Innovations In Clinical Neuroscience

SEP-OCT 2014

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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[ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ] Innovations in CLINICAL NEUROSCIENCE 87 could not be suicidal because they have no psychopathology has clear flaws. It is true that psychopathology is the most i mportant antecedent and correlate of suicidal behavior worldwide. 45 However, as Brooke Rogers and colleagues of Kings College London observe, studies on the psychopathology of suicide terrorists have not been systematic and what evidence does exist is mixed. 4 6 It is possible that psychiatric disorders such as depression and PTSD are higher in this population than is generally assumed. To complicate matters, the precise role of psychopathology in suicide is not as straightforward as might appear. Indeed, there is increasing evidence from twin studies that while psychopathology is often associated with suicide, susceptibility to suicidal ideation and behavior may be transmitted genetically independently of the presence of a psychiatric disorder. 47 There is growing evidence, moreover, that suicidality is associated with a long list of medical and psychiatric disorders, and that it is not always associated with depression as is popularly assumed. 48 These findings have led to the suggestion that suicidality may be made up of several primary disorders that can be comorbid but are independent of other psychiatric disorders. 49,50 In support of this view is the finding that in the treatment of depression medication may make suicidality worse in some, better in others, and have no effect in a third group. On the other hand, some medications associated with suicide reduction (e.g., lithium and clozapine) are not indicated or approved for the treatment of depression. 51–54 Recruitment argument. The assumption that recruiters successfully reject candidates who are mentally ill is also problematic. It's not just that recruiters may actually seek out depressed candidates—Anat Berko in her interviews in Israeli prisons found that, contrary to the conventional wisdom, dispatchers are often told to "look for sad guys." 55 Nor is it just that we have anecdotal evidence, at l east from Afghanistan, that many of those who are recruited are "mentally challenged." 37 There is an additional problem. How exactly do these recruiters actually screen out the mentally ill? What tools do they use and to what extent are they influenced by cultural frames? Cultural frames may be particular barriers for recruiters in the context of Islamic terrorist recruitment. Okasha and Okasha observe that religious people in the Muslim world often miss psychiatric symptoms or interpret them from a religious perspective. For example, negative signs of psychosis (withdrawal, poverty of thought) may be interpreted in terms of piety while positive ones (auditory or visual hallucinations) are viewed as "gifts of God." 56 The express focus of recruiters on finding candidates with high motivation and a sense of duty may also backfire. In fact, there is good evidence that these very traits, together with lack of help-seeking, are the ones that best predict suicidal behavior in soldiers in combat situations. 57 Impulsivity argument. The notion that suicide terrorists could not be suicidal because their acts are meticulously planned and suicide is impulsive is simply wrong. While impulsive traits have been shown to increase the risk of suicide in some populations, especially those with bipolar disorder and alcohol abuse, decades of research have shown that the majority of those who commit suicide do not do so impulsively and, in fact, have had suicidal ideation for some time and made prior plans for these acts. 58,59 Murderous intent argument. The proposition that suicide terrorists could not be suicidal because they have murderous intent represents a false dichotomy. Even if suicide terrorists have murderous intent, that fact does not mean that they cannot also have suicidal intent. They may be both suicidal and homicidal. And, depending on the culture in which the act occurs, the degree of homicidal intent may b e higher or lower. Williams notes that, at least in the initial phases, suicide attacks were less effective and took fewer victims in Afghanistan than in Iraq. This may be because of cultural taboos on killing innocents in Pashtun culture. 37 Religiosity argument. Finally, the notion that suicide terrorists cannot be suicidal because many are religious and religion protects against suicide is debatable on several counts. First, not all suicide terrorists are religious. Many are secular. The Palestinian Fatah, the PFLP, and the PKK, for example, have little or no connection to fundamentalist Islam. Moreover, one of the terrorist organizations that have regularly employed suicide terrorism as a strategy in modern times is the LTTE. Not only are members of this organization not Muslim, most of them are not religious at all. Second, the protective power of religion in preventing suicide may be overstated. 6 0 It is true that religious affiliation has been found to be associated with lower rates of suicide attempts in some clinical populations. 61,62 These findings, however, may be biased since disclosure of suicidal ideation and behavior might be lower in people with religious affiliations because of the taboos against it. 63–65 In relation to Islam specifically, Okasha and Okasha note that suicide is forbidden by the Qu'ran, and few Muslims will admit to suicidal behavior when questioned directly although they will do so when the questions are open-ended. 56 Taboos against suicide can result in underreporting of suicide, 66 and there is growing evidence that suicide is underreported in Muslim countries. For example, in an analysis of suicide and undetermined deaths in 17 predominantly Islamic countries,

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