Chapter 1 - The Epidemiology of Suicide
CHAPTER 1 Page 9
THE EPIDEMIOLOGY OF SUICIDE
"The psychoanalytic theories of suicide prove,
perhaps, only what was already obvious: that
the processes which lead a man to take his own
life are at least as complex and difficult as
those by which he continues to live. The
theories help untangle the intricacy of motive
and define the deep ambiguity of the wish to
die but say little about what it means to be
suicidal, and how it feels. "
- A. Alvarez, The Savage God
Suicide is the eighth leading cause of death in the United
States.(1) Based on the assumption that suicide is not a rational
choice, society has long sought to prevent or discourage the
practice. In fact, society has generally regarded a suicide attempt
as a plea for help or an indication of a need for psychiatric
treatment. The debate about legalizing assisted suicide and
euthanasia has challenged these assumptions, suggesting that for at
least some individuals, society should shift from prevention to
toleration or assistance.
Central to the current discussion of assisted suicide and
euthanasia is a need to understand the nature of suicide, the
motivation of individuals who commit suicide, and the specific risk
factors. Suicide outside the context of terminal or chronic illness
has been the subject of extensive study by sociologists,
psychiatrists, and epidemiologists. Their findings shed light on
the phenomenon of suicide overall, and on the motivations of those
who request suicide when facing a terminal or severe illness.
According to available data, only a small percentage of terminally
ill or severely ill patients attempt or commit suicide. What
distinguishes their life circumstances, medical conditions, or
outlook from those who are also severely ill and do not attempt
suicide? What do they have in common with individuals who do not
face physical illness and attempt or commit suicide?
(1) G. Winokur and D. W. Black, "Suicide - What Can Be Done,"
New England Journal of Medicine 327 (1992): 490-91.
page 10 WHEN DEATH IS SOUGHT
Data about the desire for and incidence of suicide are not
available for all patient populations. However, important studies
have been conducted of acquired immunodeficiency syndrome (AIDS) and
cancer patients as well as the elderly.(2) In many respects, these
conditions epitomize for the public the circumstances under which
suicide might be considered a rational choice.
Suicide in the General Population
Overall, 2.9 percent of the adult population attempts
suicide,(3) and the suicide rate in the general population over a
lifetime of 70 years is approximately one percent.(4) Studies of
suicide attempters suggest that one percent to two percent complete
suicide within a year after the initial attempt, with another one
percent committing suicide in each following year.(5) Suicide is
especially prevalent among the young and the elderly. It is the
third leading cause of death for individuals 15 to 24 years of age.
Over the last 30 years, the suicide rate in this age group has
increased dramatically.(6) Among younger people who attempt suicide,
between 0.1 percent and 10 percent will eventually commit suicide.
Yet it is the elderly who have the highest rates of suicide --
overall suicide rates for individuals over 65 were approximately 22
per 100,000 in 1986.(7)
(2) See chapter 2 for a discussion of suicide and special patient
(3) D. C. Clark, "Rational Suicide and People with Terminal
Conditions or Disabilities," Issues in Law and Medicinc 8
(4) Depression Guideline Panel, Depression in Primary Care, vol.
1, Detection and Diagnosis, Clinical Practice Guideline, no. 5,
AHCPR pub. no. 93-0550 (Rockville, Md.: U. S. Department of Health
and Human Services, Public Health Sec, Agency for Health Care Policy
and Research, April 1993), 36.
(5) G. M. Asnis et al., "Suicidal Behaviors in Adult Psychiatric
Outpatients, I:Description and Prevalence," American Journal of
Psychiatry 150 (1993): 108-12.
(6) In 1950 the rate for adolescent suicides was 2.7 per 100,000;
in 1980 the rate increased to 8.5 per 100,000. C. Runyan and E. A.
Gerken, "Epidemiology and Prevention of Adolescent Injury:
A Review and Research Agenda," Journal of the American Medical
Association 262 (1989): 2273-79.
(7) P.J. Meehan, L.E. Saltzman, and R.W. Sattin, "Suicide
Among Older United States Residents: Epidemiologic
Characteristics and Trends," American Journal of Public
Health 81 (1991): 1198-1200.
