Specific anxiety disorders and suicidal behaviors
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"5774",leadTitle:"Advances in",fullTitle:"Advances in Underwater Acoustics",title:"Underwater Acoustics",subtitle:null,reviewType:"peer-reviewed",abstract:"Underwater acoustics, despite the relatively short history, has already found practical application in many areas of human activity. 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Nowadays, suicide is a major public health issue worldwide. Suicide is undoubtedly the most tragic event in human life. Globally speaking, around one million people commit suicide each year. Suicide is possibly witnessed among a wide range of population extending from normal individuals reacting differently to stress-triggering life conditions to people diagnosed with a mental disorder. Mental disorders as suicide causes have been studied in numerous researches and the correlation between depression and suicide has been particularly emphasized because major depression disorder comes first among the mental disorders that are related to both completed suicide and also suicidal ideation and attempt. The relation between anxiety disorders and suicidal behavior has been examined in limited numbers of studies with differing results. Some studies posited that there might be a relation between anxiety disorder and suicidal behavior, while in other studies it was posited that anxiety disorders on their own cannot be effective in triggering suicidal behavior. Anxiety disorders often cooccur with depression, and this may be masking a risk of suicidal behavior specifically related to anxiety. This higher likelihood was seen despite controlling for current depression, highlighting the importance of clinicians considering suicidal risk when working with anxiety patients who do not necessarily also have a diagnosis of depression. Although anxiety has been proposed to be a potentially modifiable risk factor for suicide, research examining the relationship between anxiety and suicidal behaviors has demonstrated mixed results. Until recently, anxiety disorders were not regarded as an independent risk factor for suicidal behavior which in turn limited the number of studies focusing on the significant relation between anxiety disorder and suicidal behavior. In a different saying, suicidal ideation in anxiety-diagnosed patients went unnoticed. Strong evidences have been gathered proving that panic disorder is an independent risk factor for suicide. There are uncertain findings about the possibility that specific anxiety disorders such as generalized anxiety disorder, obsessive-compulsive disorder, and posttrauma stress disorder may be independent risk factors for suicide. There are, however, stronger evidences that when anxiety disorder is codiagnosed with comorbid depression, bipolar disorder, schizophrenia, drug use, and personality disorders the risk may be substantially higher. In other words, controversy exists whether anxiety disorders are independently associated (i.e., after adjusting for comorbid mental disorders) with suicidal ideation and suicide attempts. Despite the existence of literature studies providing nonhomogenous findings, it is of great importance that clinicians focus more eagerly and attentively on suicide behavior in patients with anxiety disorder – particularly in patients codiagnosed with mental-disorder – to provide assistance to suicide prevention attempts. In this chapter, the relation between suicidal behavior and the anxiety disorder will be discussed.
Anxiety disorders belong to the most frequent mental disorders and are often characterized by an early onset and a progressive, persistent/chronic, or recurrent course. Several individual, familial, and environmental risk factors for adverse course characteristics of anxiety disorders (including higher persistence, lower probability of remission, and increased risk of recurrence) have been identified, and previous research suggests that clinical features of anxiety (e.g., higher severity, duration, and avoidance) as well as comorbid other mental disorders are particularly useful for predicting an unfavorable course of anxiety disorders [1]. The literature reviewed here is consistent in showing that anxiety disorders are common psychiatric disorders that typically has an early age of onset, a chronic course, and a high degree of comorbidity with mood disorders and other psychiatric disorders [2]. Anxiety disorders are one of the most prevalent of all psychiatric disorders in the general population [3-5]. Phobias are the most common with the highest rates for simple phobia (SP) and agoraphobia. For example, SP is the most common anxiety disorder, with up to 49% of people reporting an unreasonably strong fear. Among general population, prevalence of social anxiety disorder (SAD) meeting DSM-IV diagnosis criteria is circa 13%. Among general population, prevalence of posttraumatic stress disorder (PTSD) is 7.8%; however among particular groups (war veterans with 20%, domestic violence victim women 12%), higher prevalence of PTSD has been reported [6]. Panic disorder (PD) and obsessive-compulsive disorder (OCD) are less frequent, and there are discordant results for SAD and generalized anxiety disorder [7]. The epidemiological studies have shown that anxiety disorders are highly prevalent and important causes of functional impairment [2, 8]. However, due to their methodic differences, epidemiologic studies fail to adequately explain the effects of anxiety disorders on functionality since the high frequency of confusing sociodemographic variables (gender, age, race, ethnic structure, education, and marital status) can play different roles in the symptom severity and course of anxiety disorders [7]. Agoraphobia, SP, and generalized anxiety disorder (GAD) are more common in female, while there is no gender difference for SAD, PD, and OCD [6]. Anxiety disorders are more common among separated, divorced, or widowed people between ages 25 and 44. Anxiety disorders are rare among age 65 and above. Start age for anxiety disorders however varies for specific anxiety disorders. For instance, phobic disorders start at early age, while panic disorder is witnessed during early adulthood stage. Rather than epidemiological studies, stressful life events, childhood experiences, and familial factors as risk factors have been examined in clinical researches. Anxiety disorders are usually chronic and persistent and are generally accompanied with other psychiatric disorders such as other anxiety disorders, depressive disorders, personality disorders, and drug use. These codiagnosed conditions may negatively affect functionality and life quality. Further study is needed to better understand the comorbidity between anxiety disorders, the consistently higher rates of anxiety disorders, and the differential effects of socioeconomic and cultural factors on anxiety disorders.
