rebuilding the tower of babel: a revised nomenclature for ......rebuilding the tower of babel: a...

264 Suicide and Life-Threatening Behavior 37(3) June 2007 2007 The American Association of Suicidology

Rebuilding the Tower of Babel: A RevisedNomenclature for the Study of Suicideand Suicidal BehaviorsPart 2: Suicide-Related Ideations,Communications, and BehaviorsMorton M. Silverman, MD, Alan L. Berman, PhD, Nels D. Sanddal, MS,Patrick W. O’Carroll, MD, MPH, and Thomas E. Joiner, Jr., PhD

A revised and refined version of the O’Carroll et al. (1996) nomenclaturefor suicidology is presented, with a focus on suicide-related ideations, communica-tions, and behaviors. The hope is that this refinement will result in the develop-ment of operational definitions and field testing of this nomenclature in clinicaland research settings. This revision would not have been possible without theinternational collaboration and dialogue addressing the nomenclature of suicidol-ogy since the O’Carroll et al. nomenclature appeared in 1996.

Although it is doubtful that we will ever be able to construct universallyunambiguous criteria to comprehensively characterize suicidal behaviors (and,overall, firmly establish the intention behind them), for scientific clarity it wouldbe highly desirable that the set of definitions and the associated terminology beexplicit and generalizable.

De Leo, Burgis, Bertolote, Kerkhof, & Bille-Brahe, 2006, p. 5)

This effort was initially encouraged and supported, in part, by the Suicide Prevention ResearchCenter (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 sponsoreda meeting of the MIRECC Nomenclature Workgroup in July, 2005, which resulted in the preparationof this revision. The Director of the Denver VA VISN 19 MIRECC is Lawrence E. Adler, MD. Thecontents of this article are solely the responsibility of the authors and do not necessarily represent theofficial views of the Denver VA VISN 19 MIRECC.

Earlier drafts were read by David A. Jobes, PhD, Herbert Nagamoto, MD, and Pamela Staves,RN, MS, NP. Additional comments on the nomenclature were received from the U. S. Department ofDefense Suicide Nomenclature Work Group and representatives from the medical examiners’ offices ofthe Air Force, Navy, Army, Marines, and Coast Guard. The co-authors are grateful for their contribu-tions, critiques, and recommendations.

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 Consultantto the Denver VA VISN 19 MIRECC; Alan Berman is Executive Director of the American Associationof 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; andThomas Joiner, Jr. is the Bright-Burton Professor of Psychology at The Florida State University.

Address correspondence to Morton M. Silverman, MD, 4858 S. Dorchester Avenue, Chicago.IL., 60615–2012; E-mail: [email protected]

Silverman et al. 265

Although a number of investigators have TABLE 1Revised Nomenclatureadopted the O’Carroll et al. (1996) nomen-

clature and applied it in their studies (BryanAn outline indicating superset/subset relationships& Rudd, 2003; Daigle & Cote, 2006; Golds-of the revised nomenclature for self-injuriouston, 2003; Kidd, 2003; Rudd & Joiner, 1998;thoughts and behaviors (with elaboration on sui-Wagner, Wong, & Jobes, 2002), and otherscidal thoughts and behaviors)have acknowledged its role in highlighting

the need for clarification of terms (Dear, Self-Injurious Thoughts and Behaviors1997, 2001; De Leo, Burgis, Bertolote, Kerk- A. Risk-Taking Thoughts and Behaviorshof, & Bille-Brahe, 2004, 2006; Hjelmeland 1. With Immediate Risk& Knizek, 1999; Linehan, 1997, 2000; Maru- a. results in no injurysic, 2004; Rudd, 1997, 2000; Rudd, Joiner, b. results in injuryJobes, & King, 1999), the nomenclature has c. results in deathnot been widely used in the research and 2. With Remote Risk

a. results in no injuryclinical communities. The rationale behindb. results in injurythe rebuilding of the O’Carroll et al. nomen-c. results in deathclature is to increase the ability of clinicians,

