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Risk Management - 10 Subtle Suicide Signs,
Triggers, & the Mixed State
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In the last section, we discussed three common manifestations of bipolar disorder that seem to appear only in children, not adults, with the disorder. These three manifestations were: separation anxiety; night terrors; and rage.
As you are aware, children as young as five have been known to attempt - or mimic attempting - suicide. Even without knowledge or images that show suicide, many bipolar child clients have been known to voice suicidal wishes and thoughts. These thoughts might also be generated by the vivid and violent night terrors discussed on section 2.
In this section, we will examine three key aspects of suicide in bipolar children and adolescents. These are the rate of suicide; warning signs; and suicide triggers.
3 Key Aspects of Suicide
♦ 1. Suicide Rate
The first aspect we will discuss is the rate of suicide. Currently, suicide is the third leading cause of death in adolescence and bipolar clients. Adolescent and bipolar clients are 15 percent more likely to attempt suicide. Seventy-five percent of those children who require hospitalization are suicidal while only 33 percent treated outside of the hospital are suicidal. Researchers are not sure if a hospitalized client is made suicidal by the actual hospitalization itself or if the percentage of those sent to hospitals are already suicidal before they arrive.
The most surprising characteristic of these rates is that many of the bipolar clients who attempt suicide often give off distinct warning signs before going through with it. Many parents and family members, however, are either not trained to recognize these signs or they are in denial about their child’s condition.
Jared, a 12 year old bipolar client of mine, stated, "I thought I was being so obvious before I tried to kill myself. I mean, my thoughts of suicide were so loud I thought the entire world could read me like a book. Everything in my crappy life pointed toward one solution: death. I even said stuff like, ‘I wish I were dead’ or ‘would you even care if I hanged myself?’ I was actually surprised that my mom was so shocked when she found me getting ready to hang myself." As you can see, had Jared’s mother taken his threats more seriously, she might have been able to prevent his attempt even earlier.
♦ 2. Warning Signs
Of course, not all bipolar child clients who want to attempt suicide are going to state their wishes so explicitly. Therefore, the second aspect of suicide that we will discuss is subtle warning signs. Obviously, a therapist can usually detect suicidal behaviors due to his or her experience treating it. However, inexperienced parents are unable to recognize blatant warning signs, let alone the more subtle ones.
10 Subtle Warning Signs
To help parents monitor their child’s suicidal behaviors, I give them a "Subtle Warning Sign List" which includes, but is not limited to, the following:
1. Depressed mood
2. History of a previous attempt
3. Increased social withdrawal
4. Loss of interest and pleasure in easily enjoyable activities
5.Changes in appearance—for instance, no longer caring about one’s hair or clothing
6. Preoccupation with themes of death—the client may begin to read books with themes of death and dying
7. Increased irritability and behavior problems
8. Giving away important possessions
9. Use of drugs and alcohol
10. Changes in sleep and/or appetite patterns
Obviously, there are many more that you may wish to add to this list. Many parents find it reassuring that they no longer have to constantly fear their child will try to kill themselves.
♦ 3. Triggers
In addition to the rate of suicide and warning signs, a third key aspect is triggers. Although many bipolar clients may exhibit several of the warning signs on the list, their risk for committing suicide may greatly increase after a series of events such as a breakup in a relationship or being bullied at school.
However, I have found that the most dangerous period for an early onset bipolar client is when he or she is in a mixed state. Of course, a mixed state occurs when a client experiences symptoms from both poles. He or she might feel extremely energetic, yet still maintain feelings of hopelessness and helplessness. I say this period is so dangerous because while the client may have suicidal thoughts during full-blown depression, he or she does not have the energy required to act.
However, during a mixed state, this energy is readily available and the client is in the mood for action based on feelings. These mixed states can occur naturally but may also be the result of antidepressant therapy in a bipolar client. Antidepressant medication may increase the frequency of cycling and thereby produce prolonged mixed states. To counteract this, it is important that the child is put on mood stabilizers as well as antidepressants to keep their energy balanced and in control.
Keeping Calm while Taking it Seriously
One married couple took their daughter’s suicidal thoughts seriously and took precautionary action. Gene, the father, stated, "First, we let the therapist and psychiatrist know. We also immediately danger-proofed the house: We got rid of plastic cleaner bags; we put scissors, knives, and razors as far out of reach as possible. We locked up every bottle of aspirin and all pills in a tackle box with a combination lock. Our daughter commented to us, even while having suicidal thoughts that "Now I feel safer.’"
As you can see, by keeping calm, but taking their daughter’s condition seriously, this couple was able to give their daughter the reassurance that she was safe. I also emphasize to the parents of bipolar children that talking to their son or daughter about suicidal thoughts will not "plant ideas" in their heads. As psychiatrist Rosalie Greenberg states, "To the contrary, asking a young person about self-destructive wishes can help make him or her feel more understood and less trapped. Ignoring suicidal thoughts or behavior is a way of making suicide more likely to happen."
In this section, we discussed three key aspects of suicide in bipolar children and adolescents: the rate of suicide; warning signs; and suicide triggers.
In the next section, we will examine three differences in ADHD and bipolar characteristics: rage, mood fluctuations, and other standard criteria. Also, we will examine the possibility of comorbidity and the danger of misdiagnosis.
What are three key aspects of suicide in bipolar children and adolescents?
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