The currently accepted nomenclature of suicide-related behaviors identifies suicide, nonfatal suicide attempts, and suicidal ideation [9]. Suicidal ideation is verbally expressing one’s ideas about killing himself/herself. Suicide attempt is performing behaviors with the intention of killing oneself not ending with death but potentially causing major injuries. Completed suicide is dying as a result of the behavior performed to kill oneself. It is a requirement to make such classification for suicidal behaviors since for three different groups risk factors and clinical presentations vary. Hence this classification is needed in the prevention of suicides likewise. Global estimates suggest that each year there are 10–20 million suicide attempts and one million completed suicides [10]. Suicide attempts are costly in terms of occupational and interpersonal disruption [11]. Moreover, substantial financial costs are associated with the intensive psychiatric resources devoted to these patients [12]. Suicide is a multivariate phenomenon occurring with the combined effect of a multitude of factors such as psychological, sociological, economical, and cultural. That explains the reason why suicide can be witnessed among a vast sampling group ranging from normal individuals to patients with severe mental disorders. Mood disorders and personality disorders (borderline personality disorder in particular) are psychiatric problems most frequently associated with suicide. Besides, there have been striking findings recently that point to the increasing effect of anxiety disorders on suicide. On that account this relation should definitely be analyzed in the prevention of suicide, which is a crucial public health problem. In cases with anxiety disorder, analyzing suicidal ideation and suicide attempt may prevent completed suicides hence lower the ratios of completed suicide; because suicidal ideation and preattempted suicide are the biggest risk factors for a completed suicide [10, 13, 14]. Studying such thoughts and behaviors, therefore, may increase our understanding of who is likely to attempt or complete suicide, potentially informing suicide risk management and prevention efforts. Psychiatric disorders are one the primary risk factors for suicidality, with up to 95% of suicides committed by individuals with one or more disorders.
Patients with anxiety disorders are at high risk for suicidal ideation, regardless of whether the suicidal ideation is due to anxiety disorders itself or to cooccurring conditions. In evaluating the literature, it is necessary to review general requirements for establishing anxiety as a risk factor for suicidal behaviors [9]. In addition to establishing a meaningful and consistent interrelation of anxiety with suicidal behavior, the other requirement is the absence of a third variance (mixing factor) between suicidal behaviors and anxiety. Besides, anxiety must have existed before suicidal behavior and in suicidal behaviors anxiety must act as the independent risk factor. Psychiatric disorders are one of the primary risk factors for suicidality, with up to 95% of suicides committed by individuals with one or more disorder [15]. In particular, the mood and anxiety disorders are associated with suicide ideation and attempts [16-19]. The relationship between anxiety disorders and suicide-related behaviors has received a modest amount of attention. However, research has also accumulated over the past several years indicating that anxiety disorders confer unique risk of suicide [20, 21]. The presence of current or lifetime anxiety disorders, including panic disorder, social phobia, generalized anxiety disorder, and posttraumatic stress disorder, are associated with increased suicide risk [10, 18, 22, 23]. Individuals with anxiety disorders demonstrate increased suicidal ideation and rates of self injury and more frequent suicide attempts than those without mental health disorders [10, 16, 17]. For this reason, it is of vital importance to comprehend and manage the risk factors for suicide among individuals with anxiety disorders. Despite the prevalence of high risk for suicide within cases with anxiety disorder, the determinants of suicide risk in this group have not yet been clearly established. In other words, anxiety disorders are very common and increase risk for suicide attempts. Little is known about predictors of increased risk specifically among individuals with anxiety disorders [19]. Studies of individuals with specific anxiety disorders including panic disorder, social phobia, and posttraumatic stress disorder indicate that the additional presence of depression and substance use disorders increases suicide risk [10, 24]. Severity and aspects of functional impairment are also related to suicide risk in patients with anxiety disorders. For example, anxiety symptom severity is associated with increased suicidal ideation and attempts in patients with PD and patients with PTSD [10, 25, 26]. Associations between suicide risk and impairment in general functioning in PTSD and social functioning in both PTSD and PD are also documented [27, 28]. Twelve-month prevalence rates of suicidal ideation in patients with obsessive-compulsive disorder (OCD, 27.3%), the prevalence rate of suicide attempts in panic disorder (3.6%) and the prevalence rate of suicide attempts in OCD (3.3%) were the highest [21]. The overall 12-month and lifetime prevalence of GAD was 0.8% and 1.2%, respectively. Being older than 25 years and female, lower education level, unemployed status, and lower monthly income were associated with increased risk of GAD in China [29]. It remains unclear whether certain anxiety disorders are risk factors for suicide. For instance, Uebelacker et al. [19] have reported that PTSD, major depressive disorder (MDD), intermittent depressive disorder, epilepsy, pain and low social functionality are, according to univariate analysis, predictors of suicide attempt. In the same study, the findings of multivariate analysis showed that, even when the suicide attempts of the past are controlled, MDD and intermittent depressive disorder are independent risk factors in current attempts for suicide. However, it was concluded in this research that except panic disorder, no other specific anxiety disorder constituted an independent risk factor for suicide attempt. Mood disorders and past history of suicide attempts are the most powerful predictors of a future suicide attempt. Particularly, the patients with comorbid major depressive disorder anxiety are at higher risk for suicide. Thereby primary care health service doctors, emergency and mental health professionals, and clinicians who frequently come across with anxiety disordered cases should be alerted and attentive against potential suicidal ideation and suicide attempts among these patients.