CHAPTER 1 - THE EPIDEMIOLOGY OF SUICIDE page 11
Suicide is generally described as the intentional taking of
one's own life. For the individual who commits suicide, the act
usually represents a solution to a problem or life circumstance that
the individual fears will only become worse.(8) Believing that their
suffering will continue or intensify, suicidal individuals can
envision no option but death. As articulated by a prominent
suicidologist, the common stimulus to suicide is intolerable
psychological pain. Suicide represents an escape or release from
Contrary to popular opinion, suicide is not usually a reaction
to an acute problem or crisis in one's life or even to a terminal
illness. Single events do not cause someone to commit suicide.
Instead, certain personal characteristics are associated with a
higher risk of attempting or committing suicide. The way in which
an individual copes with problems over the course of his or her life
usually indicates whether the person is emotionally predisposed to
suicide. Studies that examine the psychological background of
individuals who kill themselves show that 95 percent have a
diagnosable mental disorder at the time of death. Depression,
accompanied by symptoms of hopelessness and helplessness, is the
most prevalent condition among individuals who commit suicide. This
is especially true of the elderly, who are more likely than the
young to commit suicide during an acute depressive episode.
In general, individuals who attempt suicide differ from those
who complete suicide. Suicide attempters are likely to be female
and generally attempt suicide by taking an overdose of medication.
Suicide completers, by contrast, are more often male and tend to use
more lethal means.(10) Approximately 40 percent of patients who
commit suicide have made previous suicide attempts. (11) Thoughts
about suicide, referred to as "suicidal ideation," are an important
risk factor for suicide. However, many individuals experience
suicidal ideation but never commit or attempt suicide. This is
especially true for patients with advanced terminal illness or
debilitating chronic illness.
(8) A. Alvarcz describes how it feels to be suicidal as
follows: The logic of suicide is different. It is like the
unanswerable logic of a nightmare, or like the science-fiction
fantasy of being projected suddenly into another dimension:
everything makes sense and follows its own strict rules; yet at
the same time, evething is also different, perverted, upside
down. Once a man decides to take his own life he enters a
shut-off, impregnable but wholly convincing world where every
detail fits and each incident reinforces his decision." A.
Alvarez, The Savage God: A Study of Suicide (New York: Random
(9) E. S. Shneidman, "Some Essentials for Suicide and Some
Implications for Response," in Suicide, ed. A. Roy (Baltimore:
Williams and Wilkins, 1986), 1-16.
(10) S. B. Sorenson, "Suicide Among the Elderly: Issues
Facing Public Health," American Journal of Public Health 81
(11) Asnis et al.
page 12 WHEN DEATH IS SOUGHT
The highest rates of suicide occur among patients with major
affect or mood disorders (including depression), alcoholics, and
schizophrenics. Individuals with clinical, or major, depression
have a 15 percent rate of suicide. Ten percent of schizophrenics
commit suicide, while alcoholism carries a four percent to six
percent risk.(12) The elderly are also at increased risk for suicide
and depression,(13)especially elderly white males, who have a
suicide rate five times that of the general population.(14)
Individuals who commit suicide generally have no history of
mental health treatment, although they often evidence a major
psychiatric illness at the time of death. The primary risk factors
for completed suicides are major depression, substance abuse, severe
personality disorders, male gender, older age, living alone,
physical illness, and previous suicide attempts. For terminally ill
patients with cancer and AIDS, several additional risk factors are
Another significant predictor of suicide is a feeling of
hopelessness or helplessness, a principal symptom of depression.
Hopelessness is the common factor that links depression and suicide
in the general population. In fact, hopelessness is a better
predictor of completed suicide than depression alone.(16) Feelings
of hopelessness and helplessness interact with the perception of
psychological pain and the individual's sense that his or her
current suffering is inescapable.
Individuals who are terminally ill constitute only a small
portion of the total number of suicides. In fact, most people who
kill themselves are in good physical health. Among all suicides,
only two percent to four percent are terminally ill.(17) One study
of adults over 50 years of age showed that more individuals
committed suicide in the mistaken belief that they were dying of
cancer than those who actually had a terminal illness and committed
(13) H. Hendin and G. Klerman, "Commentary: Physician-Assisted
Suicide: The Dangers of Legalization," American Journal
of Psychiatry 150 (1993): 143-45.