B. Suicide-Related Thoughts and Behaviorsepidemiologists, policy makers, and research-1. Suicide-Related Ideationsers to better communicate with each othera. With No Suicidal Intentand study similar populations at risk for sui-(1) casualcide-related ideations, communications, and(2) transientbehaviors (Silverman, Berman, Sanddal,(3) passiveO’Carroll, & Joiner, this issue). (4) active(5) persistent

b. With Undetermined Degree of SuicidalTHE REVISED NOMENCLATURE Intent

(1) casualIn our revised nomenclature outline (2) transient

(Table 1), we had to account for terms in (3) passivegeneral usage that we felt would be difficult (4) active

(5) persistentto eliminate or easily re-name. We had thec. With Some Suicidal Intentmost difficulty with the terms suicidal threat,(1) casualsuicidal gesture, and suicidal plan. In the end,(2) transientwe eliminated suicide gesture, mainly be-(3) passivecause of the pejorative quality it has acquired(4) activeover time (Daigle & Cote, 2006). We created(5) persistenta superset category called suicide-related

2. Suicide-Related Communicationscommunication to account for suicidal threata. With No Suicidal Intentand suicide plan. A suicide-related communi-(1) verbal or nonverbal; passive or active

cation can include a suicide note (suicidal (Suicide Threat, Type I)threat) or a systematic formulation of a pro- (2) a proposed method of achieving a po-gram of action that can lead to self-injury tentially self-injurious outcome (Sui-(suicide plan). Further, we tried to streamline cide Plan, Type I)the nomenclature by eliminating the suffix b. With Undetermined Degree of Suicide“-related” and, in so doing, clearly change Intentthe supersets to suicidal ideation, suicidal (1) verbal or nonverbal; passive or covertcommunication, and suicidal behavior. How- (Suicide Threat, Type II)

(2) a proposed method of achieving a po-ever, despite the brevity and succinctness thattentially self-injurious outcome (Sui-these new terms would convey, we realizedcide Plan, Type II)that the added adjective “-related” was neces-

266 A Revised Nomenclature: Part 2

TABLE 1 A full discussion of the OCDS system andthe WHO definitions can be found elsewhereContinued(De Leo et al., 2006; O’Carroll et al., 1996).

c. With Some Degree of Suicidal Intent The component elements that uniquely de-(1) verbal or nonverbal; passive or covert fine each suicide-related thought and behav-(Suicide Threat, Type III) ior are illustrated in Tables 2 and 3, whereas(2) a proposed method of achieving a po-

the relationships between the proposed termstentially self-injurious outcome (Sui-for suicide-related behaviors and currentlycide Plan, Type III)used terminology may best be understood by3. Suicide-Related Behaviorsreference to Table 4.a. With No Suicidal Intent

(1) without injuries (Self-Harm, Type I) A related issue, discussed among sui-(2) with injuries (Self-Harm, Type II) cidologists on the Internet, involved the dis-(3) with fatal outcome (Self-Inflicted Un- tinction between behavior, which can be con-intentional Death) strued as either a discrete event or a continuous

b. With Undetermined Degree of Suicide process that is repeatable, and an act, whichIntent may signify a more goal-directed event.(1) without injuries (Undetermined Sui- Here, again, in deciding how to revise andcide-Related Behavior, Type I)

refine, we encountered what seemed to be(2) with injuries (Undetermined Suicide-splitting hairs. We chose to keep with ourRelated Behavior, Type II)plan to try to maintain the commonly used(3) with fatal outcome (Self-Inflicted

Death with Undetermined Intent)c. With Some Degree of Suicidal Intent(1) without injuries (Suicide Attempt, TABLE 2Type I) Suicide-Related Thoughts and Behaviors

(2) with injuries (Suicide Attempt, TypeII) Suicide-Related Ideations

Suicide-Related Communications(3) with fatal outcome (Suicide)Suicide Threat I (no intent)Suicide Threat II (undetermined intent)Additional Modifiers for B2 (a, b, c) and B3 (a, b, c):

A. Intrapersonal focus—to change internal Suicide Threat III (some intent)Suicide Plan I (no intent)state (escape/release)

