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SUICIDALITY CLASSIFICATION PROJECT. Kelly Posner, Ph.D. Maria A. Oquendo, M.D. The Problem : Limitations in Suicide Assessment and Nomenclature. Lack of agreement on common terminology In clinical descriptions of suicidal acts

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suicidality classification project


Kelly Posner, Ph.D.

Maria A. Oquendo, M.D.

the problem limitations in suicide assessment and nomenclature
The Problem : Limitations in Suicide Assessment and Nomenclature
  • Lack of agreement on common terminology
    • In clinical descriptions of suicidal acts
    • In research descriptions of suicidal acts (even among experts in suicidal behavior)
  • Importance of reliability (all define/assess the same way) and validity (some truth to dfn)
suicide attempt
Suicide Attempt
  • A self-injurious act committed with at least some intent to die.
  • Intent does not have to be explicit. Eg: patient denies intent to die, but thought that the behavior could be lethal. Intent can be inferred.
other classifications suicidal behavior w o injury
Other Classifications: Suicidal Behavior w/o Injury

Interrupted Attempt: individual is stopped by an outside circumstance from starting the self-injurious act

Aborted Attempt: individual takes steps towards making a suicide attempt, but stops himself before engaging in any potentially self-destructive behavior

suicidal intent
Suicidal Intent
  • Presence of intent to die differentiates suicidal acts from self-injury

-Determine whether self-injurious act was thought of as a means of causing or facilitating death

-Support for validity of using intent to define suicidality: Completed suicide predicted by previous intent measures (Beck et al, 1989)

examples of non suicidal self injury
Examples of Non-Suicidal Self-Injury
  • Teenage girl reported mother was being cruel and neglectful and she wanted to escape from mother’s home. States she researched lethal doses of ibuprofen to make sure she took an amount that would not be life-threatening. Took 6, feeling certain it was not enough to kill her, she definitely did not want to die, only to escape from mother’s home. Taken to ER and then admitted to psych. hospital
  • Person described 12 incidents of cutting himself. States he did this only “to relieve tension” and “to play with danger to see how far I would go” and no part of him wanted to die. Thought about it for hours before acting on the urge and felt relieved of tension afterwards. Did not feel pain while cutting self.
research support of classifications
Research Support of Classifications


  • excellent reliability (kappa= .97) utilizing classification system in NIMH- funded treatment, biological, and genetic trials
  • Multi-site reliability with other centers in family genetic studies and treatment of adolescent suicide attempters trial
validity of classifications
Validity of Classifications
  • Individuals classified as suicide attempters have as much as 2.5X risk of future attempts or completions (Dorpat, 1967, Nordstrom, 1995, Oquendo, in press)
  • Interrupted attempters are reported to be 3X more likely to commit suicide than uninterrupted attempters (Steer et al 1988)
  • Aborted attempters are at risk for eventual attempts and were more likely to have made an actual attempt in the past (Marzuk et al 1997)
classification methodology
Classification Methodology
  • Blinding of data by experienced child psychiatrist not on panel
  • Determination of event classification based on reliable and valid constructs
  • Training on classification system to establish reliability of panel members
  • Consensus discussion of non-concordant cases

Expert Panel

with 9 members

Review of cases

N = x

Subgroup Reviews

x/3 + 5 +5 cases

Subgroup Reviews

x/3 + 5 +5 cases


x/3 + 5 + 5 cases

(additional cases to

prevent stratification bias)

Generate Classified Cases



Non Suicidal


Suicidal Ideation

Unable to

Classify Due

To Limited Data







-other sxs

(eg. akathesia)



Suicidal Behavior without injury:

Aborted attempt

Interrupted attempt

future directions
Future Directions
  • Develop guidelines as to how to better capture data, enabling appropriate classification of suicidality:

Utilization of research assessment tools

(what questions to ask, how to ask, and what measures aid this)

Consistency of Nomenclature and Classification

Improved, More Valid Identification and

Documentation Of Suicidality

Also describes 12