(14) Y. Conwell and E. D. Caine, "Rational Suicide and the
Right to Die: Reality and Myth," New England Journal of
Medicine 325 (1991): 1100-1103.
(15) See chapter 2 for discussion.
(16) W. Breitbart, "Suicide Risk and Pain in Cancer and
AIDS Patients," in Current and Emerging Issues in Cancer Pain:
Research and Practice, ed. C. R. Chapman and K. M. Foley
(New York: Raven Press, 1993), 49-65.
CHAPTER 1 - THE EPIDEMIOLOGY OF SUICIDE page 13
suicide. The study supports the estimate that two thirds of older
persons who die by suicide are in relatively good physical
Individuals with serious chronic and terminal illness face an
increased risk of suicide -- some studies suggest that the risk for
cancer patients is about twice that of the general population. Some
experts, however, have observed that many terminally ill patients
experience a phenomenon called "cancer cures psychoneuroses." This
phenomenon occurs when patients become aware that they have cancer
or another progressive terminal illness, and the process of facing
and mastering their fear of death dissolves many other anxieties or
neuroses. As explained by one psychiatrist, "As one's focus turns
from the trivial diversions of life, a fuller appreciation of the
elemental factors in existence may emerge."(19)
Thus, some terminally ill patients may exhibit lower
psychological stress than might be expected. Apart from
circumstances where patients are depressed, terminally ill
individuals are often resilient, and fight for life throughout their
illness. Studies indicate that for many patients with severe pain,
disfigurement, or disability, the vast majority do not desire
suicide. In one study of terminally ill patients, of those who
expressed a wish to die, all met diagnostic criteria for major
depression.(20) Like other suicidal individuals, patients who desire
suicide or an early death during a terminal illness are usually
suffering from a treatable mental illness, most commonly
Risk Factors for Suicide
Depression, including major depression and depressive
symptoms, is a critical risk factor for completed suicides.(22)
(19) F. P. McKegney and M. A. O'Dowd, "Clinical and
Research Reports: Suicidality and HIV Status,"American
Journal of Psychiatty 149 (1992): 396-98.
(20) J. H. Brown et al., "Is It Normal for Terminally Ill
Patients to Desire Death?" American Journal of Psychiatry 143
(22) As early as the 17th century, writers identified a
link between depression or melancholy and suicide. The Anatomy
of Melancholy, written in 1621 by Richard Burton, identified
melancholy as a medical and psychological phenomenon. The
author argued that suicide "is the result of melancholy that
desires self-destruction: 'In other diseases there is some hope
likely, but these unhappy men are born to misery, past all hope
of recovery, invariably sick, the longer they live the worse
they are, and death alone must ease them."' T. L. Beauchamp,
"Suicide in the Age of Reason," in Suicide and Euthanasia:
Historical and Contemporary Themes, ed. B. A. Brody (Dordrecht:
Kulwer Academic Publishers, 1999),172.
page 14 WHEN DEATH IS SOUGHT
Depression is present in 50 percent of all suicides, and those
suffering from depression are at 25 times greater risk for suicide
than the general population.(23) In addition, older persons with
depression are more likely to commit suicide than younger persons
who are depressed.(24)
The prevalence of major depressive disorder in western
industrialized nations is 2.3 percent to 3.2 percent for men and 4.5
percent to 9.3 percent for women. An individual's lifetime risk of
depression ranges from seven percent to 12 percent for men and 20
percent to 25 percent for women. Studies indicate that the risk of
depression is not related to race, education, or income.(25)
The general population. Depressive disorders should clearly
be distinguished from realistically depressed or sad moods that may
accompany specific losses or disappointments in life. Clinical
depression is a syndrome described as an abnormal reaction to life's
difficulties. In addition to sadness, clinical depression
encompasses a variety of symptoms: pervasive despair or
irritability, hopelessness, loss of interest in activities that are
usually considered enjoyable, trouble sleeping or excessive
sleeping, appetite loss or weight change, fatigue, and preoccupation
with death or suicide.
