248 Suicide and Life-Threatening Behavior 37(3) June 2007

 2007 The American Association of Suicidology

Rebuilding the Tower of Babel: A Revised

Nomenclature for the Study of Suicide
and Suicidal Behaviors
Part 1: Background, Rationale,
and Methodology
Morton M. Silverman, MD, Alan L. Berman, PhD, Nels D. Sanddal, MS,
Patrick W. O’Carroll, MD, MPH, and Thomas E. Joiner, Jr., PhD

Since the publication of the O’Carroll et al. (1996) nomenclature for suicid-
ology, there have been a number of published letters and articles, as well as an
active e-mail dialogue, in response to, and elaborating upon, this effort to establish
a standard nomenclature for suicidology. This new nomenclature has been pre-
sented on a number of occasions at both national and international meetings. In
this paper we provide the background, rationale, and methodology involved in the
process of revising the O’Carroll et al. nomenclature, based on the feedback and
discussions that have ensued over the past 10 years.

Those who have written and studied the phenomenon of suicide have not
defined the term so simply . . . how the word is defined has implications and large
effects for statistics that are compiled on the official number of suicides, and for
researchers, so that there is clear communication regarding what and who is being
studied.
Among writers in the field of suicidology there is no single common ac-
cepted definition . . . the term suicide refers not to a single action but more broadly
to a great many varied behaviors. For example, one can speak of suicidal thoughts,
intentions, ideation, gestures, attempts, completions, equivalents.
Thus far, no single term, definition, or taxonomy has served to sufficiently
represent the complex set of behaviors that have been suggested as suicidal. A

Morton Silverman is a Clinical Associate Professor of Psychiatry at the University of Chicago,

Senior Advisor to the Suicide Prevention Resource Center (Newton, MA), and Educational Consultant
to the Denver VA VISN 19 MIRECC; Alan Berman is Executive Director of the American Association
of Suicidology; Nels Sanddal is President and CEO of Critical Illness and Trauma Foundation, Inc.,
Bozeman, MT; Patrick O’Carroll is Regional Health Administrator, Public Health Region X; and
Thomas Joiner, Jr. is the Bright-Burton Professor of Psychology at The Florida State University.
This effort was initially encouraged and supported, in part, by the Suicide Prevention Research
Center (SPRC) at the University of Nevada School of Medicine, Las Vegas, Nevada. Principal investiga-
tors were G. Thomas Shires, MD, and John Fildes, MD. The Denver VA VISN 19 MIRECC sponsored
a meeting of the MIRECC Nomenclature Workgroup in July, 2005, which resulted in the preparation
of this revision. The Director of the Denver VA VISN 19 MIRECC is Lawrence E. Adler, MD. The
contents of this article are solely the responsibility of the authors and do not necessarily represent the
official views of the Denver VA VISN 19 MIRECC.
Earlier drafts were read by David A. Jobes, PhD, Herbert Nagamoto, MD, and Pamela J. Staves,
RN, MS, NP. The co-authors appreciate their contributions, critiques, and recommendations.
Address correspondence to Morton M. Silverman, MD, 4858 S. Dorchester Avenue, Chicago, IL.
601615-2012; E-mail: msilverman@suicidology.org
Silverman et al.
standard set of terms and definitions are greatly needed to advance the science of
suicidology and aid communication and understanding of the field.
Suicide researchers recognize that the gener-
alizability of their findings is affected by the
populations they study, participation rates
they obtain, and the type of data they collect.
Most agree that the use of inadequate and
contradictory definitions of suicide and sui-
cidal behavior is often a limitation of suicide
research and communication. Limitations
also include hindsight bias and informant
bias regarding documentation of suicidal
thoughts, intent, and behaviors (Duberstein
& Conwell, 1997). There is a range of sui-
cidal behaviors, which includes thoughts
about suicide (Beck, Steer, & Brown, 1993),
attempts ranging from low lethality to medi-
cally serious (Beautrais, Joyce, & Mulder,
1999), and deaths by suicide (Fischer, Com-
stock, Monk, & Spencer, 1993). Yet the sui-
cide literature remains replete with confusing
terms, definitions, and classifications that
make it very difficult, if not impossible, to
compare and contrast one research study or
epidemiological survey with another (Beck et
al., 1973; Berman & Cohen-Sandler, 1982;
Jenkins & Singh, 2000; Leenaars et al., 1997;
Rudd & Joiner, 1998; Shneidman, 1985; Sil-
verman, 2006), or to make comparisons, gen-
eralizations, or extrapolations (Linehan, 1997;
Santa Mina & Gallop, 1998; Westefeld et al.,
2000).
Suicide attempts are not only much
more frequent than completed suicides, but
the distribution of the most common meth-
ods and the populations exhibiting these be-
haviors is meaningfully different. No na-
tional or international surveillance system
exists for the primary purpose of monitoring
suicidal behaviors and estimating annual na-
tional rates of occurrence. Those national
surveys that collect information on suicidal
behaviors in the service of other primary mis-
sions use different terminologies and differ-
ent definitions for suicidal behaviors. In or-
der to conduct meaningful surveillance, the
terms used need to be clearly defined and
mutually exclusive (e.g., suicide ideation, sui-
249
McIntosh (1985, pp. 18–19)
cide threat, suicide, self-harm, suicide at-
tempt, etc.).
There are a large number of scales and
measures that purport to quantitatively and
qualitatively measure the presence of suicidal
ideation, intent, and motivation, as well as
the intensity, duration, frequency, and conse-
quences of suicide attempts (Brown, 2001;
Goldston, 2003). Most measures assume that
the respondent already possesses a definition
of suicidal ideation, intent, motivation, and
attempt. Often researchers assume, even
when they are using the same measures across
studies and across populations, that all re-
spondents are basing their responses on the
same conceptualizations and definitions of
suicide-related terms. Rarely do these mea-
surement tools provide the respondent with
clear definitions for the suicide-related terms
(Kessler, Berglund, Borges, Nock, & Wang,
2005).
Measures of suicide and nonfatal sui-
cidal behavior continue to be hindered by the
lack of: (1) a standard nomenclature (De Leo,
Burgis, Bertolote, Kirkhof, & Bille-Brahe,
2004, 2006; Rudd & Joiner, 1998); (2) clear
operational definitions (Garrison et al., 1993;
Silverman & Maris, 1995; McKeown et al.,
1998; Moscicki, 1989, 1995); and (3) stan-
dardized lethality measures (Berman, Shep-
herd, & Silverman, 2003; Farberow, 1980;
Smith, Conroy, & Ehler, 1984). Reliable sta-
tistics on the numbers, types, and methods of
nonfatal, intentional self-inflicted injuries, in
conjunction with national and regional sui-
cide mortality data, are required for the de-
velopment, targeting, and evaluation of na-
tional and regional suicide prevention
strategies (O’Carroll, 1989).