The presence of anxiety disorder is frequently associated with suicide ideation and behaviors. Considering the high costs of suicidal behaviors for the individuals and also the society, it is a foremost priority to prevent suicide. Grasping the factors related to increased risk for suicide among people with anxiety disorders may be contributive to suicide prevention attempts [10]. Anxiety disorders are independent risk factors for suicide attempts and underscore the importance of anxiety disorders as a serious public health problem [17]. The relationship between anxiety disorders and completed suicide is not known exactly. There are a limited number of studies on this subject [30, 31]. It is unclear whether clinical and behavioral suicide risk factors, identified primarily among men, can be extended to women. Personality variants and gender differences among suicide completers with psychopathological autopsy method were investigated. Among women, the ratio of completed suicides is lower than men. Impulsivity and alcohol use are risk factors for completed suicides. It is less common among women to see lifelong alcohol consumption, and among women with alcohol addiction, there is less prevalence of comorbid depression when compared to men. There exists a correlation between alcohol consumption and impulsivity. The low ratio of impulsivity among women triggers alcohol consumption as well. Furthermore, when the relation between impulsivity and applied suicide method is examined, it surfaces that among cases with high ratio of impulsivity, the tendency to apply violence methods is more common. It is argued that women prefer nonviolent suicide methods less pain causing but regardless of their sex, cases with anxiety disorder apply to nonviolent methods more frequently. On the other hand, when high ratio of impulsivity is combined with alcohol consumption, there may occur an elevated risk of suicide for both sexes [30].
The relationship between anxiety disorders and racial and ethnic differences has been studied in several research. For instance, Vanderwerker et al. [32] examined in their study covering 131 adults from different ethnic and racial origins (more than half of the cases with African American roots) the differences of risk factors for suicidal ideation and suicide attempts. They have detected that among young white adults, anxiety disorder (not depression) has an independent relation with suicide tendency, while there is no such relationship for African-Americans among whom there is a significant relation between suicidal behavior and social support could be identified. These findings clearly prove that suicide risk factors vary among races and ethnicities [32]. The results suggest that race/ethnicity-specific risk profiles may improve the detection of suicidality in vulnerable populations. But, Beautrais et al. [33] were found no ethnic differences in suicidal ideation. Risks of suicidal ideation, plan, and attempt were associated with mood disorder, substance use disorder, and anxiety disorder. Major depression was the specific disorder most strongly associated with suicidal ideation, plan, and attempt [33]. In a different study based on society sampling, a number of variables (demographic, work status, mental and physical health condition, personality features, stressful life experiences, and social environment) impacting the suicide-attempt speed in cases with suicidal ideation have been examined. Among age groups between 20–24 and 40–44 having committed suicide attempt, it has been seen that there was a higher ratio of suicidal ideation with respect to age-matched groups and higher levels of anxiety and depression. Upon checking the remaining variables, it has been reported that in cases between ages 20–24, rather than suicidal ideation but anxiety itself constituted a risk factor for suicide attempt. Particularly among men between ages 40–44, physical diseases and unemployment, rather than anxiety and depression, posed greater risks for suicide attempt. In a different saying, Fairweather et al. [34] found that ideators and attempters experience comparable levels of depression and anxiety. Rates of self-harm and associations between self-harm and suicidal behaviors, anxiety, hostility, and paranoid ideas were reported by Fliege et al. [35]. Although there has been significant interest in whether anxiety disorders are risk factors for suicidal behavior, this remains a controversial area. Cross-sectional community and clinical studies have repeatedly demonstrated in univariate models that anxiety disorders are associated with suicidal ideation, attempted suicide, and completed suicides. In multivariate models, it has been questioned whether panic disorder is associated with suicidal behavior after adjusting for other anxiety and psychiatric disorders. Because anxiety disorders are highly comorbid with other anxiety disorders and tend to cluster together, it is important to address whether anxiety disorders as a group of psychiatric disorders have an impact on suicidal behavior after adjusting for other types of other psychiatric disorders (especially mood and substance use disorders) [16].