B. Interpersonal focus—to change external Suicide Plan II (undetermined intent)Suicide Plan III (some intent)state (attachment/control)

C. Mixed focus Suicide–Related BehaviorsSelf-Harm (no intent)Self-Harm, Type I (no injury)Self-Harm, Type II (injury)Self-Inflicted Unintentional Death (fatal out-sary after all, because we were also trying tocome)subsume under these superset categories such

Undetermined Suicide-Related Behavior (unde-concepts as suicide threat, suicide plan, and termined degree of suicidal intent)deliberate self-harm, which may not, in their Undetermined Suicide-Related Behavior,strictest usage, be purely secondary to sui- Type I (no injury)cidal ideation, communication, or behavior, Undetermined Suicide-Related Behavior,but, rather, to conditions closely related to Type II (injury)

Self-Inflicted Death with Undetermined In-these superset categories.tent (fatal outcome)The revised nomenclature in Table 1

Suicide Attempt (some degree of suicidal in-derive from the Operational Criteria for thetent)Determination of Suicide (OCDS) definition

Suicide Attempt, Type I (no injury)of suicide, which differ somewhat from theSuicide Attempt, Type II (injury)World Health Organization’s (WHO) defini-Suicide (fatal outcome)tions (Rosenberg et al., 1988; WHO, 1986).


TABLE 3 conceptualized suicide-related ideation as anexample of weighing options, suicide threat asSuicide-Related Behaviorsa form of a coping communication to regain

With No Suicidal Intent (Self-Harm) control or attachment, self-harm as a deficientWithout Injuries (Self-Harm, Type I) coping response to obtain a time out or toWith Injuries (Self-Harm, Type II) reset an imbalance between stressors and re-With Fatal Outcomes (Self-Inflicted Uninten-

sources, and suicide as a final solution to ob-tional Death)tain release or escape (often from psychologi-With Undetermined Degree of Suicidal Intentcal pain). We base our definitions on the(Undetermined Suicide-Related Behavior)presence or absence of suicidal intent. ThereWithout Injuries (Undetermined Suicide-

Related Behavior, Type I) are some, however, who suggest that suchWith Injuries (Undetermined Suicide- definitions are nonscientific (Egel, 1999), im-Related Behavior, Type II) precise, vague, and not easily quantifiable or

With Fatal Outcome (Self-Inflicted Death qualifiable (De Leo et al., 2006; Mayo, 1992).with Undetermined Intent)

With Some Degree of Suicidal Intent (Suicide Definitions for the New NomenclatureAttempt)

Without Injuries (Suicide Attempt, Type I)When we began the task of revisingWith Injuries (Suicide Attempt, Type II)

the nomenclature we were cognizant of theWith Fatal Outcome (Suicide)number of terms that still existed in the re-search and clinical literatures. We again re-viewed existing nomenclatures and theoreti-cal models to ascertain the key elements thatparlance as best as possible, and therefore left

the term behavior in the original definitions, are most frequently associated with the sui-cidal process and the terms used to describealbeit acknowledging that, more often than

not, what is being labeled by the observer is these cognitions, emotions, and behaviors(Silverman et al., this issue). In their reviewa discrete event (“act”) as opposed to a poten-

tially continuous process (“behavior”). of the historical definitions of suicide, DeLeo et al. (2006) found a number of commonAs O’Carroll et al. cautioned, it is of

great importance that readers understand key aspects from all the definitions: “Theoutcome of the behavior, the agency of thethat neither Table 1 nor Figures 1 and 2 are

meant as a clinically applicable classification of act, the intention to die or stop living in or-der to achieve a different status, the con-suicide-related thoughts and behaviors, nor

are they meant to reflect causal or behavioral sciousness/awareness of the outcomes” (p. 7).We determined that we needed to accountpathways. Rather, they are simply meant to

clarify which terms represent subsets or su- only for a small number of terms that cap-tured the essential components. These termspersets of other terms; however, such an out-

line displays only the universe of terms that are: suicide-related ideations, suicide-related com-munications (suicide threats and suicidewe feel should comprise the nomenclature of

suicide-related thoughts and behaviors. For plans), and suicide-related behaviors (self-harm,suicide attempts, and suicide). Rather thanpurposes of comparison, Figures 1 and 2

show the mutually exclusive relationships adding additional terms to the suicide no-menclature to account for combinations andamong these terms. Once validated, this re-

vised nomenclature might well become the permutations of clinical variables (e.g., pres-ence or absence of intent, self-injury, andcommon vocabulary for the field.

