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Endogenous Opiate Activity Imbalance - a Physiological Basis for Psychosocial Dysfunction?
- Andrew J Ashworth (17 April 2006)
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A small indicator of a huge problem.
- Claire A I Sweeney (17 April 2006)
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Goth Idol
- Mark Taubert, Jegajothy Kandasamy (18 April 2006)
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A confounding factor?
- Martin D Ferry (19 April 2006)
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Re Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study
- Wenbin Liang (20 April 2006)
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Re: Re Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study
- CC Ahasoo (22 April 2006)
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Re: A confounding factor?
- CC Ahasoo (22 April 2006)
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Who Ya Gonna Call? - Gothbusters?
- Phil Eaglesham (26 April 2006)
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Goth sub culture
- DCM Wieland (28 April 2006)
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Goth study merely reinforces popular stereotypes
- Michelle Phillipov (1 May 2006)
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A couple of comments...
- Sam J Line (2 May 2006)
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It's misleading to say "goths self harm"
- J Macedo (8 May 2006)
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Does Youth Subculture Research Have An Aim?
- Simon P Lammy (8 May 2006)
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comments on statistics
- Ewa D Okon-Rocha (10 May 2006)
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Author's reply
- Robert Young, Helen Sweeting, Patrick West, and Michael Van Beinum (19 May 2006)
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Suicide: a psychiatric condition
- Vibha Pandey (30 January 2008)
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Andrew J Ashworth, General Practitioner Davidson's Mains Medical Centre, 5 Quality St, EDINBURGH, EH4 5BP
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The observed association between deliberate self harm and the Goth subculture is seen as most likely to be by self-selection. I propose a physiological basis for that self-selection that is consistent with this and other evidence and offers theraputic possibilities. The recorded method of deliberate self-harm in this study was “cutting, scratching or scoring”: all activities that might be expected to release endogenous endorphins systemically. Those who have suffered long term trauma can be expected to have higher levels of dynorphins (chronic endogenous antinociceptives), which are opiate kappa agonists, reducing dopamine secretion in the Nucleus Accumbens and causing reduced mood reactivity. “Driving” dopamine secretion through increased opiate mu secretion through physical (eg cutting), psychological (eg taking part in dangerous activity) or drugs (eg Heroin), or by smoking (Nicotine acts directly on Dopaminergic fibres)can rebalance the opiate system by overcoming the inhibitory kappa effect to permit perceived normality. Reactivity of mood mediated by dopamine can thus be subject to behavioural control, including deliberate self-harm by cutting, scratching or scoring. In prison, the rates of suicide and self harm are highest in the first three months of incarceration(1), perhaps related to reducing endorphin secretion as the initial excitement/fear of incarceration settles. Those who deliberately harm themselves in prisons have a tendency to have reduced facial expression (similar to that seen in early Parkinson’s disease)(2). The Goth subculture normalises lack of facial expression through heavy make up and may even normalise an unreactive mood (only a third of those “Goths” who self-harmed did so while actively involved in the subculture). If deliberate self harm is a behavioural technique to influence dopamine secretion, medical research and interventions might be explored beyond the largely impotent psychosocial approaches that currently dominate the “market”. Flooding opiate mu receptors with Methadone has become a popular pharmacological approach for controlling dysfunction in Heroin users (who may be an associated group) but kappa blockade is also possible as a method of restoring endogenous opiate activity balance through the combination of Buprenorphine (a mu agonist and kappa antagonist) with Naltrexone (a mu antagonist) as demonstrated by Rothman et al in the USA(3). A less contentious approach is to apply low frequency TENS to improve the endorphin/dynorphin balance as demonstrated in China(4), an approach I have successfully tried (2) in a handful of patients. 1. Bogue, J. and Power, K. 1995, 'Suicide in Scottish Prisons, 1976- 1993', The Journal of Forensic Psychiatry, vol. 6, no. 3, December, pp. 527-540. 2. Personal Observation 3. Rothman, R B. Gorelick, D A. Heishman, S J. Eichmiller, P R. Hill, B H. Norbeck, J. Liberto, J G. An open-label study of a functional opioid kappa antagonist in the treatment of opioid dependence. Journal of Substance Abuse Treatment. 18(3):277-81, 2000 Apr. 4. Han, J S. Chen, X H. Sun, S L. Xu, X J. Yuan, Y. Yan, S C. Hao, J X. Terenius, L. Institution Effect of low- and high-frequency TENS on Met-enkephalin-Arg- Phe and dynorphin A immunoreactivity in human lumbar CSF. Pain. 47(3):295-8, 1991 Dec. Competing interests: None declared |