The Diagnostic and Statistical Manual of Mental Disorders,
third edition, revised (DSM-III-R), published in 1987 by the
American Psychiatric Association, lists criteria for major
depression.(26) At least five of the following symptoms must be
present during the same period, one of which must be depressed mood
or loss of interest or pleasure, to satisfy these criteria for
depression. Symptoms must be evident most of the day, on a daily
basis for at least two weeks:
1. depressed mood
2. markedly diminished interest or pleasure in
almost all activities
3. significant weight loss/gain
5. psychomotor agitation/retardation
7. feelings of worthlessness (guilt)
8. impaired concentration (indecisiveness)
9. recurrent thoughts of death or suicide.
(23) W. Breitbart, "Cancer Pain and Suicide," in Advances
in Pain Research and Therapy, ed. K. M. Foley et al., vol
(New York: Raven Press, 1990), 399-412.
(25) Depression Guideline Panel, 23.
(26) Ibid., 18.
CHAPTER 1 - THE EPIDEMIOLOGY OF SUICIDE page 15
Unfortunately, because a common symptom of depression is a
loss of insight and a feeling of hopelessness, depressed people
usually have little understanding of the severity of their illness.
They are often the last to recognize their problem and seek help.
It is therefore critical that primary care physicians develop the
skills to recognize depression in patients, particularly the
terminally ill and elderly, whose depressive symptoms may be masked
by coexisting medical conditions such as dementia or coronary artery
Risk factors for major depressive disorder. Overall, women
have higher rates of depression than men. Individuals with a
history of depressive illness in first-degree relatives are also
more prone to depression. Prior suicide attempts and prior episodes
of major depression also place individuals at risk. Other important
risk factors for major depression include onset of depression under
age 40, postpartum period, lack of social support, stressful life
events, and current alcohol or substance abuse. In addition, other
general medical conditions are risk factors for major depression.
Depressive symptoms are detectable in approximately 12 percent to 16
percent of patients with another nonpsychiatric medical
condition.(27) When major depression is present, it should be
treated as an independent condition.
Depression may coincide with other medical conditions for
several reasons. First, the medical condition may biologically
cause depression. Second, the condition may trigger depression in
patients who are genetically predisposed to depression. Third, the
presence of illness or disease can psychologically cause depression,
as is often observed in patients with cancer. Finally, especially
for cancer patients, some treatments or medications have side
effects that cause depressive moods or symptoms.
A wide range of chronic illnesses are associated with an
increased risk of depression. Studies indicate that patients with
dementia illnesses such as Parkinson's, Huntington's, and
Alzheimer's diseases have higher rates of major depression.
Diabetes patients are three times as likely as the general
population to develop major depression.(28)
(27) Ibid., 5.
(28) Ibid., 55-65. This source discusses the incidence of
depression in several other chronic conditions - coronary artery
disease, chronic fatigue syndrome, fibromyalgia, and stroke.
page 16 WHEN DEATH IS SOUGHT
Treatment for depression in patients with chronic illness may
offer patients the ability to adjust to the complex circumstances
they face in coping with illnesses that are frequently debilitating
Patients with advanced disease or terminal illness frequently
experience many psychological symptoms, including anxiety, fatigue,
and lack of concentration. Terminally ill patients may also develop
major depression or severe depressive symptoms. Although it is
normal and expected that terminally ill patients "feel sadness for
the anticipated loss of health, life and all it means, and loss of a
future with all that it might hold," most patients call upon their
coping mechanisms to manage these feelings.(29) It is a myth,
however, that severe clinical depression is a normal and expected
component of terminal illness.
Healthy individuals, including health care professionals,
often believe that it is normal for terminally ill patients to
experience major depression. They understand feelings of
hopelessness as expected and rational given the patient's condition
and prognosis. As one psychiatrist explains:
Expressions like "I'd want to die if I
were in that situation" or "I'd be depressed
too" are common, even among health care
professionals. This misunderstanding may
contribute to the poor diagnosis and treatment
of depression in patients with chronic or
terminal illness. The presence of physical
symptoms that are associated with both the
illness and depression make the diagnosis even
more difficult. Terminal illness as well as
depression may cause a patient to experience
physical symptoms of fatigue, apathy,
insomnia, weakness and loss of libido.(30)
For this reason, psychological symptoms of depression, such as
hopelessness and helplessness, are often more reliable markers than
physical symptoms in the assessment and treatment of major
depression among individuals with chronic and terminal illness.