When thinking about the different ter- outcome), we chose to simplify the terminol-ogy by demarcating subtypes (Type I, Typeminologies in clinical terms, whereby the cli-

nician can understand the suicidal behavior II, etc.) that would account for the variationswithin each suicide-related category.as a form of coping with or responding to

different contexts (internal and external), we The definitions of the terms below are


TABLE 4Conversion Table of Terminology

EXISTING TERMS REVISED TERMS

Accidental Suicide Self-Inflicted Unintentional DeathCompleted Suicide SuicideIntentional Self-Harm Self-Harm Types I–IIIntentional Self-InjuryDeliberate Self-HarmInstrumental Suicide-Related Behavior Suicide Threat, Types I–IIINonsuicidal Self-Injury Self-Harm, Types I–IIParasuicide Suicide Attempt, Types I–IISuicidal Behaviors Suicide-Related Behaviors

Suicide-Related IdeationsSuicide-Related Communications

Suicidality Suicide-Related BehaviorsSuicide Attempt Suicide Attempt, Types I–IISuicide Gesture Self-Harm, Types I–IISuicide Plan Suicide Plan, Types I–IIISuicide Threat Suicide Threat, Types I–IIThought/Ideation Suicide-Related Ideations

presented in their logical branches, rather terpersonal act of imparting, conveying, ortransmitting thoughts, wishes, desires, or in-than alphabetically, so that their relationships

to other terms are clearer. Table 2 and Figures tent for which there is evidence (either ex-plicit or implicit) that the act of communica-1 and 2 provide a visual reference of these

relationships. A basic and overriding premise tion is not itself a self-inflicted behavior orself-injurious. We included under this cate-is that our nomenclature only refers to those

ideations, communications (threats and plans), gory those verbal and nonverbal communica-tions that may have suicidal intent but haveand behaviors that are self-initiated. Our no-

menclature schema is based on the key con- no injurious outcome. This broad definitionincludes two subsets. A Suicide Threat is anycepts of differentiating between the presence

or absence of suicidal intent, and the pres- interpersonal action, verbal or nonverbal,without a direct self-injurious component,ence or absence of injury. We purposely

avoided adding a third domain of lethality (or that a reasonable person would interpret ascommunicating or suggesting that suicidaldegree of injury) because we currently lack

any agreed-upon definition or measure. behavior might occur in the near future. ASuicide Plan is a proposed method of carryingHere, injury refers only to self-inflicted in-

juries, implying, by definition, that they are out a design that will lead to a potentiallyself-injurious outcome; a systematic formula-potentially self-destructive or suicidal in na-

ture—leaving aside the measurement of the tion of a program of action that has the po-tential for resulting in self-injury.degree to which they may be lethal. Figures

3 and 4 illustrate the relationship of the key Because suicide-related phenomenaoften have interpersonal motivations, wecomponents and terms for suicide-related be-

haviors. thought of suicide-related communicationsas a half-way point between private thoughtsabout suicide (cognitions) and actions di-Suicide-Related Communicationsrected at self-injury (behaviors). Communi-cation is interpersonal in nature and involvesThe first set of terms falls broadly un-

der Suicide-Related Communications: Any in- putting into words how one might advance


Figure1.Suicide-relatedcommunications.


Figure2.Suicide-relatedbehaviors.


