These people think that they are in unbearable torment, that their distress is intolerable, and that death is a salvation for them.
- Those who believe that death will bring them honor and a good rank in the afterlife,
- Those who wish to leave those whom their deaths will cause to mourn and grieve with a constant sense of distress and guilt, or who believe that by doing so they will win the love and sympathy of those who have been denied it,
- The broken, the old, the hopeless. Those who have lost their place, position, honor, and dignity in society,
- People who commit suicide due to delusions and hallucinations caused by a mental illness.
2. Psychological theories
Dynamic theory
In 1918, Freud stated at the Symposium on Psychoanalysis in Vienna that suicide could not be explained. Freud called suicide “an unsolved problem from the point of view of science” and explained suicide as “the humiliation of the ego by the cruel or strict superego to the extent that it does not find the ego worthy of living, or the ego under the pressure of the superego destroys the superego, which is the representative of the parent who constantly hindered him by not meeting his needs in the past, in a sense, the ego’s revenge on the superego.
3. Behavioral theory
Those who try to explain suicidal behavior through the learning theory argue that suicidal behavior, like other behaviors, can be learned. The individual learns this behavior pattern as a suitable method for solving his/her problems. In such a model, the purpose of suicide, i.e. the goal to be achieved or thought to be achieved at the end of suicidal behavior, is necessarily seen as the person who commits suicide giving a lasting message by making a lasting impact on certain people or groups of people in the social environment in which he/she lives.
4. Existentialist theory
Yalom examines the issue of suicide by examining the relationship between life and death. He believes that feeling that life is meaningless and not taking responsibility for creating one’s meaning is one of the most important causes of neurosis and perhaps eventually suicide.
5. Biological (Genetic) theories
Biochemical research on suicide has begun to examine the concentrations of biological amines and their metabolites in the brains of those who have died by suicide, but these studies have not yielded conclusive results. Risk factors for suicide While risk factors for suicide may be useful in identifying high-risk groups, such criteria are of limited value when individual risk is estimated. For example, while age and gender are useful in determining suicide risk for a group, they are of limited utility when it comes to the individual. On the other hand, not only the presence of risk factors but also the interaction between risk factors should always be taken into account. For example, while lack of social support is a serious risk factor for suicide in the absence of persecutory delusions, it is a weak risk factor in the presence of persecutory delusions. However, it should be kept in mind that multiple factors may be effective for suicidal behavior.
6. Mood disorders
Depression is the most common cause of psychiatric admissions and mood disorders were found in about half (30–65%) of the suicides in some studies. In a long follow-up study in patients with mood disorders, it was found that 15% of these patients ended their lives by suicide, which is 30 times higher than in the general population, and that the risk of suicide is relatively highest in the early stages of the disease and, as expected, during depressive episodes rather than during remission. Studies show that affective disorders, substance abuse, and co-occurring illnesses are the most common conditions for completed suicide in all age groups.
7. Alcohol substance abuse
Alcohol dependence is a disease that carries a high risk for suicidal behavior. Alcohol predisposes to suicidal behavior by disrupting social support and interpersonal relationships on the one hand, and through its negative effects on cognitive functions and mood on the other. It has been found that the lifetime suicide attempt rate in alcohol dependence varies between 11 and 15% on average, and the suicide rate in alcoholics is 10 times higher than in non-alcoholics. In a study conducted between 1989 and 1992, it was found that younger suicides were more commonly associated with substance abuse and psychotic disorders, whereas older suicides were more commonly associated with mood disorders, especially late-onset, single-episode major depression, and major depression was associated with alcoholism or substance abuse, patients were found to be more suicidal than nonalcoholic depressive patients, more likely to have a low sense of self-worth, higher impulsivity, impaired functioning, and more impairment in personal and social relationships.
8. Schizophrenia
Approximately 10–15% of schizophrenics end their lives by suicide. The male/female ratio of US schizophrenics has decreased to 2/1, which may be related to decreased suicide inhibition in female patients. Suicides in schizophrenics occur mostly in the early stages of the disease, unlike in other psychiatric diseases. In the majority of studies, it was found that schizophrenics who ended their lives by suicide had an illness history of fewer than ten years, 23.3% of suicides in schizophrenics occurred during inpatient hospitalization, 30% within the first month after leaving the hospital, and 50% within the first three months, 43% of suicides occurred during hospital treatment and the majority of these were committed by patients who were about to be discharged from the hospital or who left the hospital without permission. The risk is even higher in schizophrenic patients with hopelessness, suicidal ideation, fear of losing their mind, previous suicide attempts, chronic relapsing disease course, and non-compliance with treatment. Most suicides in schizophrenics occur in young unemployed men and in people who had a high level of functioning before they became ill. The presence of alcohol or substance abuse in these patients is another factor that increases the risk of suicide. The presence of persistent auditory hallucinations is another clinical factor that increases the risk of suicide in schizophrenics. Some studies show that psychotic symptoms are more intense in suicidal schizophrenics compared to control groups and that violent and high-risk-of-death methods such as firearms, jumping from heights, drowning in water, or entering a lion’s cage in a zoo are preferred.