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Claire A I Sweeney, Medical Student Liverpool University, L683DA
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I read this article with much interest. In my recent experience of being a teenager, Deliberate Self Harm was a huge problem. Amongst the Goth Culture it seems to be a dangerous expression of angst, yet these issues seemed to extend into all the social groups at school. 53% is a very worrying proportion. DSH leaves people with emotional and physical scars, and what can start as a secret coping mechanism in teenage years can become a destructive addiction as this generation grow up. I agree that more research is needed, to determine the prevalence amongst teenagers of this problem. The main issue that needs addressed however is what can we do?? I think the most important thing is to find out from the teenagers what could help them. Psychiatrist and Psycologists, or councellers that thier parents have to know about are all frightening, and most teenagers I knew kept it all a secret. Maybe research or surveys to determine what can be done, what the teenages want, would help? Access to a confidential school counceller maybe one lunchtime a week could provide a non-threatening approachable atmosphere? Thank you for your article, which again raises the awareness of the extent of this problem in groups at schools. There are so many services to address the mental health needs of adults, and those severly mentally ill teenagers. Yet there remains a large population of teenagers at school self-harming, and slowly spiralling into depression and suicidal intention. We need to address this problem at the root, do something for these teenagers as they are first exposed to self-harm in their communities at school, and address the issues when they first arise in the teenage angst stage. Otherwise in 10 years time these 'difficult goths' and 'confused adolescants' will present to us as lost adults, caught in cycles of addictions and self-punishment so deep rooted that it takes years of therapy to resolve. The research paints a worrying picture, its time to find out how we can take action.. not just for the teenagers who get found out and see the doctor/councellor/social worker, but for your average teen, whos hiding the problem and beginning on a slippery slope to destruction. Competing interests: None declared |
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Mark Taubert, Senior House Officer in Palliative Medicine Holme Tower Marie Curie Hospital, Cardiff ,CF643YR, Jegajothy Kandasamy
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EDITOR – Young’s interesting study (1) claims to find a strong association between Goth subculture and deliberate self-harm before and after adjusting for confounders. Importantly, it fails to distinguish that the Goth subculture is not easily defined or categorised, spans several continents and has evolved to include a wide range of musical and clothing styles. This contemporaneously includes Mallgoths in the US, Gogans in Australia, Dark in Latin America, Cuervos in Spain and Spooky kids and Neogoths in the UK (2, 3). Young et al should have made it clear in their discussion that any conclusion only relates to a small sample of gothic youth in the Central Clydeside Conurbation. One cannot assume that Goth youths’ subcultural trends, icons and ideals would be similar in other geosocial regions. Perhaps not all confounders have been taken into consideration given that Young’s study was conducted in Scotland between 2002 and 2004. During this period, a Scot won ‘Pop-Idol’ (Michelle McManus) and another won ‘Fame-Academy’ (David Sneddon). Both these TV programmes were difficult to avoid given the intense media coverage. The study concludes that the causality for Goths self-harming more than, say, Pop-Fans (53% and 7% respectively) remains unclear. The exasperation with current popular cultural trends may have driven one subculture, the Goths, to drastic methods of protest, such as overt self-harming. Could frequent, involuntary exposure to mass-produced pop music affect the mental health of one youth sub-culture population more than another’s? As Ovid states in Tristia: Est quaedam flere voluptas. References: 1) Young R, Sweeting H, West P Prevalence of deliberate self-harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study BMJ, doi: 10.1136/bmj.38790.495544.7C 2) Kilpatrick, Nancy: The Goth Bible: A Compendium for the Darkly Inclined. 2004: St. Martin's Griffin. ISBN 0312306962 3) Voltaire: What is Goth? (WeiserBooks, US, 2004; ISBN 1578633222) - a humorous and easy-to-read view of the goth subculture Competing interests: Secretly, MT and JK are fans of the Eurovision Song Contest and despite this have never considered self-harming |
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Martin D Ferry, Student G11
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As an inhabitant of the Central Clydeside Conurbation, I can't help but notice the unusually high prevalence of obesity among young women who adopt "Gothic" modes of dress. Given what is known about the relationship between eating disorders, obsesity and self harm, does the apparent propensity for self harm in this group persist after correction for body mass index? Competing interests: None declared |
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Wenbin Liang, master candidate School of Public Health Curtin University of Technology