Figure 3. Nomenclature for Suicide-Related Behaviors.

from ideation to action (suicide plan), or how it Suicide Threat, Type I. If there is an unde-termined level of suicidal intent, it is labeledone might move from ideation to pre-action

(suicide threat). If there is no suicidal intent Suicide Threat, Type II. If there is some degreeof suicidal intent we call it Suicide Threat,associated with the communication, we label


Figure 4. Schematic Representation of Suicide-Related Behaviors.

Type III. If there is no intent but the expres- intended at some undetermined or someknown degree to kill himself/herself. Suicide-sion of a definite plan to end one’s life, it is

called a Suicide Plan, Type I. If there is an un- Related Behaviors can result in no injuries, in-juries, or death. Suicide-related behaviors com-determined level of intent with a definite

plan, it is called Suicide Plan, Type II. If there prise self-harm, self-inflicted unintentionaldeath, undetermined suicide-related behaviors,is some suicidal intent with a definite plan,

we label it Suicide Plan, Type III. self-inflicted death with undetermined intent,suicide attempt, and suicide.

The first major bifurcation of the no-Suicide-Related Behaviorsmenclature is based on intent to die, whichis answered affirmatively, negatively, or withWe chose the term Suicide-Related Be-

haviors over self-injurious behaviors or self- uncertainty (De Leo et al., 2004, 2006). Ifthere was not an intent to die associated withinitiated behavior because it best captured

our emphasis on behaviors that don’t always the suicidal behavior, then a separate branchof the nomenclature is explored, starting withresult in death, but are “related” to the pro-

cess or concept of self-inflicted death (De Self-Harm. Self-harm is defined as a self-inflicted, potentially injurious behavior forLeo, Bertolote, & Lester, 2002). Suicide-

related behavior is a self-inflicted, potentially which there is evidence (either implicit or ex-plicit) that the person did not intend to killinjurious behavior for which there is evi-

dence (either explicit or implicit) either that: himself/herself (i.e., had no intent to die).Persons engage in self-harm behaviors when(a) the person wished to use the appearance

of intending to kill himself/herself in order they wish to use the appearance of intendingto kill themselves in order to attain someto attain some other end; or (b) the person


other end (e.g., to seek help, to punish oth- mined categories. Nevertheless, we felt thatthis “undetermined” best described the situa-ers, to receive attention, or to regulate nega-

tive mood). Self-harm may result in no injur- tion when there is a self-inflicted potentiallyinjurious behavior where intent is unknown.ies, injuries, or death. If the self-harm did not

result in injury, it is defined as Self-Harm, Regarding observed behavior that pre-viously might have been labeled a suicideType I. If the self-harm resulted in nonfatal

injury, it is defined as a Self-Harm, Type II. If gesture, if there is no suicidal intent, we sug-gest that the behavior be labeled as Self-the self-harm resulted in death, it is classified

as a Self-Inflicted Unintentional Death, and de- Harm, Type I (no injury) or Self-Harm, TypeII (with injury), because the purpose of thefined as death from self-inflicted injury, poi-

soning, or suffocation where there is evi- behaviors we used to call “gestures” wasreally to alter one’s life circumstances (inter-dence (either explicit or implicit) that there

was no intent to die. This category includes personal or intrapersonal) in a manner thatwas without suicidal intent, but involved self-those injuries or poisonings described as un-

intended or accidental. inflicted behaviors (whether or not it resultedin injuries). If there is an undetermined de-Due to the controversy generated by

O’Carroll et al.’s prior dichotomous bifurca- gree of suicidal intent, it is labeled as Unde-termined Suicide-Related Behavior, Type I (notion of intent to die (yes/no), we recognized

the need to add a third category—undeter- injury), or Undetermined Suicide-Related Be-havior, Type II (with injury).mined intent to die by suicide—when there

is a self-inflicted, potentially injurious behav- Suicide Attempt is now defined as a self-inflicted, potentially injurious behavior withior where intent is unknown. For example, if

a person is unable to admit positively to the a nonfatal outcome for which there is evi-dence (either explicit or implicit) of intent tointent to die, due to being unconscious, un-

der the influence of alcohol or other drugs die. A Suicide Attempt may result in no in-juries, injuries, or death. If there is some de-(and therefore cognitively impaired), psy-

chotic, delusional, demented, dissociated, gree of suicidal intent, then we label it as Sui-cide Attempt, Type I (no injury), or Suicidedisoriented, delirious, or in another state of

altered consciousness; or is reluctant to admit Attempt, Type II (with injury), regardless ofthe degree of injury or lethality of method.positively to the intent to die due to other

psychological states, we categorize the self- If the suicide attempt resulted in death, it isdefined as a Suicide. Hence, our use of theinjurious behavior as an Undetermined Suicide-

