Indirect Self-destructive Behaviour Across the Lifespan

Historically, a number of terms have been used to differentiate indirect self-destructive behaviours (ISDBs) from overt acts of suicide such as partial, focal and chronic suicide, sub-intentional death, deliberate self-harm and silent suicide. Each of these terms encompasses a wide range of behaviours such as: refusing to drink or eat, medication mismanagement, self-mutilation, self-neglect, and medical noncompliance. These behaviours all describe deleterious, life-threatening actions that ultimately undermine the health of the individual and lead to premature death. ISDBs are life threatening and commonly occurring, but poorly understood, behaviours that can mask suicidal intent. While many psychological, behavioural, and biological risk factors for completed suicide have been identified, the etiology, role, and clinical correlates of ISDBs have not been satisfactorily examined. In an attempt to reach common ground in describing subtypes of indirect self-destructive behaviour, the National Institute of Mental Health Mental (NIMH) convened 22 experts who defined an ISDB as “…an act of omission or commission that causes self-harm leading indirectly, over time, to the patient’s death”. Reports issued by the Institute of Medicine and by the NIMH of the Aging Research Branch noted that ISDBs are of major concern because they are highly prevalent and result in greater morbidity and mortality than more easily recognized overt suicidal behaviours. These reports recommended that a standardized method to ascertain the extent and nature of ISDBs be developed to examine the etiology and clinical correlates of these behaviours. This chapter reviews the existing literature on ISDBs and offers research, clinical, and policy recommendations.