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Dear Editor, This study would be hard to avoid misclassification of self harm (outcome), and misclassification of belonging to Goth youth subculture (exposure) as the information was self-reporting. [1] If the misclassification of outcome and exposure was associated, validity of the study may be strongly affected. Given that the information on self harm (outcome) and wether belonging to Goth youth subculture (exposure) was both provided/ observed/partly defined by the same person (the participant), the observation of the outcome and the observation of exposure may be considered as related, and therefore misclassification of outcome and exposure may be associated. Reference: 1. Young, R., H. Sweeting, and P. West, Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study. Bmj, 2006. Competing interests: None declared |
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CC Ahasoo, social worker 59601
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These observations are from my own observations in San Francisco, United States: As I’m sure you noticed with your participant study about the Goth Culture, the real key to this crew is extreme boredom. It’s spurned out of a watered-down white (there are a few more 'minorities' in the Goth Culture, but is overall 'white/caucasian') culture that offers nothing of substance for a group of youths who are: highly imaginative, critically intelligent (I've met quite a few Goths who were of remarkable intellect/genius IQ & very well read), emotionally sensitive, socially reclusive, and somewhat effeminate (the males). This combination makes this bunch a group of ‘misfits’ that have no real use for standard issue mores of society, and create their own mild ‘culture’. It is of no surprise that this subculture has the highest rates. There isn’t one shred of anything within the Goth Culture that encourages positive behavior. The choice of drugs, clothing, hair styles, clubs, etc, are designed to further distance themselves from ordinary society. Heck, when you’re already depressed from any lack of interest in doing anything (except shoot for being in a band or busting your butt to become a significant artist), why not be enthralled with dying, -what other really enticing choices are there? What Leaders/Governments don’t lie, or what truly decent, non-soul-sucking careers exist (that you can be proud of, and also have security in holding) anymore? The best thing this culture has going for it is ‘safety in numbers’ and that is all. Unfortunately, even within the Goth culture, there are serious codes of conformity which smack of hypocritical display. They look almost identical, dress accordingly for acceptance/identification, and listen to the same music. They don’t want to be ‘bothered’, and prefer to be left alone by society. I have never, ever seen a 'sober' Goth. Most Goths get bored over time with the same old scene and realize their original romanticized attraction was nothing more than a falsehood. Most Goths make a humble (in rare cases, an excellent living) financial career out of drug dealing. A few have their act together with decent jobs in the computer fields. Some find their way into local theaters, or appear somewhat ‘dressed down’ and playing in classical symphonies (I knew of one that played the violin in a classical ensemble). The major contribution this culture has added to mainstream society is a few good music bands (Bowie, Bauhaus, Ministry, Sisters of Mercy, etc.). Traditionally, they like staying up all night, sleeping all day and eat speed/LSD/psychedelics/herion/Extasy more than common food alone (being super-skinny is the ‘correct look’). A few have some very wealthy families whom they ‘sponge’ cash from, and in turn, buy loads of dope for their much poorer buddies (making them super popular/the elite) and can also afford the nicest leather/latex gear above all others. The sex scene (most are bi-sexual or gay) within the Goth culture is off the scales, and most have unprotected sex (and it should be noted about the really dangerous fascination with ‘vampirism’: what do you get when you mix unprotected sex with ingesting another’s blood AND on lots of drugs?.....Extreme stupidity and a short lifespan. Wouldn’t you kill yourself if you found out you had HIV?! Not very sexy anymore!) I’d have to say this bunch ought to be handed over the whole Porn Industry for their extreme fascination of it. Between having a very advanced sexual appetite, taking copious amounts of drugs, staying up all night, and dodge EVER having to cope/socialize with common people, AND listen to music which is totally depressing; how long will it be before catching HIV, one or more VD’s, gaining a criminal record/getting busted for dope, and then becoming so despondent from being bored after trying out every seedy and sinful indulgence with a fried-out drug-addled mind, that there really isn’t much left than other to kill yourself? I know of one 'Goth' that committed suicide, but far more that contracted HIV and then AIDS. Also, many had venereal diseases at one point or another. There is little regard for protecting one's health. If you are perpetually 'depressed', why care about what happens to you? This culture produces a massive number of addicts. Along with the self-induced 'cuttings', these acts are performed from a few impulsive sources: clinical depression, drug induced from hallucinations, and 'blood-letting' from sucking their own blood, or someone else sucking their blood (fantasy-based vampirism) during concocted 'rituals' or combined with sex. If you decide to do any further research on this culture, ask your participants about how BORED they are with their own human race, and then you’ll find the base reasoning of why there are subcultures (Punk, Hippie, Goth, etc). They have simply tried to start their own (culture) from whence there is none but cookie-cutter conformity which bores you to death (debt, kids, poor paying job, college loans, etc) in the long run. Goth: is essentially a group of bored, potentially depressed people who gravitate to each other and create a wide variety of dangerous behaviors and call it a subculture. Competing interests: None declared |