Related Behavior. If the behavior was with an term suicide attempt relates specifically to aself-inflicted act with the intent to end one’sundetermined degree of suicidal intent and

without injuries, it is called an Undetermined life, and is distinguished from self-harm andundetermined suicide-related behavior. WeSuicide-Related Behavior, Type I. If there were

injuries, it is called an Undetermined Suicide- had some misgivings about the term completedsuicide, because we believe it is redundant andRelated Behavior, Type II. If the injuries were

fatal, it is called a Self-Inflicted Death with Un- potentially pejorative, although we recognizethe ubiquitous use in the parlance of suicid-determined Intent (self-inflicted death for

which intent is either equivocal or unknown). ology. For purposes of the nomenclature, wedecided to simply use the term suicide to de-We struggled over the use of the term

undetermined versus equivocal, unexplained, in- note when there was a self-inflicted deathwith evidence (either explicit or implicit) ofdeterminate, unknown, or probable to distin-

guish this category from actions with no sui- intent to die. We believe that our simplifieddefinition contains all the “fundamental re-cidal intent and actions with some degree of

suicidal intent. We fully recognized that the quirements” as set forth by the WHO/EURO Multicentre Study on Parasuicide:medical examiner classification system does

not allow for the clarification of undeter- “responsibility, awareness of the potential le-


thality of the act, intention to die/provoke Using other definitions, research has shownthat suicide attempters and those who die bythose changes that the subject is assumed to

prefer to living conditions otherwise perceived suicide may be two separate, but overlappingpopulations (Beautrais, 2001). Using our re-as unbearable” (De Leo et al., 2006, pg. 12).

Substituting Self-Harm for Instrumen- vised nomenclature, those who engage inself-harm and those who engage in suicidetal Suicide-Related Behavior and Deliberate

Self-Harm. O’Carroll et al. initially chose attempts may have some overlapping features.the term instrumental suicide-related behavior(ISRB) to encompass instrumental suicide-related behavior with or without injury, and CONCLUSIONwith fatal outcome (accidental death). Wewere subsequently convinced that a better With a recent number of other no-

menclatures to choose from (Brown, Jeglic,term for ISRB is deliberate self-harm (DSH), aterm used by our colleagues, especially in Henriques, & Beck, 2006; De Leo et al.,

2006; Hammad, Laughren, & Racoosin,Europe (Pattison & Kahan, 1983; Zahl &Hawton, 2004). The European definition of 2006; U.S. Dept., 2001) and a plethora of

suicide-related terms to choose from (Silver-DSH is: intentional self-poisoning or self-injury, irrespective of motivation (Hawton et man, 2006), what is a clinician, researcher, or

policy maker to do? Case definition leads toal., 2003). We decided that DSH conveyedthe same meaning as ISRB, provided it did clarification of incidence and prevalence

(Phillips & Ruth, 1993). Epidemiologicalnot include suicide attempts within its defini-tion, and was more palatable to our col- studies lead to development of treatment mo-

dalities and preventive intervention ap-leagues than ISRB. DSH does not require forits usage the establishment of suicidal intent; proaches (Moscicki, 1989, 1995). Treatment

and prevention studies result in further re-however, self-harm, as used in the Americanresearch literature, is defined as a deliberate finement and development of approaches

that eventually lead to the reduction andand often repetitive destruction or alterationof one’s own body tissue without suicidal in- amelioration of the observed behavior (Sil-

verman & Maris, 1995; Soubrier, 1999). Un-tent (Favazza, 1989; Favazza & Rosenthal,1993). Inasmuch as the term suggests the til such time as everyone adopts a common

language with a common set of definitions,connotation of deliberateness, consumers ofmental health services in the United King- there is little likelihood that the data from

research and clinical centers, as well as fromdom petitioned the Royal College of Psychi-atrists to change the term deliberate self-harm different communities (let alone countries),

can be compared, contrasted, and discussedto self-harm (Hawton & James, 2005). Wechose to follow that recommendation. with any degree of reliability and validity