9. Anxiety disorders
Among the causes of death of patients previously hospitalized with a diagnosis of anxiety disorders, suicide was found to be up to 20%. In a psychological autopsy study conducted in Finland on all suicide cases that occurred during one year, anxiety disorders were found in 11% of all suicide victims, and approximately one-third of them were diagnosed with panic disorder. The predominant view of the current research is that panic disorder does not seem to be lean enough to be considered an independent risk factor on its own, whereas anxiety disorders, including specific phobia, agoraphobia, posttraumatic stress disorder, generalized anxiety disorder, and obsessive-compulsive disorder, significantly increase the risk of suicide when comorbid with personality disorders, alcohol and substance abuse and especially mood disorders.
10. Personality disorders
It has been reported that personality disorders were found in approximately 55% of suicide attempts and 9% to 28% of suicides that resulted in death, and in the presence of depression accompanying borderline personality disorder, suicidal behavior was observed more than depression alone or another second axis disorder accompanied by depression.
11. Familial risk factors
The most common psychiatric disorders seen in the families of suicide victims are alcoholism and drug addiction. The presence of a family member who has attempted or committed suicide before is also one of the important facilitating factors. In one study, it was found that suicide was 7 times more common in such families.
12. Situational risk factors
The suicide of a family member, the suicide of a familiar person who can be a model, or even a suicide event in the media can be risk factors for susceptible individuals. Young people are more open and sensitive to such influences than adults. Detainees and prisoners are also at increased risk of suicide. In studies, it has been reported that suicide is more common, especially at the beginning of detention or before the trial, and that those who make successful suicide attempts are older than those who injure themselves. One of the strongest situational risk factors is the presence of a firearm in the home. The presence of one or more firearms at home increases the risk of suicide in both sexes and almost all age groups. Approximately 60% of all suicide deaths in the United States involve firearms. This is the most commonly chosen method for both men and women.
13. Biological factors
Various biochemical and neuroendocrine abnormalities have been reported in suicidal individuals. Cortisol hypersecretion may accompany depression and suicidal behavior. However, cortisol hypersecretion is not present in all suicidal individuals. The role of biogenic amines in the development of depression and suicidal behavior has been investigated. It has been shown that decreased serotonergic activity in depressed individuals is associated with an increased risk of suicide.
14. Methods are chosen for suicide
There are 160 types of suicide described in the literature. Among the different methods of suicide, those that are considered to be easy to apply, less painful, well-known, and sometimes fashionable are usually chosen. It may also be observed that more than one method is used. The choice of method is influenced by the person’s mental structure, gender, age, and social values. For example, harakiri is known to be a Japanese method. Among Buddhists, self-immolation is one of the preferred methods. After Goethe published “The Sorrows of Young Werther”, self-immolation with a bullet to the head became fashionable in Germany and France for a while. Looking at completed suicides in the U.S., it is seen that the most common method of suicide is firearms, followed by hanging, jumping from a height, carbon monoxide poisoning, and drug overdose. According to the statistics of the World Health Organization, hanging and shooting are more common in men. The rate of attempted suicide by taking sleeping pills is 90% in both men and women. It is thought that taking medication, especially sleeping pills, is preferred because of the belief that it will not be painful. The percentages of suicide methods in Turkey according to the data of the State Institute of Statistics (2000) are given in below.
Percentage distribution of suicide methods in Turkey:
Hanging 43.1%
Firearm 22.7%
Chemical substance 16.2%
Jumping from a height 10.9%
Using a sharp instrument 1.9%
Jumping into water 1.3%
Burning 1.2%
Other 2.7%.
From these data, it can be concluded that the most commonly chosen method in Turkey is hanging, with firearm and chemical substance use coming in second and third place. Suicide methods also vary according to gender and education level. As the level of education increases, the percentage of firearms and jumping from a height in suicides increases, while the percentage of hanging decreases. Nevertheless, the highest rate is observed in suicide by hanging in every education level group. Although there are differences in the prevalence of suicide methods according to age groups, and social and cultural conditions, it is seen that people choose the method that they can access the fastest.
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50. İntiharın kısa tarihçesinden sebep ve yöntemlerine genel bir bakış :Erkut Ragıp Bulut, Hüdaverdi Küçüker, Necati Serkut Bulut Adli Tıp (Dr. E. R. Bulut), Adli Tıp Kurumu Sakarya Şube Müdürlüğü, TR-54100 Sakarya, Adli Tıp Anabilim Dalı (Doç. Dr. H. Küçüker), Sakarya Üniversitesi Tıp Fakültesi TR-541040 Sakarya, Psikiyatri Anabilim Dalı (Dr. N. S. Bulut), Marmara Üniversitesi Tıp Fakültesi, TR-34722 İstanbul)