THE O’CARROLL
ET AL. NOMENCLATURE
In 1995–96, under the auspices of the
National Institute of Mental Health and the
250
American Association of Suicidology, a no-
menclature working group was formed to
clarify the nomenclature used in the field to
describe suicidal ideations and suicidal be-
haviors. Faced with the recognition that cer-
tain terms are entrenched in the public’s vo-
cabulary and in clinical communications, the
nomenclature group nevertheless proposed
terminology that best defined the range of
suicidal behaviors and communications. The
work of this group was summarized in a sci-
entific publication in 1996 (O’Carroll et al.,
1996), and is outlined in Table 1. O’Carroll
et al. distinguished suicidal behaviors by
three characteristic features: intent to die, ev-
idence of self-inflicted injury, and outcome
TABLE 1
O’Carroll et al. (1996) Nomenclature
An Outline Indicating Superset/Subset Relation-
ships of the Proposed Nomenclature for Suicide
ands Self-Injurious Thoughts and Behaviors
Self-Injurious Thoughts and Behaviors
A. Risk-Taking Thoughts and Behaviors
1. With Immediate Risk (e.g., motocross, sky-
diving)
2. With Remote Risk (e.g., smoking, sexual
promiscuity)
B. Suicide-Related Thoughts and Behaviors
1. Suicide Ideation
a. Casual Ideation
b. Serious Ideation
(1) persistent
(2) transient
2. Suicide-Related Behaviors
a. Instrumental Suicide-Related Behavior
(ISRB)
(1) Suicide threat
(a) Passive (e.g., ledge sitting)
(b) Active (e.g., verbal threat, note
writing)
(2) Other ISRB
(3) Accidental death associated with ISRB
b. Suicidal Acts
(1) Suicide attempt
(a) With no injuries (e.g., gun fires,
missed)
(b) With injuries
(2) Suicide (completed suicide)
A Revised Nomenclature: Part 1
(injury, no injury, or death) (Figure 1). This
nomenclature has been referred to as the
“nomenclature for suicide-related behaviors
in terms of outcome and intent to die from
suicide” (Daigle & Cote, 2006).
The goal of developing a uniform no-
menclature was to increase the ability of cli-
nicians, epidemiologists, policy makers, and
researchers to better communicate with each
other and study similar populations at risk. If
the nomenclature was accepted, the next step
was to develop and test standard, operational
means for applying these definitions in clini-
cal practice, research, and public health. Dis-
seminating and encouraging the use of an op-
erationalized nomenclature would constitute
a third stage in this process.
Adoption of the O’Carroll
et al. Nomenclature
A number of investigators have adopted
the O’Carroll et al. nomenclature and ap-
plied it in their studies (Bryan & Rudd, 2006;
Daigle & Cote, 2006; Goldston, 2003; Kidd,
2003; Rudd & Joiner, 1998; Wagner, Wong,
& Jobes, 2002). Others have acknowledged
its role in highlighting the need for clarifica-
tion of terms (Dear, 1977, 2001; De Leo et
al., 2004, 2006; Hjelmeland & Knizek, 1999;
Linehan, 1997, 2000; Marusic, 2004; Rudd,
1997, 2000; Rudd, Joiner, Jobes, & King,
1999). In addition, the American Psychiatric
Association (2003) has acknowledged and
adopted the O’Carroll et al. definitions as the
basis for their recently issued practice guide-
lines for the assessment and treatment of pa-
tients with suicidal behaviors. In contrast, the
nomenclature has not been widely used in
the research and clinical communities.
Following the publication of the
O’Carroll et al. terminology the authors re-
ceived over 100 communications (letters, e-
mail, phone calls) from around the world
commenting on the proposed nomencla-
ture—offering further recommendations, re-
visions, and refinements. Despite its utility
and general acceptance in the mental health
community, the nomenclature has not been
universally accepted, due, in part, to its intro-
Silverman et al.
Figure 1. O’Carroll et al. (1996) nomenclature.
duction of new terminology and definitions.
Of particular note is that some of the terms
proposed (instrumental suicide-related be-
havior; non-zero intent; and suicide act) were
deemed by others to be too broad, too vague,
or too unwieldly. In fact, others have subse-
quently offered alternative nomenclatures,
including ones that attempt to avoid the con-
cepts of motivation, intent, and planning
(Marusic, 2004; Brown, Jeglic, Henriques, &
Beck, 2006).
Some members of the initial work
group (ALB, MMS) continued to refine the
nomenclature and to seek ongoing input by
making presentations on the proposed no-
menclature nationally and internationally
251
(O’Carroll et al., 1997). This resulted in a de-
cision to undergo a total revision of the ini-
tial effort. Before discussing our revised no-
menclature, we share the background to our
deliberations.
THE CURRENT STATE
OF OUR NOMENCLATURE
There remains confusion about exactly
what constitutes suicidal behavior, deliberate
self-harm, suicide-related behavior, parasuicide,
or suicidality, and how to define suicide and
suicide attempt (De Leo et al., 2006; Silver-
man, 2006). The plethora of terms has re-
252
sulted in a lack of clarity and precision in the
scientific literature, and among suicidolo-
gists, clinicians, researchers, theoreticians,
and epidemiologists (Mayo, 1992; Rosenberg
et al., 1988; Sommer-Rotenberg, 1998;
World Health Organization [WHO], 1968,
1986). While a clear set of definitions is valu-
able, it is possible that the roles and needs of
the various disciplines that comprise suicidol-
ogy (e.g., coroners and medical examiners,
clinicians, researchers, public health prac-
titioners) are sufficiently heterogeneous to
require a number of indicators rather than a
single measure. Although it is necessary to
recognize that different disciplines have dif-
ferent needs for their understanding and pre-
vention of suicide, it still holds that a uniform
set of criteria and definitions offers the po-
tential to advance all these fields simultane-
ously (Silverman, 2006). Using a similar ra-
tionale, in April 2004, the National Center
for Injury Prevention and Control (Centers
for Disease Control and Prevention) con-
vened a group of experts to begin develop-
ment of uniform definitions for self-directed
violence surveillance. This effort is still un-
derway.
The Benefits of a Revised Nomenclature
The refinement of investigative tools
and techniques can only improve the effi-
ciency, effectiveness, sensitivity, and specific-
ity of clearly describing the populations and
behaviors being studied. For research, clini-
cal, and prevention purposes, the use of mu-
tually exclusive terminology would more
clearly define subgroups for study. If the no-
menclature can be revised in a manner that
satisfies the needs of the clinical, research,
and/or public health communities, then this
can lead to a greater use of this nomencla-
ture, which would, in turn, greatly improve
communication between and among re-
searchers, clinicians, administrators, policy
makers, and the public. It would allow for
better comparability between and among re-
search studies and clinical trials. It would
clarify relationships between concepts and
categories. The further benefit of clarifying
A Revised Nomenclature: Part 1
terms would be to assist genetic studies in
differentiating valid phenotypes from one an-
other, so that underlying genotypes can be
more accurately identified. A valid and reli-
able nomenclature will allow the develop-
ment of a classification for suicidology.
Classification systems have been at-
tempted in the past and each one has its mer-
its and applicability (Arensman & Kerkhof,
1996; Barber, Marzuk, Leon, & Portera,
1998; Beck et al., 1973; Ellis, 1988; Farb-
erow, 1980; Hammad, Laughren, & Racoo-
sin, 2006; Kreitman, 1977; Lester, 1990;
Maris, 1992; Orbach, 1997; Shneidman,
1968). As a whole, however, they lack univer-
sal appeal because of the reliance on different
terminologies and definitions of key con-
structs (De Leo et al., 2006). Hence there re-
mains a need to simplify the nomenclature,
even while recognizing that suicide is a be-
havior (not a disorder or diagnosis), and all
behavior is multidetermined and multidi-
mensional.
Further clarification of the nomencla-
ture would also lead to a better understand-
ing of the relative predictive value of each
term retained. For example, what percent of
individuals who make a suicide attempt have
had a prior ideation or threat that was related
to the present suicide attempt? To what ex-
tent have prior “indirect self-destructive be-
haviors” predicted future suicide-related be-
haviors (Farberow, 1980; Maris, Berman, &
Silverman, 2000; Santa Mina & Gallop,
1998)? More specifically, to what extent are
self-harm behaviors related to future suicidal
behaviors?