Pain and Suffering
For some patients, uncontrolled pain is an important
contributing factor for suicide and suicidal ideation.
(29) Jimmie C. Holland, Chief, Psychiatry Services, Memorial
Sloan-Kettering Cancer Center, "Letter to the Task Force on
Life and the Law," August 16, 1993.
CHAPTER 1 - THE EPIDEMIOLOGY OF SUICIDE page 17
Patients with uncontrolled pain may see death as the only
escape from the pain they are experiencing. However, pain is
usually not an independent risk factor. The significant variable in
the relationship between pain and suicide is the interaction between
pain and feelings of hopelessness and depression. As stated by one
psychiatrist: "Pain plays an important role in vulnerability to
suicide; however, associated psychological distress and mood
disturbance seem to be essential co-factors in raising the risk of
Suffering represents a more global phenomenon of psychic
distress. While suffering is often associated with pain, it also
occurs independently. Different kinds of physical symptoms, such as
difficulty breathing, can lead to suffering. Suffering may also
arise from diverse social factors such as isolation, loss, and
Pain. The International Association for the Study of Pain
defines pain as follows:
"An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage... Pain is always subjective... It is
unquestionably a sensation in a part or parts
of the body but it is also always unpleasant
and therefore an emotional experience.(32)
This definition reflects a distinction between pain and
nociception.(33) Nociception refers to activity produced in the
nervous system in response to potentially damaging ("noxious")
stimuli. Pain is the patient's perception of nociception. A
patient's pain reflects both the activity of his or her nervous
system, and psychological, personal, and physiological factors.(34)
Different types of pain vary both in the way they affect
patients and in their responsiveness to treatment. Acute pain,
which is of limited duration, may arise from injury or as a result
of a surgical procedure. Chronic pain is pain that persists well
beyond the normal course of healing of a disease or injury or, most
typically, is associated with chronic or progressive
(3l) Breitbart, "Suicide Risk and Pain," 54.
(32) International Association for the Study of Pain,
"Pain Terms: A Current List with Definitions and Notes on
Usage," Pain (1986), suppl. 3, S217.
(33) Activity induced in the nociceptor and nociceptive
pathways by a noxious stimulus is not pain, which is always a
psychological state, even though we may well appreciate that
pain most often has a proximate physical cause." Ibid.
(34) Portenoy, 3; International Association for the Study of
Pain; World Health Organization, Cancer Pain Relief
(Geneva: World Health Organization, 1986), 9-10.
page 18 WHEN DEATH IS SOUGHT
diseases. Some types of pain are responsive to treatment
while others, such as neuropathic pain or pain arising from chronic
illness, are harder to treat. Pain may be constant, or it may occur
as a result of activity. The characteristics of pain such as
severity, quality (e.g., burning or stabbing), time course
(continuous or intermittent), and location are important in
assessing the nature of the pain.(35) Severity of pain may be less
important than the patient's perception of pain and the fear of
Pain may be characterized in terms of its mechanism or cause.
Somatic pain, which may be caused by injury to a bone or damage to
tissue, is generally localized and may be described as aching,
stabbing, or pressure-like. Visceral pain, such as that arising
from obstruction of the intestine or ureter, is more poorly
localized, and may be felt as aching or cramping. Neuropathic pain
results from damage to the nervous system.(36)
Pain is terribly real and immediately present for the person
in pain, but can be less apparent to observers. This divergence can
lead to a sense of isolation on the part of the patient, and to
inadequate responses by others in alleviating pain.
For the person in pain, so incontestably
and unnegotiably present is it that "having
pain" may come to be thought of as the most
vibrant example of what it is to "have
certainty," while for the other person it is
so elusive that "hearing about pain" may exist
as the primary model of what it is "to have
doubt." Thus pain comes unsharably into our
midst as at once that which cannot be denied
and that which cannot be confirmed.(37)
(35) R. K. Portenoy, "Pain Assessment in Adults and
Children," in Why Do We Care?, Syllabus of the Postgraduate
Course, Memorial Sloan-Kettering Cancer Center, New York City,
April 2-4, 1992, 4-5; Acute Pain Management Guideline Panel,
Acute Pain Management: Operative or Medical Procedures and
Trauma, Clinical Practice Guideline, AHCPR pub. no. 92-0032
(Rockville, Md.: U. S. Department of Health and Human Services,
Public Health Service, Agency for Health Care Policy and
Research, February 1992), 7-14; E. Scarry, The Body in Pain:
The Making and Unmaking of the World (New York: Oxford
University Press, 1985), 7-8.