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CC Ahasoo, social worker 59601
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In regards to noticably 'heavyset' women in the Goth Culture, it is the same in all subcultures (Punk: Fat Mike from NOFX, Hippie: look at Jerry Garcia/Grateful Dead), etc). In subcultures, the purported 'castaways' of society (those who don't fit in for whatever reasoning) fit in well with subcultures who accept all types (gay, fat, etc) that haven't 'met' the normal acceptance (tan, healthy, good-looking, plays sports, social clubs, wealthy, well-adjusted families, paid-for college) criteria of the common, moral majority. Here in the United States, it is common knowledge of job-hiring criteria that 'good-looking people' are hired faster than anyone else. Besides, as fashionably noted, wearing 'black' clothing apparently makes you appear slimmer! On a serious note, being very overweight is also a major contributor of depression. If I wasn't happy with myself, my perfect-looking peers made fun of me in school, -why not join up with people who don't care what you look like at all? Which takes us back around to 'safety in numbers.' As anyone recalls from high school, you are an easy 'target' if alone. You are less likely to get beaten up or verbally ridiculed when clustered together as a whole group. Competing interests: None declared |
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Phil Eaglesham, Health Improvement Officer Greenock, scotland
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This article interested me both from the perspective of co-ordinating suicide prevention work aimed in part at local young people and I must confess to having been a 'Goth' in Glasgow, Scotland back in the day (1982 -5). From my understanding the original scene re-glamourised post punk UK and it's legacy is still felt in some pretty prolific singers/songwriters (Nick Cave, Gavin Friday, Siouxsie Sioux, Lydia Lunch, Robert Smith, The Cocteau Twins - probably all of whom rightly shudder at the term). Like most 'youth cults' it left a trail of substance use and wreckless sexual abandon and visually expressed the doom-laden angst that eclipsed young people in Thatcher's UK at the time. Has history repeated itself? I'm unsure whether current identification as a 'Goth' relates to this older term - I observe a current 'gothic look' but am aware of a HUGE range of musical and cultural influences on this group in Glasgow alone; Heavy Metal, Metal-Core, Death / Black metal, Emo, Hardcore, Grunge, Post- rock, Math/tech-metal, Punk, Electroclash etc. (any reader under 25 is probably cringing right now at my feeble ramblings). The themes therein range from angst and despair, through extreme personal pride, to stoned and drunken bliss and onwards to utter rage. Sounding familiar? Teenage transition & turmoil experiences, basically. Either way, as a 'youth cult' it does exactly what it's intended to do - bond and support young people beyond their family groups, create a specific and timely language & culture and disturb/offend/perplex the adult masses with at times transgressive acts and art. I worry that there could be confusion and assumption here about key 'suicide' figures in music; Derby Crash (The Germs), Ian Curtis (Joy Division) and Kurt Cobain (Nirvana) especially - and our assumptions that depressed people making depressive music equals depressed listeners. Since 1972 the NYC band 'Suicide' have confronted and terrify audiences with a synthesiser and a microphone, utterly hated for the USE of the word - such is our fear. Hunter S. Thomson tragically committed suicide last year, how do we now relate to this great man's books? I have also observed the ongoing hysteria in mainland Europe as young 'death & black metal' fans occasionally commit horrendous crimes (murder, infanticide, arson) in small numbers, confirming adults worst fears about the voodoo-like power of such music. The case of the 'West Memphis Three' in the USA and the revealing HBO documentaries further confirm this concern. It is of note, however that 'Gothic' music does not feature in the 52 songs recently cited as the most depressing ever - Billy Joel, Phil Collins and The Carpenters do however. Are these findings concluding that vulnerable young people are self harming and are DRAWN to this scene or are in greater numbers WITHIN this group? Either way we must offer more information, support and hope to them without dismantling, stigmatising and attacking the helpful peer support element therein. FOSTER youth cult and groups in diversity, while informing, supporting and valuing young people. My key and eventual question would be - do we need a specific intervention? Gothbusters anyone? Further Unscientific Reading: 'I Hate Myself and Want To Die - the 52 most depressing songs ever heard' - Tom Reynolds (Sanctuary) 'And the Ass Saw The Angel' - Nick Cave (Penguin) 'Suicide - No Compromise' - David Nobakht (SAF) 'Fear & Loathing - The Strange And Terrible Saga of Hunter S. Thomson' - Paul Perry (Plexus) 'The Primal Screamer' - Nick Blinko (Spare Change) 'Lexicon Devil - The Fast Times and Short Life of Derby Crash and The Germs' - Brendan Mullin / Don Bolles / Adam Parfrey (Feral House) 'Gavin Friday - The Light and The Dark' - Caroline Van Oosten De Boer (Von B Press) 'American Hardcore - A Tribal History' - Steven Blush (Feral House) 'Black Coffee Blues'- Henry Rollins (2.13.61) 'Paradoxia: A Predator's Diary'- Lydia Lunch - Introduction by Hubert Selby, Jr. (Creation) 'Lords Of Chaos - The Bloody Rise Of the Satanic Metal Underground' - Michael Moynihan / Didrik Soderlind (Feralouse) 'Bowling For Columbine' - Dir. Michael Moore (2002) Miramax 'Paradise Lost 1 & 2 - The Child Murders at Robin Hood Hills' - HBO Television / Warp Films (2005) Competing interests: None declared |