In addition, a standardized nomencla-
ture will lead to a standardized set of ques-
tions for determining the presence or ab-
sence of suicidal cognitions, motivations,
emotions, and behaviors. For example, sug-
gested questions in the clinical literature to
ascertain the presence of suicidal ideation
currently range from, “Have you ever
thought of hurting yourself?” to “What do
you see for yourself in the future?” Just be-
cause a person says, “I feel like life is not
worth living” or “I can’t take anymore of
this,” does not necessarily imply that that
Silverman et al.
person has the thought, motivation, or intent
to end their life. Suicide and other self-destruc-
tive behaviors often are the consequences of
intention, motivation, and preparation (which
have cognitive, emotional, and behavioral
components). A full discussion of the role of
intention vs. motivation in the development
and expression of suicide-related behavior
has been presented elsewhere (Hjelmeland &
Knizek, 1999). Motivation to die and prepa-
ration to die do not, necessarily, place an in-
dividual at either acute or high risk for sui-
cide.
Challenges to the Development
of a Revised Nomenclature
A critical stumbling block is how to af-
firm and assess suicidal intent. Is it simply
based on a patient’s self-report of a wish or
desire to die, to cease suffering, and/or is it
based on an independent assessment of, or
inference from, the lethality of the means or
methods by which the behavior was under-
taken (the instrumentality of the behavior)
(De Leo et al., 2004, 2006; Range & Knott,
1997; Wagner et al., 2002)? Without the in-
dividual self-report, can we infer intent, and,
if so, using what criteria? Because suicide, by
definition, is self-initiated, we would take the
position that it is predicated on the intent to
die. Hence we are dependent upon the coop-
eration and collaboration of the individual to
best ascertain the labeling of the behavior
under investigation. The relative weight
placed on prior suicidal ideations is impor-
tant, as is assessment of past and present sui-
cidal threats and attempts in determining the
presence of intent. The difficulty is in search-
ing for prior verbal expressions of intent,
prior behaviors that imply intent (suicide
notes, warning signs, suicide attempts, or
verbalizations), or approximations of intent
based on information provided by others
(i.e., implicit or explicit evidence) (Berman,
1993; Jobes, Berman, & Josselson, 1987;
Jobes, Casey, Berman, & Wright, 1991).
A related problem is how to define and
classify suicidal risk, be it a classification using
high vs. medium vs. low, short-term vs. long-
253
term, or imminent vs. acute vs. chronic (Rudd,
Joiner, & Rajab, 1999; Silverman, 2006;
Simon, 2006). Often there seems to be some
“fuzzy logic” in exactly what criteria are be-
ing used to label a suicidal risk (Wagner et
al., 2002). Does it pertain to the risk for dy-
ing by suicide, or does it refer to the risk for
a range of suicide-related behaviors (that may
include self-harm, threats, attempts, and sui-
cide)? A clarification of the behavioral out-
comes (e.g., self-harm, suicide attempt, sui-
cide) may also help clarify “risk factors for
suicide,” “risk factors for suicide attempt,”
and “risk factors for self-harm behavior”
(Kraemer et al., 1997). Not all risk factors
convey acute risk (Simon, 2006). It would be
helpful if the nomenclature could lead to a
better classification of risk factors whereby
the presence of a particular risk factor clearly
contributes to a determination of acute vs.
short-term vs. long-term risk (or low vs. me-
dium vs. high risk) for a range of self-destruc-
tive behaviors (Fawcett et al., 1990).
THE PROCESS OF REVISING
THE O’CARROLL
ET AL. NOMENCLATURE
The major challenges O’Carroll et al.
(1996) encountered when they developed
their nomenclature included: (1) ascertaining
the need to establish the presence or absence
of intent in order to define a behavior as sui-
cidal; (2) clarifying the role of intention ver-
sus motivation; (3) selecting among the terms
deliberate self-harm, parasuicide, and suicide at-
tempts to best convey self-destructive behav-
ior that doesn’t end in death; (4) retaining
such commonly used, but poorly defined
terms as suicide attempt, suicidal threat, suicidal
gesture, and suicidal ideation; and (5) distilling
the existing suicide terminology to its most
basic conceptual categories.
In our efforts to revise the nomencla-
ture, we faced similar challenges. Our initial
review of the extensive literature on nomen-
clature, terminology, and classification pro-
vided us with certain constraints that were
immutable given the degree to which certain
254
terms and conceptual ideas had become per-
manently embedded in the language of sui-
cidology. For example, in order to separate
intentional injuries (suicide and homicide)
from unintentional injuries (accidents), we
had to acknowledge and incorporate the psy-
chological concept of intent. Suicide and
other suicidal behaviors involve purposeful
action or movement toward a desired out-
come. Thus, intent is an integral component
of our nomenclature.
Defining Intent
We determined that we needed the
term intent to distinguish between and among
self-destructive behaviors, and also to remain
consistent with the coroner’s Natural-Acci-
dent-Suicide-Homicide (NASH) and CDC’s
Operational Criteria for the Determination
of Suicide (OCDS) classification systems
(Rosenberg et al., 1988; O’Carroll et al.,
1996). We also wanted to remain consistent
with the emerging terminology in the public
health, injury control, and violence preven-
tion literature. Over the last decade, the in-
ternational community of injury control and
prevention experts has developed a nomen-
clature and classification system that estab-
lishes a major distinction between intentional
injuries (homicides and suicides) and unin-
tentional injuries (motor vehicle crashes,
worksite injuries). Thus, we have avoided the
old term of accident and replaced it with in-
jury.
Hjelmeland and Knizek (1999) at-
tempted to clarify some of the terminology
used in the literature regarding nonfatal sui-
cide acts. They suggested that an “intent”
implies an action to change the future, while
“motivation” implies an effort to affect inter-
personal relations and a change in social mi-
lieu. Our position is that intent refers to the
aim, purpose, or goal of the behavior. Al-
though it implies an action, the action itself
is not a given (“I intend to kill myself by
hanging” does not mean that the action has
occurred). In addition to investigating the
presence of intent, we may also need to as-
A Revised Nomenclature: Part 1
certain reasons and rationales for certain ac-
tions in order to determine if the actions are
truly suicidal in nature. There are a set of
self-reported “reasons for suicide” that are
commonly identified in studies (Hjelmeland
& Hawton, 2004). They include a wish to es-
cape, a desire to obtain relief from an un-
bearable situation, and a wish to end over-
whelming psychological or emotional pain.
Hence, a motivation to die can be under-
stood as the driving force behind the ideation
or intent, and may also change the future so-
cial milieu.
The assessment of intent is the most
difficult part of any investigation into the
true nature of self-injurious behaviors. Dif-
ferent stakeholders (statisticians, public health
practitioners, coroners, medical examiners,
death scene investigators, and prevention-
oriented suicidologists) require different
standards of evidence, different levels of cer-
tainty for such evidence, and place different
emphases on different aspects. A number of
pieces of evidence are taken into account
when arriving at a decision that a self-destruc-
tive behavior was intentional in nature. Such
evidence includes: (1) intention to take the
action; or (2) intention to harm himself or
herself by the action; or (3) intention to die
as a result of the action; and/or (4) at the time
of acting, a capacity to understand the likely
consequences of the act and form the desire
to die (Moller, 1997).
Intent connotes a conscious desire or
wish to leave (or escape from) life as we know
it. This phrasing is intentional, as some per-
sons who die by suicide intend to continue in
an afterlife, or to be reborn, or to be trans-
formed. Intent also connotes a resolve to act.
It does not necessarily denote that an indi-
vidual has undertaken an analysis or has
knowledge of the medical lethality of differ-
ent methods/means (although having such is
indirect evidence of intent), knowledge of
how to invoke the method/or means, or how
to choose among them (Berman et al., 2003).
A clear understanding of what we mean by
intent is essential for selecting the techniques
and methods used to investigate its presence.
