Toward a New Definition of Suicidality? Are We Prone to Fregoli's Illusion?

Abstract

Subjects with Fregoli’s illusion recognize a number of different people as differing in appearance, but they have the delusional belief that all of them are in fact the same familiar person (Sims, 1995). Do we suicidologists tend to behave as if we were experiencing this illusion when recognizing a number of our patients or clients, usually differing in cognitive and behavioral aspects of suicidality, as the same familiar person? Do we have a tendency to investigate, manage, or treat them as if they were in fact a single suicidal case? Are we consistent enough in defining suicidality in our cases? Is there sufficient external validity present in our definitions of suicidality? Can one’s definition of suicidality be sent as a letter across the Pacific and be really understood as written when mailed or does the message in the bottle somehow get lost? In their famous paper, O’Carroll et al. (1996) stated: “Suicidology finds itself confused and stagnated for lack of a standard nomenclature.” Their paper proposed a nomenclature for suicide-related behavior in the hope of improving communications, advancing suicidological research, and improving the efficacy of clinical interventions. Of course, they were not the first. Nor were Beck et al. (1974) the first ones to develop a classification scheme for suicidal behavior differentiating between the suicidal idea, the suicide attempt, and the completed suicide. Interestingly, each of the three types was further specified by certainty of the rater, lethality, intent to die, mitigating circumstances, and method used. Unfortunately, neither these nor any other classification efforts have been widely adopted. Why? Is Fregoli that resistant? In the mid-1980s, the Centers for Disease Control (CDC) published the Operational Criteria for the Determination of Suicide – OCDC (Rosenberg et al., 1988). Suicide was defined in terms of three components: death as the results of injury (yes), self-inflicted (yes), and intentionally inflicted (by self), which were seen as essential elements distinguishing suicide from death due to natural causes (no; no; not applicable), accidental death (yes; no; not applicable), and homicide (yes; yes; by others). Interestingly, this was not to constitute a classification scheme; rather, they established a clear definition of the evidential component elements that are necessary for a certification of suicide, thus guiding coroners as to the kind of death-scene evidence to be sought and considered in cases of possible suicide. The OCDC undoubtedly represents a good basis for a nomenclature. However, in the same way as various suicidality states are not attributable to one single cause, they are similarly not presenting themselves in a single way. Presentations of suicidality are traditionally divided into various forms of suicidal ideation (from passive ideation to active suicidal thoughts with plans and clear intent or even threat), various forms of suicidal behavior (from parasuicides and deliberate self-harm to suicidal attempts with corresponding suicidal intent), and the completed suicide. Classical definitions have defined suicide as a deliberate act of selfdestruction resulting in death; as a conscious self-directed act intended to lead to death; or a willful self-inflicted lifethreatening act resulting in death (Retterstol, 1993). In other words, classical definitions tend to stress intent of selfdestructiveness, an act that is self-directed and life-threatening, and that will be fatal. Similar to the OCDC, the above three components can be proposed as essential elements distinguishing completed suicide from other suiciderelated behaviors (not necessary fatal) and non-suicide related deaths, too: 1. intention (yes; no) and 2. act of self-destruction (yes; no) 3. death (yes; no).