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DCM Wieland, PHd student Bangor University
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I take great exception to the views expressed by some of the contributors, most "goths" in this country (Britain) are employed either in the caring professions or other professions most are over 30 and have long term partners and children. I myself am 46 years old and have never self harmed in my life. To say "this group of misfits have no time for standard issue mores of society" is an absolute insult. I go to goth festivals, I do not as a woman have to worry about being subjected to unwanted attention, drinks spiked or violence as depicted on our television screens when clubs and pubs close. This piece of research was carried out in small area and with a single age group, any research student can tell you this is not the way to carry out good research. Nor has the research looked at cause and effect ie do they self harm because they are goths or have they become goth because they self harm, the goth culture is an inherently inclusive non-judgemental culture and this may be why it appears that self harmers are more likely to be goth. Competing interests: None declared |
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Michelle Phillipov, Postgraduate Student Dept of English, University of Adelaide 5005
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It is somewhat unexpected that BMJ would publish such an article, which attempts to determine traits associated with the Goth subculture—a grouping which potentially comprises of 100,000s adherents globally—based on a sample of only 15 individuals in a single locality. While Goth subculture is the article focus, just two references are given, and only one of them academic. There is a failure both to consult other pertinent studies—including Wright [1] and Siegel [2]—and to frame the results with respect to existing knowledge. For example, while Young et al’s results show a significant prevalence of males (about 2:1) in the ‘Goth’ category, Hodkinson—the only academic reference on Goth cited by the authors (see Young et al, ref [5])—clearly states that the Goth subculture is comprised of equal numbers of males and females. The reluctance to address this inconsistency with respect to their own cited reference is not only a significant oversight, it also makes it impossible to determine whether the authors’ findings are the result of male over- or female under-identification as Goth, or if they are simply symptomatic of untenable sample size and study design. In addition, while Young et al find females at risk of attempted suicide, the known suicide rate for the 15-19yr group in 2000 was 4 to 1 with respect to males (see Young et al, ref [1]). Hence, the results directly contradict what is logically expected. Furthermore, it is notable that members of the Goth subculture practice self-harm almost exclusively by means of cutting, scratching and scoring, and not through more extreme methods such as punching or self- poisoning. However, the authors unwillingness to consider the context(s) in which cutting, scratching and scoring occur, along with their readiness to subsume potentially diverse practices into a single discourse of pathology, makes it impossible to draw conclusions about the meaning and effects of these behaviours for the Goth subculture. While the authors seek to link cutting, scratching and scoring to depression, attempted suicide and psychiatric illness, these techniques can in fact be practised for a range of different reasons. For example, within some subcultural contexts, these practices are used to induce fine scarring in decorative patterns on the body; that is, they are used as methods of bodily decoration and adornment, much like tattooing or body piercing. Without an understanding of context, it is impossible to determine whether this is the case for the Goth subculture. However, the tendency for medical and mental health discourse to systematically misrecognise body modification as self-mutilation or self-harm has been noted elsewhere [3]. Unfortunately, studies like the current one, which adopts an epidemiological approach to assessing traits within subgroups, habitually seem to support prevailing popular stereotypes. Perhaps this explains the ready acceptance and promulgation of the findings, whilst disregarding the lack of substantiation and generalisability, as well as the serious methodological flaws. [1] Wright R. I’d sell you suicide: pop music and moral panic in the age of Marilyn Manson. Popular Music 2000; 19: 365-86. [2] Siegel C. Goth’s dark empire. Bloomington: Indiana University Press, 2005. [3] Pitts V. Body modification, self-mutilation and agency in media accounts of a subculture. In Body Modification (Ed. Featherstone M). London: Sage, 2000, pp291-303. Competing interests: None declared |