Silverman et al.
The level at which we decide what consti-
tutes “intent to die” will determine how
many questions need to be asked and how
much exploration will be required to deter-
mine its presence. As Shea (1999) recom-
mends, information must be gathered from
as many sources, and in as many formats, as
possible in order to determine if intent is
present; however, we need to bear in mind
that an individual’s level of intent can change
quite rapidly and without obvious warning,
moving one’s current status from intentional
to unintentional, or vice-versa (Daigle & Cote,
2006).
Rudd (2006b) suggested that there are
two types of suicidal intent: (1) subjective or
expressed intent; and (2) objective or observed
intent. He opined that, because of the nature
of the underlying illness and/or current emo-
tional/physical state (e.g., overdose), acutely
suicidal patients are unable to provide us with
a clearly expressed intent. Rudd placed the
onus on the clinical evaluator to rely on other
tools and techniques to arrive at the true na-
ture of the intent by seeking clarification and
resolution of discrepancies between the ob-
served behavior and the reported cognition.
O’Carroll et al. (1996) struggled with
the distinction between “asking about” intent
vs. “measuring” intent objectively (Beck,
Schuyler, & Herman, 1974). We felt that the
quantification of intent was beyond the no-
menclature, but may be more suitable for
classification. We explored the relationship
between intent and lethality, as well as the
causal relationship between intent, lethality,
and outcome (no injury, injury, or death)
(Bridge, Barbe, Birmaher, Kolko, & Brent,
2005), and concluded that the presence of in-
tent assumes: (1) a desire or wish to end life
as a conscious experience; (2) knowledge (ac-
curate or inaccurate) of risk associated with a
behavior; (3) some perception that means or
methods are available to achieve the desired
outcome; and (4) some knowledge about how
to use the means or methods. We recognized
that at times it may be difficult to establish
intent, but without the inclusion of intent, it
is virtually impossible to distinguish between
255
types of suicide-related behaviors and other
self-injurious behaviors. We also are aware
that there is an imperfect correlation be-
tween intent and outcome.
O’Carroll et al. differentiated the ter-
minology of suicide-related phenomena along
three major axes: the presence or absence of
intent to die (differentiating suicidal acts
from instrumental suicide-related behaviors,
respectively); the presence or absence of in-
strumental thinking; and whether the behav-
ior resulted in injuries (with or without injur-
ies) or death (accidental or completed suicide).
Many colleagues objected to invoking the di-
chotomous concepts of “zero intent to die”
and “non-zero intent to die.” Some critics ar-
gued that these are very difficult concepts to
verify in practice, and that “non-zero intent
to die” was too broad and all-encompassing.
Due to this controversy, as well as appreciat-
ing that in emergency settings an individual
may be unable to clarify whether suicidal in-
tent was present or not, we decided to reor-
ganize the nomenclature along three catego-
ries: no intent, uncertain intent, and intent
(Kjoller, Norlev, & Davidsen, 2004).
The Concept of Lethality
Another stumbling block was whether
or not a truly suicidal act must result in an
observable injury. This distinction led O’Car-
roll et al. to the debate about whether the
lethality of the means or methods should be
a determining factor. We decided that, al-
though establishing a lethality index is an im-
portant clinical determination to undertake
(Berman et al., 2003; Smith et al., 1984), the
degree of lethality should not supersede the
first order of business—establishing the pres-
ence of intent as a defining factor (Denning,
Conwell, King, & Cox, 2000).
Brown, Henriques, Sosdjan, and Beck
(2004) found a minimal association between
the degree of suicide intent and the extent of
medical lethality for patients who attempted
suicide, suggesting that suicidal intent and le-
thality are independent dimensions of suicide
attempt behavior and that both of these char-
256
acteristics require careful assessment for ac-
curate identification of suicide attempters.
Their study supports the low validity of med-
ical lethality as a measure of the seriousness
of intent, given that over half of the patients
had inaccurate expectations of the lethality of
their attempt. Nevertheless, for most clini-
cians, high medical lethality suggests high in-
tent, even though high intent doesn’t always
suggest high lethality.
Many variables seem to be involved in
the matter of lethality, among which are:
availability/proximity of the method, per-
sonal knowledge about the lethal effects of
the means and/or the dosage needed to
achieve a certain outcome, familiarity with
and/or comfort level in choosing and using a
particular means, and contributory factors
such as the presence of alcohol or other
drugs/medications in the person (over-the-
counter, illicit, or prescribed), discoverability,
rescuability, timing, and sequencing (De
Moore & Robertson, 1999; McIntosh, 1992).
As previously noted, we accepted the clinical
observation that an individual might not have
a clear understanding or clear recall of their
intent at the time they engaged in the sui-
cidal act; however, the range of questions to
determine the presence or absence of suicidal
intent is fairly limited (“Did you intend to
die?”). Developing a lethality score that
would be more consistently and easily em-
ployed remains a challenge.
Suicide Threat and Gesture
Communication about a suicidal state
can be through (1) ideation (I’m thinking
about killing myself”), (2) threats (with more
of an emphasis to coerce—“I’m going to kill
myself if . . .”), or (3) behaviors. While a
threat may be verbal, nonverbal, or implied,
there is a distinction between the expression
of a suicide threat that might result in subse-
quent action at some unspecified time in the
future, and a direct threat which carries with
it a high likelihood of action in the very near
future. This results in the use of modifiers
such as imminent versus long-term, direct
versus indirect, and acute versus chronic
A Revised Nomenclature: Part 1
when describing threats. The assignment of
a value (high vs. medium vs. low; acute vs.
long-term; active vs. passive) involves an as-
sessment of temporality, as well as the deter-
mination of the frequency, duration, inten-
sity, and potential lethality of the threat.
When a threat evolves into a condition with
behavioral components, the lines between a
threat, a gesture, and a suicide attempt be-
come important clinically, as well as from the
perspective of foreseeability.
Another reason for establishing a defi-
nition of suicide threat is that the literature
is confused about whether a suicide threat is
a precursor for a suicidal gesture, deliberate
self-harm, a plan for a suicide attempt (i.e.,
self-destructive behavior not leading to
death), or suicide. A threat implying self-
harm or deliberate self-harm may be differ-
ent than a threat to one’s life. A suicide gesture
might be construed as a behavioral form of a
suicide threat, in that this term has been
meant to convey a low lethality suicidal act
meant to influence others. In common par-
lance, the term suicidal gesture has been used
to convey the notion of a physical act or be-
havior that is self-inflicted (with or without
suicidal intent), but nonetheless of low le-
thality and low intent to die. The term has
been also used to refer to suicide-related be-
havior that is preparatory to a suicide at-
tempt; suicidal behavior with the intention to
communicate or manipulate others or the so-
cial environment; and deliberate self-harm
without the intent to die (Compton, Daniel,
& Goldston, in press). Because the observed
behavior is self-inflicted and because it “may
be self-injurious” in nature, but seemed to
others “half-hearted” or “minimally injuri-
ous,” the behavior has taken on a pejorative
connotation (Aschkenasy, Clark, Zinn, &
Richtsmeier, 1992; Daigle & Cote, 2006).
Hence, we chose not to include this term in
our nomenclature and incorporated such be-
haviors under the term self-harm.
Additional Terms
O’Carroll et al. tried to eliminate re-
dundant phrases such as “completed suicide,”
Silverman et al.
fatal suicide,” and “fatal suicidal behavior.” In
addition, O’Carroll et al. tried to resolve
phrases such as “nonfatal suicidal behavior”
and “parasuicide” (DeLeo et al., 2004, 2006).