(36) Portenoy, 4-5; Acute Pain Management Guideline Panel,
7-14; N. Coyle et al., "Character of Terminal Illness in the
Advanced Cancer Patient: Pain and Other Symptoms During the
Last Four Weeks of Life," Journal of Pain and Symptom Management
5 (1990): 84. While pain may arise primarily from
psychological causes, this is understood to occur only in rare
(37) Scarry, 4.
CHAPTER 1 - The EPIDEMIOLOGY OF SUICIDE page 19
In recent decades, new approaches have been developed to
assess and report pain. Self-reporting of pain by patients is
central to pain assessment. While self-reporting can be
supplemented by physiological and behavioral observation, it is
widely recognized that patients' behavior and physiological
characteristics do not always correlate with the level of pain
experienced by the patient.(38) Assessing and reporting pain is
critical to effective pain relief.(39) It can also lead to important
information about other aspects of the patient's medical condition,
alerting the patient to disease and preventing further injury.(40)
Different types of pain impose different burdens for patients
and present distinct challenges to health care professionals. Acute
pain and chronic pain differ both physiologically and in the
difficulties they entail. Acute pain has a well-defined temporal
pattern of onset, and generally results from potentially damaging
stimuli associated with injury or disease. It usually is associated
with observable physical signs and responses of the autonomic
nervous system. Acute pain usually does not persist beyond days or
Chronic pain has been defined as "pain that persists a month
beyond the usual course of an acute disease or a reasonable time for
an injury to heal or that is associated with a chronic pathological
process that causes continuous pain or pain [that] recurs at
intervals for months or years."(42) Chronic pain may be caused by a
patient's chronic or progressive disease, or by prolonged
dysfunction of the nervous system. Although chronic pain may be
severe and debilitating, a patient in chronic pain may not display
the objective signs associated with acute pain. Chronic pain may
(38) Acute Pain Management Guideline Panel, 7-14;
International Association for the Study of Pain, Task Force on
Professional Education, Core Curriculum for Professional
Education in Pain (Seattle: IASP Publications, 1991), 4-7,
39) The American Pain Society reports that "the most
common reason for unrelieved pain in U.S. hospitals is the
failure of staff to routinely assess pain and pain relief."
Principles of Analgesic Use in the Treatment of Acute Pain and
Cancer Pain, 3d ed. (Skokie, Ill.: American Pain Society,
1992), 2. A similar view was shared by 76% of respondents in a
survey of cancer specialists. J. H. Von Roenn et al.,
"Physician Attitudes and Practice in Cancer Pain Management: A
Survey from the Eastern Cooperative Oncology Group,"Annals of
Internal Medicine 119 (1993):121-26.
(4O) Portenoy, 5; Acute Pain Management Guideline Panel.
(41) K. M. Foley, "The Treatment of Cancer Pain," New
England Journal of Medicine 3 (1985): 85; J. J. Bonica,
"Definitions and Taxonomy of Pain," in The Management of Pain,
ed. J. J. Bonica, 2d ed. (Philadelphia: Lea and Febiger,
(42) Bonica, 19.
page 20 WHEN DEATH IS SOUGHT
therefore be less visible, adding to the burden individuals
face in coping with the pain in their daily activities and
relationships with others.
Millions of patients in the United States experience
significant or severe chronic pain. Among the most common
conditions are recurrent severe headaches, back disorders, and
arthritis. Pain may also arise from other chronic illnesses such as
sickle cell disease, nerve injury, and sinusitis.
Chronic pain often entails serious physical, emotional, and
financial burdens for the patient and those closest to him or her.