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Sam J Line, Research student in psychopharmacology University pf Oxford
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I shall make no comment on either the quality or significance of this study, but I would like to point out a result that doesn't seem to have been discussed. From the data, it would appear that people identifying themselves as "indie" have an unusually low incidence of self harm. Can we infer from this that indie music has a protective effect against self harm? Perhaps indie music should be played to those at risk of self harm?! One other point I'd like to make is that the friends of people who self harm are more likely to self harm themselves, as the behaviour can (in part, at least) be considered a learned coping method. It is also true that goths tend to be friends with goths. Is it known whether the 15 individuals in this study who identified themselves as "goth" were also part of the same friend group? Competing interests: None declared |
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J Macedo, GP Registrar Leicester
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Dear Editor, I'm writing in response to the article in the 6th May Edition of the BMJ "prevalence of deliberate self harm and attempted suicide within contemporary goth youth subculture: longitudinal cohort study" I fear the conclusions drawn may be misleading to clinicians and to the mass media. As Young himself stated to the BBC: Only 2 people identifying themselves with the goth subculture self-harmed afterwards. He also suggested that the study needed to be repeated. Can we make generalisations about a subculture containing many thousands on the basis of 25 individuals studied? Young suggests that perhaps identifying with goth was a way of finding a different outlet for coping and may be protective. I note that, from my own observation, goth is a permissive subculture where mental illness, disability ans sexuality may find less discrimination than other subcultures - perhaps even more so in the image conscious teenage population. And how, clinically, does this contribute to improvements in care for our patients? Can we extrapolate results regarding teenagers to goths in their 20's 30's and 40's? Can we identify people who used to be goths, or can clinicians accurately identify people who are goths? Most UK goths would not consider Marilyn Manson to be goth for example. Can you, as a clinician, tell the difference between a 'goth' and a 'metaller'? What about the 90% of teenagers who self harm who aren't goths (73 of 81 people in this study)? The truth is that conclusions drawn by this paper are picked up on by the press, and may well alarm parents and teachers. They may increase negative associations towards a subculture, thereby increasing rather than decreasing prejudice already experienced by goths. All this without necessarily furthering our ability as clinicians to seek out young people at risk of self harm. Ref: BMJ 332, 6 May 2006, 1055-1061 Goths 'More likely to self-harm' http://news.bbc.co.uk/1/hi/health/4905898.stm Attacker targets teenage 'goth'. http://news.bbc.co.uk/1/hi/england/merseyside/4924144.stm Mick Mercer. 21st Century Goth, 2002, Reynolds & Hearn Ltd. London. ISBN 1 903111 28 5 Competing interests: as the study would say, some subcultural identification with "goth" |
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Simon P Lammy, 3rd Year Medical Student: Medical Students' Officer: University of London Union Royal Free & University College Medical School WC1E 6BT
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The article (Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study: BMJ 332) presents society at large with an interesting challenge. Self harm has been popularised by the media to exist amongst such youth subcultures through numerous films and documentaries which has not often been thoroughly evidence based. This article despite studying a relatively small cohort of youth in an environment that is not at all throroughly representative of the country has qualitatively demonstrated an increased bond between self harm and attempted suicide to those young people who engage in Goth cultural practices. The challenge that such an article presents is that in an era where individualistic mind sets and world views reign supreme how can society be reconciled to such people who through such practices are a significant threat to their own existences and thus society at large? Surely anyone reading this article would wish to decrease the incidence of self harm and attempted suicide amongst those so young. To do so one would have to discourage the number of young people becoming enveloped in such a culture especially when one considers that the strong connection to the above two disadvantageous scenarios is not weakened by removing any cofounding factors. But can such a quest be executed to any success when personal liberties reign supreme (e.g. you cannot even smack a child on the underground these days so although society may show concern about Goth culture who are you to discourage anyone to be caught by its attraction?) It would be interesting to compare the rates of self harm and attempted suicide to other youth subcultures whom society shows concern toward (e.g. hip-hop youth culture). Further it would be interesting to ascertain any steps that have been taken (i.e. medical and political) through the decades to discourage the youth from becoming members of some of the most supposedly destructive clubs around and how effective they have been. Although such research is interesting it should be more than an academic discipline. What problems does such research hope to solve? Ultimately how does such research hope to improve society? The reason for my questions is that it has now been known for many many years although maybe not conclusively shown that such links exist and nothing apparently has been done at both a medical and political stage. Thus is this research just purely academic? If so then it is not worth pursuing! Competing interests: None declared |