Similarly, we tried to distinguish between
ideation (or thoughts) and intent. Although
ideations, intent, and motivation are cogni-
tions of one sort or another (as opposed to
physical behaviors or actions), ideations are
purely cognitive in nature, while intent as-
sumes, in part, an emotional component to
the cognitive process, as well as a higher de-
gree of mental engagement.
Furthermore, O’Carroll et al. tried to
place the planning process on a continuum
from a thought (“I thought about killing my-
self”), to an intent (“I want to die”), to a plan
(“I have a plan to effect my death”). O’Car-
roll et al. reasoned that one cannot con-
sciously make a plan to die without having
thought about it (ideation) and having a de-
sire or wish to act on it (intent). We subse-
quently needed to rethink this position, in
part due to recent findings that, for some in-
dividuals, suggest the role of impulsivity in
the suicidal process (Kessler, Borges, & Wal-
ters, 1999; Mann et al., 1999; Simon et al.,
1991), although we think that ideation and
intent remain very important components,
even considering the potential influence of
impulsivity. Ideation and intent are fluid and
dynamic and so can change rapidly, and per-
haps do change more rapidly in impulsive in-
dividuals.
Although we felt that O’Carroll et al.’s
term, “instrumental suicide-related behavior”
(ISRB), came very close to accurately identi-
fying and defining the self-destructive behav-
ior which is not intended to result in death,
yet is potentially self-injurious and contain-
ing a communication component, we were
persuaded by our colleagues that the term
“ISRB” is a “mouthful” which can be easily
misunderstood, and would be difficult to in-
sert into the existing vocabulary of suicidol-
ogy. We were offered alternatives, including
“pseudosuicidal behavior,” “suicidiform be-
havior,” and “metasuicide” (Egel, 1999). In-
asmuch as ISRB was intended to encompass
such behaviors as suicide threat, we chose to
257
adopt and adapt Dear’s (2001) expanded rec-
ommendation to change the concept to sui-
cide-related communication to account for
the presence of suicidal threats and suicidal
plans.
We tried to avoid terms such as suicid-
ality because it is used to encompass a wide
range of thoughts and behaviors, including
suicidal ideation, the act of suicide, and those
behaviors associated with suicidal attempts,
and as such loses its meaning, distinctiveness,
and clarity. However, some authors utilize
this term to describe the totality of suicide-
related ideations and behaviors, and it has be-
come a popular term (Rudd, 2006b; U.S. De-
partment of Health and Human Services
[DHHS], 2006), although it is not yet found
in a dictionary. Possibly a better term to en-
compass all forms of suicidal behaviors would
be suicidal activity, because an activity can
have cognitive, emotional, or physical com-
ponents, whereas the behavior only refers to
an action that is observable (DHHS, 2001).
Furthermore, “behavior” connotes an ongo-
ing, continuous activity, whereas an “action”
connotes a time-limited event (Wagner et al.,
2002). Nevertheless, we chose to remain with
the 1996 terminology: suicide-related ideations
and suicide-related behaviors, but we added sui-
cide-related communications.
What Defines a Suicide Attempt?
The existing literature consistently re-
ports that the history of a prior suicide at-
tempt is a statistically significant risk factor
associated with future self-destructive behav-
iors, including death (Rudd, 2006a). A his-
tory of repeated attempts further increases
the risk of death by suicide. Hence, under-
standing and labeling what is a suicide at-
tempt, and what is not, is an important task
that informs prognosis and the selection of
interventions. For example, the distinction
between attempted suicide and attempted homi-
cide is that the latter has a very clear defini-
tion as an attempt to murder someone else
(encompassing both intent and behavior),
whereas the former encompasses a wide
range of nonfatal self-inflicted behaviors. Al-
258
though the O’Carroll et al. definition of a
suicide attempt emphasized the importance
of an intent to kill oneself and of self-injuri-
ous behavior, clinically it is sometimes diffi-
cult to determine whether an individual in-
tended to kill themselves or whether an
individual actually engaged in a self-injurious
behavior (Brown et al., 2006). A clarification
of what is a suicide attempt will lead to the
development of specific, selective, and sensi-
tive questions that clarify precisely whether
the self-injurious behavior under investiga-
tion was intended to end one’s life (clear sui-
cidal intention), or was secondary to other
mitigating factors (Wagner et al., 2002).
Self-reported suicide attempts have
limited validity due to inconsistent defini-
tions and problems with recall bias (Kjoller,
Norlev, & Davidsen, 2004). Freeman, Wil-
son, Thigpen, and McGee (1974) conducted
a study that attempted to assess intention to
die in cases of self-injury. They concluded
that: “This study has shown that the vast ma-
jority of heretofore called ‘suicide attempts’
are in fact not that at all, but rather are, be-
haviorally speaking, events of self-injury or
self-poisoning. The intent is, in nearly all
cases, not that of dying, but of living” (p. 38).
In the CDC’s Youth Risk Behavior Survey
(2005), only 1 in 3 adolescents who reported
a suicide attempt required any medical atten-
tion, leaving the investigator very unclear
about what self-reporters are referring to
when they report a suicide attempt. No study
has yet to demonstrate the validity or reli-
ability of adolescents’ or adults’ self-reported
suicide attempts (Rosenbaum, 2006; Santa
Mina & Gallop, 1998).
Meehan, Lamb, Saltzman, and O’Car-
roll (1992) found that for every ten self-
reported attempts, only one resulted in hos-
pitalization. Only two others resulted in
medical attention. The intent and lethality of
the other 70% is unknown, thus seriously
compromising the validity of self-reported
suicide attempts. Since suicide means inten-
tional self-injury that results in death, any
meaningful definition of suicide attempt
should also incorporate a high likelihood of
death as well as a true intent to kill oneself.
The fact that Meehan et al. (1992) found that
A Revised Nomenclature: Part 1
the great majority of self-reported suicide at-
tempts did not even result in medical atten-
tion strongly indicates that the term is vastly
overused to describe other forms of distress or
self-injury. Thus, as O’Carroll et al. noted, “Be-
cause the term ‘attempted suicide’ potentially
means so many different things, it runs the risk
of meaning almost nothing at all” (p. 238).
Freeman, Wilson, Thigpen, and Mc-
Gee (1974) advocated for eliminating the
term suicide attempt, a recommendation that
we felt we could not abide, because, in part,
the term is too well ingrained in the language
of suicidology. Instead, we decided to more
narrowly define the term (which invokes in-
tention) and, in so doing, clearly distinguish
it from other terms, such as self-harm (which
lacks intent to die). The behavioral conse-
quence of self-harm is to change the circum-
stances of one’s environment or internal state
in a meaningful way (albeit through a self-
injurious act). This term held great appeal to
us, because it served as a conceptual juxtapo-
sition to suicide attempt (where the hoped-
for or intended outcome is to remove oneself
from one’s environment forever) and as an al-
ternative to “low lethality attempt with un-
certain intent.”
Meehan et al. (1992) suggested that to
assess a suicide attempt, a series of questions
are needed with independent verification
from a knowledgeable source, such as an
emergency room physician, in addition to
self-reports from the individual. This series
of questions should elicit a description of the
injury that occurred, if any, so that indepen-
dent raters may judge the potential lethality
of the event; whether medical attention or
hospitalization followed; and whether the
self-initiated behavior was indeed intended to
cause one’s own death or injury. We would
add that an investigation of the context of the
suicidal attempt (environmental, psychologi-
cal, ecological) would also assist in defining
the behavior and potentially classifying it.
