The fear of dying during a panic attack is an independent risk factor for subsequent suicide attempts among individuals with depressive disorders, psychiatrists Zimri Yaseen, MD, Igor Galynker, MD, PhD, and colleagues conclude in their recently published prospective study.1 This finding, they assert, may help clinicians assess suicide risk and ultimately prevent suicides.
“Suicide is an epidemic. Rates are rising despite medications. And we are really pitiful at predicting suicide in a specific person,” said Galynker, Professor of Clinical Psychiatry at Albert Einstein College of Medicine in New York and Associate Chairman of Psychiatry at Beth Israel Medical Center.
According to the CDC’s latest published report, there were 38,364 suicides in the US in 2010—an average of 105 each day. Globally, an estimated 1 million suicides occur annually.
“We know a fair amount about who is more likely than average to commit suicide,” said Yaseen, who is with the Department of Psychiatry and Behavioral Sciences at Beth Israel Medical Center. “But we cannot predict the acute event. So we need to better understand the acute state that might trigger suicide. We think that in many cases the acute state might be a panic-like state.”
Even the most planned suicidal act is an urge and an effect of emotional action as opposed to a thought and rational action, Galynker said. When people feel like they are trapped and that no options exist, he said, they start panicking and as a result develop distorted cognitions and impaired judgment, which leads to the suicidal act.
Both ruminative flooding and frantic hopelessness are integral to the positive-feedback model of suicide described in the published article, said Galynker. Individuals are flooded with thoughts they cannot control, usually regarding some negative events in their life about which they feel guilty. The ruminative flooding is coupled with an acute frantic hopelessness, in which not only is there a fatalistic conviction that life cannot improve but also an oppressive sense of entrapment and imminent doom.
The article, Yaseen said, also included an expanded version of the positive-feedback model of suicide that explored an attachment-informed psychiatric understanding of the linkage between panic and depression. The expanded model proposes that panic and depression are connected by a negative view of the self; conditions of psychosocial stress elicit a separation distress response in the form of panic; and negative cognitions about the self result in simultaneous fear of and self-imposition of punishment, which feed the positive-feedback cycle of the panic attack.
Body of evidence
A large and growing body of evidence links panic and suicide. “Bolton2,3 and Sareen4 in Canada have done excellent epidemiological work on panic and other anxiety disorders in relation to the risk for suicide,” said Yaseen. “Separately, Hendin5 and Fawcett6 have done some great studies on the acute suicidal state. In Austria, Deisenhammer7 has been doing really meticulous work on suicide.”
The recent study authored by Yaseen, Galynker, and others builds on the authors’ retrospective study of panic attacks and panic symptoms as they related to lifetime suicidal ideation and attempts. Published in 2011, that study involved 2679 community-dwelling individuals who had experienced major depressive episodes and who were participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).8
The 2011 study found that past-year history of panic attacks was significantly associated with a lifetime history of suicidal ideation, suicide attempts, and suicide attempts among ideators, even after controlling for sociodemographic and comorbid clinical variables.
That study also found that catastrophic cognitions of panic (ie, fears of dying and of losing control or going insane) were more strongly associated with suicide attempt than were dissociation, choking sensations, and chest pain. Catastrophic cognitions may specifically distinguish ideators at higher risk for suicide attempt.
1. Yaseen ZS, Chartrand H, Mojtabai R, et al. Fear of dying in panic attacks predicts suicide attempt in comorbid depressive illness: prospective evidence from the National Epidemiological Survey on Alcohol and Related Conditions. Depress Anxiety. 2012 Dec 20; [Epub ahead of print].
2. Bolton JM, Pagura J, Enns MW, et al. A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder. J Psychiatr Res. 2010;44:817-826.
3. Bolton JM, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow-up study. Depress Anxiety. 2008;25:477-481.
4. Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 2005;62:1249-1257.
5. Hendin H, Al Jurdi RK, Houck PR, et al. Evidence for significant improvement in prediction of acute risk for suicidal behavior. J Nerv Ment Dis. 2010;198:604-605.
6. Fawcett J. Diagnosis, traits, states, and comorbidity in suicide. In: Dwivedi Y, ed. The Neurobiological Basis of Suicide. Boca Raton, FL: CRC Press; 2012:chap 1.
7. Deisenhammer EA, Ing CM, Strauss R, et al. The duration of the suicidal process: how much time is left for intervention between consideration and accomplishment of a suicide attempt? J Clin Psychiatry. 2009;70:19-24.
8. Katz C, Yaseen ZS, Mojtabai R, et al. Panic as an independent risk factor for suicide attempt in depressive illness: findings from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC). J Clin Psychiatry. 2011;72:1628-1635.
9. Matthews K, Milne S, Ashcroft GW. Role of doctors in the prevention of suicide: the final consultation. Br J Gen Pract. 1994;44:345-348.
10. Yaseen ZS, Gilmer E, Modi J, et al. Emergency room validation of the revised Suicide Trigger Scale (STS-3): a measure of a hypothesized suicide trigger state. PLoS One. 2012;7(9):e45157. http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0045157.