The physical symptoms arising from chronic pain are distressing:
loss of sleep, a decline in physical activity, fatigue, and
progressive physical deterioration. It can lead to changes in the
patient's personality and life-style, affecting the ability to carry
out even the simplest daily tasks.(43 As described by one physician,
chronic illness also entails mourning over the loss of good health
and a constant struggle to avoid the next episode of illness:
"Each time the cycle of symptoms begins,
the sufferer loses faith in the dependability
and adaptability of basic bodily processes
that the rest of us rely on as part of our
general sense of well-being. This loss of
confidence becomes grim expectation of the
worst, and, in some, demoralization and
hopelessness. ...The fidelity of our bodies
is so basic that we never think of it --- it
is the certain grounds of our daily
experience. Chronic illness is a betrayal of
that fundamental trust.(44)
Physical symptoms. Many patients who are terminally or
chronically ill undergo distressing physical symptoms in addition to
pain. These symptoms may include dyspnea (difficulty in breathing),
nausea, diarrhea, constipation, and fatigue. Multiple symptoms may
be present simultaneously. In advanced cancer patients, for
instance, "pain, dyspnea and other symptoms do not occur in
isolation: they interact so as to produce a `crescendo' effect.
The dyspneic patient will experience increasing anxiety and rapid
breathing, which may then exacerbate pain arising from metastases in
the ribs and spine."(45)
(43) Foley, 85; Bonica, "Definitions and Taxonomy of Pain,"19;
Bonica, Management Of Pain, 189-95.
(44) A. Kleinnian, The Illness Narratives: Suffering
Healing, and the Human Condition (New York: Basic Books,
(45) World Health Organization, Cancer Pain Relief and
Palliative Care: Report of a WHO, Expert Committee, WHO
Technical Report Series 804 (Geneva: World Health
CHAPTER 1 - THE EPIDEMIOLOGY OF SUICIDE page 21
Both pain and other physical symptoms directly diminish a
patient's quality of life. Apart from the experience of pain or
discomfort itself, pain and other symptoms of serious illness may
severely limit a patient's activities, denying some patients the
capacity to engage in the activities of daily living most important
to their sense of well-being and self.(46)
Severe or chronic pain can be associated with mild or severe
disability as well as psychological conditions, such as major
depression.(47) Patients with terminal illness and those with a
nonterminal condition may suffer from chronic pain. To date,
medicine has less experience treating chronic pain for nonterminal
patients. While most pain arising from terminal illness responds to
treatment, the alleviation of pain caused by nonterminal, chronic
illness is less certain.(48)
Suffering. Suffering is a more global experience of impaired
quality of life.(49) As defined by one physician, suffering is "the
state of severe distress associated with events that threaten the
intactness of the person."(50) The threat might be to the person's
existence or integrity, to maintaining his or her role in the family
or in society, or to his or her sense of self and identity. While
pain and suffering are often associated, minor pain can occur
without causing suffering, and suffering can occur in the absence of
physical pain. Distressing physical symptoms and disabilities can
lead to intense suffering for patients with degenerative disorders
such as amyotrophic lateral sclerosis (ALS), or those who are
quadriplegic as the result of a spinal cord injury. Moreover,
suffering is not limited to medical patients. Suffering may arise
from many causes, including physical incapacity, social isolation,
fear, the death of a loved one, or frustration of a cherished
(46) Coyle et al.
(47) M. J. Massie and J. C. Holland, "The Cancer Patient
with Pain: Psychiatric Complications and Their Management,"
Journal of Pain and Symptom Management 7 (1992): 100-101;
Breitbart, "Cancer Pain and Suicide," 404; R. K. Portenoy,
"Overview of Symptom Prevalence and Assessment," in Why Do We
Care?, Syllabus of the Postgraduate Course, Memorial
Sloan-Kettering Cancer Center, New York City, April 2-4,
(48) World Health Organization, Cancer Pain Relief, 10.
On the treatment of chronic pain see Chapter 3.
(49) Portenoy, 3.
(50) E. J. Cassell, "The Nature of Suffering and the
Goals of Medicine," New England Journal of Medicine 306
(51) Ibid., 64l-44.
page 22 WHEN DEATH IS SOUGHT
Even more so than with pain, an individual's experience of
suffering reflects his or her unique psychological and personal
characteristics. Suffering is in effect the experience of severe
psychological pain, arising from medical or personal causes.
Because the experience of suffering is subjective, people are often
unaware of the causes or extent of another person's suffering.
Ultimately, suffering is a distinctly human, not a medical,