Overlap Between Suicide and Nearly
Lethal Suicide Attempts
A number of recent studies have looked
at the degree to which there is a distinction
Silverman et al.
between suicide and nearly lethal suicide at-
tempts (or “medically serious suicide at-
tempts”) (Beautrais, 2001; Silverman & Si-
mon, 2001). Beautrais concluded that suicides
and medically serious suicide attempts are
two overlapping populations that share com-
mon psychiatric diagnostic and historical fea-
tures (current mood disorder; previous sui-
cide attempt; prior outpatient psychiatric
treatment; admission to psychiatric hospital
within the previous year; low income; a lack
of formal educational qualifications; exposure
to recent stressful interpersonal, legal, and
work-related life events), but are distin-
guished by gender (males were more likely to
kill themselves) and patterning of psychiatric
disorder (attempters were more likely than
those dying by suicide to have a current diag-
nosis of anxiety disorder and to be socially
isolated).
The Houston Case Control Study
found that up to 24% of nearly lethal suicide
attempters had spent less than 5 minutes be-
tween the decision to attempt suicide and the
actual nearly lethal attempt (5% reported
spending just one second) (Simon et al.,
2001). For 52.6% of the nearly lethal suicide
attempters, it was their first suicide attempt.
Male gender and a history of involvement in
physical fights differentiated impulsive at-
REFERENCES
American Psychiatric Association. (2003).
Practice guidelines for the assessment and treat-
ment of patients with suicidal behaviors. American
Journal of Psychiatry, 160(Suppl.), 1–60.
Andriessen, K. (2006). On “intention” in
the definition of suicide. Suicide and Life-Threaten-
ing Behavior, 36, 533–538.
Arensman, E., & Kerkhof, A.J.F.M.
(1996). Classification of attempted suicide: A re-
view of empirical studies, 1963–1993. Suicide and
Life-Threatening Behavior, 26, 46–67.
Aschkenasy, J. R., Clark, D. C., Zinn, D.,
& Richtsmeier, A. J. (1992). The non-psychiatric
physician’s responsibilities for the suicidal adoles-
cent. NY State Journal of Medicine, 92, 97–104.
Barber, M. E., Marzuk, P. M., Leon,
A.A.C., & Portera, L. (1998). Aborted suicide at-
tempts: A new classification of suicidal behavior.
American Journal of Psychiatry, 155, 385–389.
Beautrais, A. L. (2001). Suicide and seri-
259
tempters from non-impulsive suicide at-
tempters. Although some would argue that
“impulsivity” may have a proximal causal role
in the suicidal process for some individuals
(Mann, Waternaux, Haas, & Malone, 1999),
what may look like an impulsive act may ac-
tually be a culmination of a thinking and
planning process that had developed over
time but had not yet reached the “tipping
point” (Goldney, 1998).
CONCLUSION
The publication of the O’Carroll et al.
(1996) nomenclature sparked a revitalization
in addressing the language of suicidology and
its conceptual foundations (Andriessen, 2006;
De Leo et al., 2004, 2006; Silverman, 2006).
The Denver Veterans Administration VISN
19 Mental Illness Research, Education, and
Clinical Care (MIRECC) Nomenclature
Workgroup reviewed the critiques and rec-
ommendations made in response to the
O’Carroll et al. paper, and proceeded to ad-
dress as many as possible in their revision. In
the article that follows, Silverman, Berman,
Sanddal, O’Carroll, and Joiner (this issue)
present the revised nomenclature.
ous suicide attempts: Two populations or one?
Psychological Medicine, 31, 837–845.
Beautrais, A., Joyce, P., & Mulder, R.
(1999). Personality traits and cognitive styles as
risk factors for serious attempts among young
people. Suicide and Life-Threatening Behavior, 29,
37–47.
Beck, A. T., Davis, J. H., Frederick, C. J.,
Perlin, S., Pokorny, A. D., Schulman, R. E., et
al. (1973). Classification and nomenclature. In
H.L.P. Resnik & B. C. Hawthorne (Eds.), Suicide
prevention in the seventies (pp. 7–12). Washington,
DC: U.S. Government Printing Office.
Beck, A. T., Schuyler, D., & Herman, I.
(1974). Development of suicide intent scales. In
A. T. Beck, H.C.P. Resnick, & D. Lettieri (Eds.),
The prediction of suicide (pp. 45–69). Bowie, MD:
Charles Press.
Beck A., Steer, R., & Brown, G. (1993).
Dysfunctional attitudes and suicidal ideation in
260
psychiatric outpatients. Suicide and Life-Threaten-
ing Behavior, 23, 11–20.
Berman, A. L. (1993). Forensic suicidology
and the psychological autopsy. In A. A. Leenaars,
A. L. Berman, P. Cantor, R. E. Litman, & R. W.
Maris (Eds.), Suicidology: Essays in honor of Edwin
S. Shneidman (pp. 248–266). Northvale, NJ: Jason
Aronson.
Berman, A. L., & Cohen-Sandler, R.
(1982). Childhood and adolescent suicide re-
search: A critique. Crisis, 3, 3–15.
Berman, A. L., Shepherd, G., & Silver-
man, M. M. (2003). The LSARS-II: Lethality of
suicide attempt rating scale—updated. Suicide and
Life-Threatening Behavior, 33, 261–276.
Bridge, J., Barbe, R., Birmaher, B.,
Kolko, D., & Brent, D. (2005). Emergent suicid-
ality in a clinical psychotherapy trial for adoles-
cent depression. American Journal of Psychiatry,
162, 2173–2175.
Brown, G. K. (2001). A review of suicide
assessment measures for intervention research
with adults and older adults. Rockville, MD: U.S.
Department of Health and Human Services.
Brown, G. K., Henriques, G. R., Sosd-
jan, D., & Beck, A. T. (2004). Suicide intent and
accurate expectations of lethality: Predictors of
medical lethality of suicide attempts. Journal of
Consulting and Clinical Psychology, 72, 1170–1174.
Brown, G. K., Jeglic, E., Henriques,
G. R., & Beck, A. T. (2006). Cognitive therapy,
cognition, and suicidal behavior. In T. E. Ellis
(Ed.), Cognition and suicide: Theory, research, and
therapy (pp. 53–74). Washington, DC: American
Psychological Association.
Bryan, C. J., & Rudd, M. D. (2006). Ad-
vances in the assessment of suicide risk. Journal
Clinical Psychology/In Session, 62, 185–200.
Centers for Disease Control and Pre-
vention. (2005). Youth risk behavior surveillance sys-
tem. Retrieved November 23, 2005, from http://
www.cdc.gov/HealthyYouth/yrbs/index.htm
Compton, J., Daniel, S. S., & Goldston,
D. B. (in press). Suicidal behaviors in DSM: A
need for clarity. American Journal of Psychiatry.
Daigle, M. S., & Cote, G. (2006). Nonfa-
tal suicide-related behavior among inmates: Test-
ing for gender and type differences. Suicide and
Life-Threatening Behavior, 36, 670–681.
Dear, G. E. (1997). Writing this was in-
strumental, whatever my intent: A comment. Sui-
cide and Life-Threatening Behavior, 27, 408–410.
Dear, G. E. (2001). Further comments on
the nomenclature for suicide-related thoughts and
behavior. Suicide and Life-Threatening Behavior, 31,
234–235.
De Leo, D., Burgis, S., Bertolote, J.,
Kerkhof, A.D.M., & Bille-Brahe, U. (2004).
Definitions of suicidal behavior. In D. DeLeo, U.
Bille-Brahe, A.D.M. Kerkhof, & A. Schmidtke
A Revised Nomenclature: Part 1
(Eds.), Suicidal behavior: Theories and research find-
ings (pp. 17–39). Washington: Hogrefe & Huber.
De Leo, D., Burgis, S., Bertolote, J. M.,
Kerkhof, A.J.F.M., & Bille-Brahe, U. (2006).
Definitions of suicidal behavior: Lessons learned
from the WHO/EURO Multicentre Study. Crisis,
27, 4–15.
