et al., 1976; Stallone et al., 1980). One study found that out of 100 consecutive suicides, 46 percent had bipolar II, 1 percent had bipolar I, and 53 percent had non-bipolar major depression (Rihmer et al., 1990). This particular vulnerability of those with bipolar II may be due to increased mixed states that include depressive and manic symptoms at the same time (see Chapter 7), and can also include severe agitation. There is a significantly increased rate of alcohol and/or substance use disorder in individuals with bipolar disorder (Brady and Sonne, 1995; Goodwin and Jamison, 1990), understood in part as an attempt to “self-medicate.” The co-occurrence of these two disorders is associated with increased rates of suicide above that for each single disorder (see section on alcohol and substance use below).

Anxiety Disorders

Anxiety disorders are ubiquitous across the globe and are the most common mental disorders in the United States (Kessler et al., 1994; Regier et al., 1993a; Weissman et al., 1997). The 1-year prevalence for the adult population has been estimated between 16 and 25 percent (Kessler et al., 1994; Regier et al., 1993a; Weissman et al., 1997). Anxiety disorders carry significant comorbidity with mood and substance abuse disorders (Goldberg and Lecrubier, 1996; Magee et al., 1996; Regier et al., 1998) that seem to eclipse the general clinical significance of anxiety disorders.

Although a few psychological autopsy studies of adult suicides have included a focus on comorbid conditions (Conwell and Brent, 1995), it is likely that the specific contribution of anxiety disorders to suicidality has been underestimated. Research from the last decade has started correcting this, however. A recent study using the National Comorbidity Survey data (Molnar et al., 2001) found that for all anxiety disorders including PTSD, the population attributable risk for serious suicide attempts is almost 60 percent for females, and 43 percent for males.

Anxiety disorders encompass a group of eight conditions2 (APA, 1994) that share extreme or pathological anxiety and fear as the principal disturbance of mood, with accompanying disturbances of thinking, behavior, and physiological activity. The longitudinal course of these disorders is characterized by relatively early ages of onset, chronicity, relapsing or recurrent episodes of illness, and periods of disability (Gorman and


The eight anxiety disorders in the DSM-IV: panic disorder (with and without a history of agoraphobia), agoraphobia (with and without a history of panic disorder), generalized anxiety disorder, specific phobia, social phobia, obsessive-compulsive disorder, acute stress disorder, and post-traumatic stress disorder.

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