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Ewa D Okon-Rocha, staff grade psychiatrist SLAM, Northover CMHT, Bromley BR1 5JX
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I have enjoyed reading the paper and all responses. Here, there are few "statistical" commments. There seemed to be several flaws in the design and execution of this study. 1. are the results valid? Authors don't give us clear description of how subjects were identified and recruited. Did they volunteer? How many refused to participate in the study? The researchers could simply have sampled the participants in such a way as to increase the chance of supporting their hypothesis. Cohort should be representative of a true population for study to be valid. Some researches use randomization procedure in cohort studies in order to choose sample, which is the most accurate picture of population. 2. Follow-up/attrition rate. Follow-up in this study was probably long enough (8years). However, in 1994, there were 2586 participants, whereas by the year 2002/04 only 1258. Could those followed-up be a biased sample? Loss of participants may effect precision and power of the study. For example, in Table 3 under Model 1 Goth subculture there is wide confidence interval (4,42 to 45,39), which may point out to undepowered study (type II error). 3. Observer Bias? Outcomes have been assesed using Voice-DISC. Participants were asked varies questions on: suicide, self-harm, identification with subculture. It is not mentioned how raters conducted the interviews, whether they used structured or semi-structured protocol, whether they were blind to the study's hypothesis. The more subjective rating is, the more important blinding becomes. The bias introduced by non-blinding is likely to overestimate findings. It seems that a decision of belonging to one subculture or another was rather subjective (participants' responses were assessed on a five point scale). All in all, no blinding, lack of structured interview, subjectivity can lead to observer bias. 4. Confounders Reseachers did adjust for some confounders (sex, social class, etc) using logistic regression. However, as somebody has already pointed out, the list of potential confounding factors is long, inc physical illness, obesity, family hx. 5. Results For prospective studies outcomes are best presented as a relative risk.One can comment then on prevalence or incidence of the disorder. In this study authors use odds ratio. 6. Study's applicability Is this study applicable in different subcultures? Probably not. In Table 3, which shows relationship between self-harm and type of subculture, majotiry of results are statistically non-significant. In conclusion, In cohort studies a group of individuals is followed-up over a period of time. The individuals should be free of the outcome (here: self- harm/attempted suicide)at the beginning of follow-up. The cohort is defined by exposure status(here: Goth subculture), which should be found out before outcome is known. Cohort study measures whether exposure effects the incidence/prevalence of the outcome,i.e. whether identification with Goth subculture increases the risk of self-harm or/and suicide. Researches believe that yes. By reading and critically analysing this study, I have arrived at different conclusions. Competing interests: None declared |
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Robert Young, research associate MRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow G12 8RZ, Helen Sweeting, Patrick West, and Michael Van Beinum
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We were pleased that our paper generated a wide variety of comments. While some contributors raised specific points, others referred to more general issues relating to issues of definition, explanations and generalisability. The definition of “Goth” is contentious, but covers a wide range of musical tastes, social groupings, and aesthetics. The most relevant distinction here is between contemporary (usually younger) “Baby, Bat or sometimes referred to as Mall (US)” Goths vs. “mature, real or Elder Goths” 1. Our paper, as is clear from the title, refers to younger Goths; the results may not apply to all Goths. The range of comments in response to our conclusion, that both selection and influence mechanisms may be involve, reflect the lack of evidence on this issue. To highlight this, we drew attention in the press release following publication to the possibility that engagement with Goth subculture could have positive rather than negative consequences for some young people. Our contribution is a first step towards producing an evidence base to test this, rather than relying on media speculation. Some contributors have suggested that the association between self- harm and Goth subculture may be accounted for by other factors. However this is unlikely, since we adjusted for the strongest and most relevant correlates of self-harm found in other