De Moore, G. M., & Robertson, A. R.
(1999). Suicide attempts by firearms and by leap-
ing from heights: A comparative study of survi-
vors. American Journal of Psychiatry, 9, 1425–1431.
Denning, D. G., Conwell, Y., King, D.,
& Cox, C. (2000). Method choice, intent and gen-
der in completed suicide. Suicide and Life-Threat-
ening Behavior, 30, 282–288.
Duberstein, P. R., & Conwell, Y. (1997).
Personality disorders and completed suicides: A
methodological and conceptual review. Clinical
Psychology: Science and Practice, 4, 359–376.
Egel, L. (1999). On the need for a new
term for suicide. Suicide and Life-Threatening Be-
havior, 29, 393–394.
Ellis, T. E. (1988). Classification of sui-
cidal behavior: A review and step toward integra-
tion. Suicide and Life-Threatening Behavior, 18,
358–371.
Farberow, N. L. (Ed.). (1980). Indirect
self-destructive behavior: Classification and char-
acteristics. In N. L. Farberow (Ed.), The many faces
of suicide: Indirect self-destructive behavior (pp. 15–
27). New York: McGraw-Hill.
Fawcett, J., Scheftner, W. A., Fogg, L.,
Clark, D. C. (1990). Time-related predictors of
suicide in major affective disorder. American Jour-
nal of Psychiatry, 147, 1189–1194.
Fischer, E., Comstock, G., Monk, M., &
Spencer, D. (1993). Characteristics of completed
suicides: Implications of differences among meth-
ods. Suicide and Life-Threatening Behavior, 23, 91–
100.
Freeman, D. J., Wilson, K., Thigpen, J.,
& McGee, R. F. (1974). Assessing intention to die
in self-injury behavior. In C. Neuringer (Ed.), Psy-
chological assessment of suicide risk (pp. 18–42).
Springfield, IL: Charles C. Thomas.
Garrison, C. Z., McKeown, R. E., Valois,
R. F., et al. (1993). Aggression, substance abuse,
and suicidal behaviors in high school students.
American Journal of Public Health, 83, 179–184.
Goldney, R. D. (1998). Variation in sui-
cide rates: The “Tipping Point.” Crisis, 19, 136–
138.
Goldston, D. B. (2003). Measuring suicidal
behavior and risk in children and adolescents. Wash-
ington, DC: American Psychological Association.
Hammad, T. A., Laughren, T., & Racoo-
sin, J. (2006). Suicidality in pediatric patients
treated with antidepressant drugs. Archives of Gen-
eral Psychiatry, 63, 332–339.
Hjelmeland, H., & Hawton, K. (2004).
Silverman et al.
Intentional aspects of non-fatal suicidal behavior.
In D. De Leo, U. Bille-Brahe, A. Kerkhof, & A.
Schmidtke (Eds.), Suicidal behavior: Theories and
research findings (pp. 67–78). Cambridge, MA:
Hogrefe & Huber.
Hjelmeland, H., & Knizek, B. L. (1999).
Conceptual confusion about intentions and mo-
tives of nonfatal suicidal behavior: A discussion of
terms employed in the literature of suicidology.
Archives of Suicide Research, 5, 275–281.
Jenkins, R., & Singh, B. (2000). General
population strategies of suicide prevention. In K.
Hawton & K. van Heeringen (Eds.), The interna-
tional handbook of suicide and attempted suicide (pp.
597–615). Chichester, England: John Wiley.
Jobes, D. A., Berman, A. L., & Josselson,
A. R. (1987). Improving the validity and reliability
of medical-legal certifications of suicide. Suicide
and Life-Threatening Behavior, 17, 310–325.
Jobes, D. A., Casey, J. O., Berman, A. L.,
& Wright, D. G. (1991). Empirical criteria for
the determination of suicide. Journal of Forensic
Sciences, 36, 244–256.
Kessler, R. C., Borges, G., & Walters,
E. E. (1999). Prevalence of and risk factors for
lifetime suicide attempts in the national comor-
bidity survey. Archives of General Psychiatry, 56,
617–626.
Kessler, R., Berglund P., Borges, G.,
Nock, M., & Wang, P. S. (2005). Trends in sui-
cide ideation, plans, gestures, and attempts in the
United States, 1990–1992 to 2001–2003. Journal
of the American Medical Association, 293, 2487–
2495.
Kidd, S. A. (2003). The need for improved
operational definition of suicide attempts: Illustra-
tions from the case of street youth. Death Studies,
27, 449–455.
Kjoller, M., Norlev, J., & Davidsen, M.
(2004). Recall bias and suicidal behavior in a six
year follow-up study. 10th European Symposium on
Suicide and Suicdal Behaviour (p. 118). Copenha-
gen, Denmark: National Institute of Public Health.
Kraemer H. C., Kazdin, A. E., Offord,
D. R., Kessler, R. C., Jensen, P. S., & Kupfer,
D. J. (1997). Coming to terms with the terms of
risk. Archives of General Psychiatry, 54, 337–343.
Kreitman, N. (1977). Parasuicide. London:
John Wiley.
Leenaars, A. A., DeLeo, D., Diekstra,
R.F.W., Goldney, R. D., Kelleher, M. J., Les-
ter, D., et al. (1997). Consultations for research
in suicidology. Archives of Suicide Research, 3, 139–
151.
Lester, D. (1990). A classification of acts
of attempted suicide. Perceptual and Motor Skills,
70, 1245–1246.
Linehan, M. M. (1997). Behavioral treat-
ments of suicidal behaviors. Definitional obfusca-
tion and treatment outcomes. In D. Stoff & J. J.
261
Mann (Eds.), The neurobiology of suicide: From the
bench to the clinic (pp. 302–328). New York: Annals
of the New York Academy of Sciences.
Linehan, M. M. (2000). Behavioral treat-
ments of suicidal behavior: Definitional obfusca-
tion and treatment outcomes. In R. W. Maris,
S. S. Canetto, J. L. McIntosh, & M. M. Silverman
(Eds.), Review of suicidology 2000 (pp. 84–111).
New York: Guilford.
Mann, J. J., Waternaux, C., Haas, G. L.,
& Malone, K. M. (1999). Toward a clinical model
of suicidal behavior in psychiatric patients. Ameri-
can Journal of Psychiatry, 156, 181–189.
Maris, R. W. (1992). Overview of the
study of suicide assessment and prediction. In
R. W. Maris, A. L. Berman, J. T. Maltsberger, R.
Yufit (Eds.), Assessment and prediction of suicide (pp.
3–22). New York: Guilford.
Maris, R. W., Berman, A. L., & Silver-
man, M. M. (2000). The theoretical component in
suicidology. In R. W. Maris, A. L. Berman, & M.
M. Silverman, Comprehensive textbook of suicidology
(pp. 26–61). New York: Guilford.
Marusic, A. (2004). Toward a new defini-
tion of suicidality? Are we prone to Fregoli’s illu-
sion? Crisis, 25, 145–146.
Mayo, D. J. (1992). What is being pre-
dicted? The definition of “suicide.” In R. W.
Maris, A. L. Berman, J. T. Maltsberger, & R. I.
Yufit (Eds.), Assessment and prediction of suicide (pp.
88–101). New York: Guilford.
McIntosh, J. L. (1985). Research on suicid-
ology: A bibliography. Westport, CT: Greenwood
Press.
McIntosh, J. L. (1992). Methods of sui-
cide. In R. W. Maris, A. L. Berman, J. T. Malts-
berger, & R. I. Yufit (Eds.), Assessment and predic-
tion of suicide (pp. 381–417). New York: Guilford
Press.