(Silverman, 1997).One potential complication with sepa-rating self-harm and suicide attempt into two The nomenclature provided here was

built with an eye toward its application inseparate categories is that it is possible forself-injurious intent and suicidal intent to be clinical research. It was conceived with the

expectation of translation into operationalpresent in an individual at the same time. Forexample, individuals with borderline person- definitions, case examples, and field testing.

It was designed to serve as an instrument toality disorder who, by definition, are oftenself-injurious, also have a relatively higher assist clinicians in better identifying those

most at-risk for suicide-related behaviors inrate of suicide than the general population.When an individual is unable to clearly com- order to help keep them alive. It is obvious

to us that the field needs to convene an inter-municate the type of intent that led to a self-injurious behavior (e.g., ambivalence about national symposium of clinicians, research-

ers, preventionists, and policy makers to dis-the intent to die), then the decision abouthow to label their behavior can be difficult. cuss the language of suicidology and to set a


course to empirically test the reliability and through field testing. This will establishwhether the nomenclature is feasible and us-validity of a set of agreed-upon terms. Multi-

national, multicentered research studies us- able. A training manual with examples willbe developed (e.g., coding forms and codinging the same nomenclature are needed before

we can answer such questions as the true in- books).A nomenclature consists of terms andcidence and prevalence of, and interrelation-

ships between and among, suicidal thinking, definitions. The definitions are a descriptionof the concept and not an explanation, andbehaviors whose outcome is self-injury, and

those behaviors which, but for successful are not value-laden or theory-driven (Maris,Berman, & Silverman, 2000). A classificationemergency medical interventions, would re-

sult in death. system is much more precise and would in-clude categories for the levels of risk and in-We hope that a revised nomenclature

will result in better surveillance and risk as- tent; the lethality of methods and outcomes;the location of the behavior; the frequency ofsessment, and, therefore, more effective

management, intervention, treatment, and suicide-related thoughts and behaviors; aswell as the severity, intensity, and duration ofprevention of individuals at risk for suicide.

As Rudd (1997) articulated, “a standard no- the suicide-related event. We see the devel-opment of a classification system as the endmenclature is essential for good science.”

Furthermore, “in some respects, precise ter- product of these current efforts.Jamison (1999) observed that, “All sui-minology and related clarification is a clinical

intervention that can be used to reduce pa- cide classification and nomenclature systemsare, to a greater or lesser extent, flawed; andtient distress and facilitate a better therapeu-

tic alliance” (Rudd, 2006, p. 13). all, or almost all will have points that are wellor uniquely taken” (p. 27). In the end, ourFuture directions for our workgroup

include the operationalization of the nomen- primary considerations in revising the no-menclature were: (1) intelligibility over preci-clature through a clinical chart review. We

plan to develop clinical cases and exercises, sion; (2) practicability over hard science; (3)consistency over convenience; and (4) reten-as well as algorithms and logic models using

key constructs and rule in/rule out criteria. tion of commonly used parlance over the in-vention of new terminology. We ask that theThe purpose of operationalizing the nomen-

clature is to establish a set of questions and field test this nomenclature with “what if”and “what about” challenges to assist in fur-guidelines to inquire about intent, explicit or

implicit behaviors, instrumentality, repeat ther refinement and ultimately better under-standing of, and intervention for, those whobehaviors, plans, threats, and ideation. Once

the nomenclature is operationalized, we will engage in suicide-related ideations, commu-nications, and behaviors.seek to establish reliability and validity (con-

current, construct, and predictive validity)

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