studies of young people. Others have suggested that our results were not valid due to the small numbers involved. We would point out that our paper underwent a formal statistical review before publication. Further, while the media focused on the 25 young people who unambiguously identified as Goth, nearly 8% of our representative sample had identified with Goth subculture, in varying degrees of intensity, and were 3-4 times more likely to self-harm, than the other participants. It has also been suggested that by adopting a quantitive approach we may have missed contextual factors (this is obviously true of any non- qualitative study), and that the high rate of self-harm found among Goths is a form of decoration, analogous to body modification. We dispute this on two grounds. Firstly, since those who self-harmed were asked why, we know that the majority, regardless of youth subculture did so to relieve anxiety, anger and other negative emotions. Secondly, while cutting could be interpreted as some form of subcultural display, such an argument is difficult to sustain in relation to attempted suicide. 1 Wikipedia contributors, 'Goth', Wikipedia, The Free Encyclopedia, 10 May 2006, 07:57 UTC, <http://en.wikipedia.org/w/index.php?title=Goth&oldid=52455549> [accessed 10 May 2006] Competing interests: None declared |
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Vibha Pandey, Psychiatric Social Worker Central Institute of Psychiatry
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The study conducted by the authors (1) no doubt have given new avenue to the cultural and ethnic factors in suicide but it is definitely not answering the biology behind the act of committing suicide. Apart from this, study has also failed in discussing “Psychiatric condition” as one of the major cause of suicide. According to 1999 data from the Center for Disease Control and Prevention, suicide was the eleventh leading cause of death (homicide was fourteenth), and the third leading cause of death between ages 15 and 24 years. The vast majority of people with suicidal intent have a major psychiatric diagnosis. It has been estimated that 90% or more of them can be shown to have a major psychiatric illness (2 & 3). Mann and colleagues (4) have proposed a stress-diathesis model of suicidal behavior, as “a psychiatric disorder is generally a necessary but insufficient condition for suicide”. The model posits that suicidal behavior is a function of an individual’s threshold for suicidal acts and the stressors that can lead to vulnerability. The authors believe that the threshold for suicidal acts is trait-dependent (diathesis), and is mediated by factors such as aggression, impulsivity, substance abuse, family history and low brain serotonin function. Stressors include psychiatric illness and interpersonal problems. There are genetic and biologic correlates of suicidality as well as the underlying psychiatric illnesses that are often associated with suicidal behavior. Low serotonin levels may be the underlying feature of suicidal behavior, aggression and substance abuse (4). Hyper intensities in the basal ganglia may be at higher risk for mood disorders and suicide attempts secondary to interference in neuroanatomic pathways. These pathways may be crucial to mood regulation (5). A number of these studies have found an association between reduced serotonin function, including low levels of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) in cerebrospinal fluid (CSF), with impulsivity, violence and suicide (6 & 7). Low CSF 5- HIAA levels may also predict future suicide attempts (8). Aggressive behavior and, independently, suicidal behavior, may have impulsivity as a common denominator, which may be mediated by serotonergic dysfunction (5). A number of psychiatric diagnoses are linked with suicidality. While patients with mood disorders (major depression and bipolar disorder) are commonly assessed for suicidality, anxiety disorders are also associated with significant suicide risk. Psychosis, in both mood disorders and schizophrenia, can heighten risk. Although borderline personality disorder has a high prevalence of suicidal ideation, impulsivity and self-injurious behavior, these patients are at risk for unexpected intentional and accidental death. REFERENCE 1. Young R, Sweeting H, West P (2006) Prevalence of deliberate self harm and attempted suicide within contemporary Goth youth subculture: longitudinal cohort study BMJ 2006;332:1058-1061 (6 May), doi:10.1136/bmj.38790.495544.7C (published 13 April 2006) 2. Henriksson MM, Aro HM, Marttunen MJ et al. (1993) Mental disorders and comorbidity in suicide. Am J Psychiatr 150(6), 935–940. 3. Mann JJ (2002) A current perspective of suicide and attempted suicide. Ann Int Med 136(4), 302–311. 4. Mann JJ, Waternaux C, Haas GL et al. (1999) Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatr 156(2), 181–189. 5. Ahearn EP, Jamison KR, Steffens DC et al. (2001) MRI correlates of suicide attempt history in unipolar depression. Biol Psychiatr 50(4), 266–270. 6. Mann JJ (1998) The neurobiology of suicide. Natl Med 4, 25–30. 7. Placidi GP, Oquendo MA, Malone KM et al. (2001) Aggressivity, suicide attempts, and depression: Relationship to cerebrospinal fluid monoamine metabolite levels. Biol Psychiatr 50(10), 783–791. 8. Roy A, De Jong J and Linnoila M (1989) Cerebrospinal fluid monoamine metabolites and suicidal behavior in depressed patients. A 5-year follow- up study. Arch Gen Psychiatr 46, 609–612. Competing interests: None declared |
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