McKeown, R., Garrison, C. Z., Cuffe,
S. P., Waller, J. L., Jackson, K. L., & Addy,
C. L. (1998). Incidence and predictors of suicidal
behaviors in a longitudinal sample of young ado-
lescents. Journal of the American Academy of Child
and Adolescent Psychiatry, 37, 612–619.
Meehan, P. J., Lamb, J. A., Saltzman,
L. E., & O’Carroll, P. W. (1992). Attempted
suicide among young adults: Progress toward a
meaningful estimate of prevalence. American Jour-
nal of Psychiatry, 149, 41–44.
Moller, J. (1997). Suicide and self harm:
What do we mean and what do we measure? Paper
presented at the International Association for Sui-
cide Prevention Conference, Adelaide, Australia,
1997.
Moscicki, E. K. (1989). Epidemiological
surveys as tools for studying suicidal behavior: A
review. Suicide and Life-Threatening Behavior, 19,
131–146.
Moscicki, E. K. (1995). Epidemiology of
262
suicidal behavior. Suicide and Life-Threatening Be-
havior, 25, 22–35.
O’Carroll, P. W. (1989). A consideration
of the validity and reliability of suicide mortality
data. Suicide and Life-Threatening Behavior, 19,
1–16.
O’Carroll, P. W., Berman, A. L., Maris,
R. W., Moscicki, E. K., Tanney, B. L., & Silver-
man, M. M. (1996). Beyond the Tower of Babel:
A nomenclature for suicidology. Suicide and Life-
Threatening Behavior, 26, 237–252.
O’Carroll, P. W., Berman, A. L., Maris,
R., Moscicki E., Tanney, B., & Silverman,
M. M. (1997). Beyond the Tower of Babel: A no-
menclature for suicidology. In R. J. Kosky, H. S.
Eshkevari, R. D. Goldney, & R. Hazzan (Eds.),
Suicide prevention: The global context (pp. 23–39).
New York: Plenum Press.
Orbach, I. (1997). A taxonomy of factors
related to suicidal behavior. Clinical Psychology: Sci-
ence and Practice, 4, 208–224.
Phillips, D. P., & Ruth, T. E. (1993). Ad-
equacy of official suicide statistics for scientific re-
search and public policy. Suicide and Life-Threaten-
ing Behavior, 23, 307–319.
Range, L. M., & Knott, E. C. (1997).
Twenty suicide assessment instruments: Evalua-
tion and recommendations. Death Studies, 21, 25–58.
Rosenbaum, J. E. (2006). Reborn a virgin:
Adolescents’ retracting of virginity pledges and
sexual histories. American Journal of Public Health,
96, 1098–1103.
Rosenberg, M. L., Davidson, L. E.,
Smith, J. C., Berman, A. L., Buzbee, H.,
Gantner, G., et al. (1988). Operational criteria
for the determination of suicide. Journal of Forensic
Sciences, 32, 1445–1455.
Rudd, M. D. (1997). “What is in a Name
. . .” Suicide and Life-Threatening Behavior, 27,
326–327.
Rudd, M. D. (2000). Integrating science
into the practice of clinical suicidology: A review
of the psychotherapy literature and a research
agenda for the future. In R. W. Maris, S. S. Ca-
netto, J. L. McIntosh, & M. M. Silverman (Eds.),
Review of suicidology 2000 (pp. 49–83). New York:
Guilford.
Rudd, M. D. (2006a). Suicidality in clinical
practice: Anxieties and answers. Journal of Clinical
Psychology: In Session, 62, 157–159.
Rudd, M. D. (2006b). The assessment and
management of suicidology. Sarasota, FL: Profes-
sional Resource Press.
Rudd, M. D., & Joiner, T. E., Jr. (1998).
The assessment, management and treatment of
suicidality: Towards clinically informed and bal-
anced standards of care. Clinical Psychology: Science
and Practice, 5, 135–150.
Rudd, M. D., Joiner, T. E., Jr., Jobes,
D. A., & King, C. A. (1999). The outpatient treat-
A Revised Nomenclature: Part 1
ment of suicidality: An integration of science and
recognition of its limitations. Professional Psychol-
ogy: Research and Practice, 30, 437–446.
Rudd, M. D., Joiner, T. E., & Rajab,
M. H. (1999). Treating suicidal behavior: An effective
time-limited approach. New York: Guilford.
Santa Mina, E. E., & Gallop, R. M.
(1998). Childhood sexual and physical abuse and
adult self-harm and suicidal behavior: A literature
review. Canadian Journal of Psychiatry, 43, 793–
800.
Shea, S. C. (1999). The practical art of sui-
cide assessment: A guide for mental health professionals
and substance abuse counselors. New York: Wiley.
Shneidman, E. (1968). Classificationn of
suicidal phenomena. Bulletin of Suicidology, 2, 1–9.
Shneidman, E. (1985). Definition of suicide.
Northvale, NJ: Jason Aronson.
Silverman, M. M. (2006). The language of
suicidology. Suicide and Life-Threatening Behavior,
36, 519–532.
Silverman, M. M., Berman, A. L., Sand-
dal, N. D., O’Carroll, P. W., & Joiner, T. E.,
Jr. (this issue). Rebuilding the Tower of Babel: A
revised nomenclature for the study of suicide and
suicidal behaviors. Part II: Suicide-related ide-
ations, communications, and behaviors. Suicide
and Life-Threatening Behavior, 37.
Silverman, M. M., & Maris, R. W.
(1995). The prevention of suicidal behaviors: An
overview. Suicide and Life-Threatening Behavior, 25,
10–21.
Silverman, M. M., & Simon, T. (Eds.).
(2001). The Houston case-control study of nearly
lethal suicide attempts. Suicide and Life-Threaten-
ing Behavior, 31(Suppl.), 1–84.
Simon, R. I. (2006). Imminent suicide: The
illusion of short-term prediction. Suicide and Life-
Threatening Behavior, 36, 296–301.
Simon, T. R., Swann, A. C., Powell,
K. E., Potter, L. B., Kresnow, M-J, & O’Car-
roll, P. W. (2001). Characteristics of impulsive
suicide attempts and attempters. Suicide and Life-
Threatening Behavior, 31(Suppl.), 49–59.
Smith, K., Conroy, R. W., & Ehler,
B. D. (1984). Lethality of suicide attempt rating
scale. Suicide and Life-Threatening Behavior, 14,
215–243.
Sommer-Rotenberg, D. (1998). Suicide
and language. Canadian Medical Association Journal,
159, 239–240.
U.S. Department of Health and Human
Services. (2006). Research on the reduction and pre-
vention of suicidality (R01). Retrieved May 20,
2006, from http://grants.nih.gov/grants/guide/pa-
files/PA-06-438.html
U.S. Department of Health and Human
Services, Public Health Service. (2001). Na-
tional strategy for suicide prevention: Goals and objec-
tives for action. Rockville, MD: Author.
Silverman et al.
Wagner, B. M., Wong, S. A., & Jobes,
D. A. (2002). Mental health professionals’ deter-
minations of adolescent suicide attempts. Suicide
and Life-Threatening Behavior, 32, 284–300.
Westefeld, J. S., Range, L., Rogers, J. R.,
Maples, M. R., Bromley, J. L., & Alcorn, J.
(2000). Suicide: An overview. The Counseling Psy-
chologist, 28, 445–510.
World Health Organization. (1968):
263
Prevention of suicide (Public Health Paper No. 35).
Geneva: Author.
World Health Organization. (1986).
Summary report: Working group on preventive prac-
tices in suicide and attempted suicide. Copenhagen:
WHO Regional Office for Europe.
Manuscript Received: June 15, 2006
Revision Accepted: October 8, 2006