The relationship between anxiety disorders and suicidal behaviors has not received sufficient amount of interest till present age. Literature review shows that when there is a definite result for a single anxiety disorder, anxiety disorders in general have high frequency relation with suicidal ideation; however its relationship with suicide attempt is not definite [9, 18, 36]. General tendency indicates that for each anxiety disorder there is a similar risk for suicide primarily obsessive-compulsive disorder, generalized anxiety disorder, and social anxiety disorder are associated with suicide ideation. The only specific anxiety disorder related most with suicide attempt is panic disorder [37]. In addition, a clear relationship was reported between PTSD and suicidal thoughts and behaviors, irrespective of the type of trauma experienced. It has been suggested that PTSD has a strong association with suicidality, predicting subsequent suicidal attempts [28, 38].
Suicidal behaviors are multifactorial behaviors. While, historically, anxiety has been regarded as an important risk factor in suicidal behaviors, epidemiological studies carried out on general population or panic patients have evidenced the possible links between suicidal behaviors and the occurrence of panic attacks [39, 40]. Both panic attacks and panic disorders are, in the society and primary health care service, independently related with the increased suicide attempt risk. In epidemiologic samplings, panic disorder is, like major depressive disorder, a risk factor for lifelong suicide ideation and suicide attempt [40-42]. For example, an association between panic and suicidal ideation has been reported by Goodwin and Roy-Byrne [43]. Epidemiologic catchment area (ECA) studies indicate that, when contrasted with other psychiatric disorders, panic disorder is associated with increased suicide ideation and suicide attempt risk [40]. Additionally, epidemiologic data show that when panic disorder is codiagnosed with major depression, alcohol addiction, personality disorders, and cocaine use, there is higher risk for suicide attempt [44, 45]. For instance, Goodwin and Roy-Byrne report that despite the vital role comorbid depression and drug abuse play, attempts for the last one year (not lifelong) are independently related to panic disorder [43]. It has been suggested that panic disorder may not increase past suicide attempt systematically but may climb the suicide attempt in the future. In a vast majority of the monitoring studies of patients with anxiety disorder, there was 20% ratio of suicide caused deaths like the results in major depressive disorder. Similarly, the ratios in suicide attempts have been similar to major depressive disorder and panic disorder [40, 46]. Existing findings are quite remarkable. Patients who suffered from major depressive disorder with related panic disorder were given to more impulsive suicide attempts, even if the difference with depressed patients without panic disorder was statistically insignificant [39]. Primary care patients with PD are at high risk for suicidal ideation, and patients with PD and cooccurring MDD are at especially high risk. Patients with PD in primary care thus should be assessed routinely for suicidal ideation and depression [42]. Although in society-based studies it is indicated that there is a strong relation between PD and suicide ideation, in many other studies with clinic sampling (receiving psychiatric treatment and hospitalized in psychiatry clinic or hospital), no statistically significant relation between PD and suicidal ideation could be detected [24, 47]. For example, Warshaw et al. [24] reported that there was no association between PD and suicidal ideation after controlling for common comorbid psychiatric disorders. In another study, it was revealed that suicidal behavior risk in panic disorder is not higher than the risk in major depressive disorder [42]. Dammen et al. [47] could not find any difference in terms of suicidal ideation between patients with or without panic disorder. Several mental disorders, such as personality disorders, and life events that that have been associated with suicidality, e.g., early childhood abuse, were not assessed and may account partially for the observed association between PD and suicidal ideation [48, 49]. In some clinical studies, patients with PD and borderline personality disorder were at significantly higher risk of suicidal behavior than were PD patients with panic disorder alone [24]. To sum up, there is still an ongoing discussion about the relation between panic disorder and suicide behavior. It is not yet identified if panic disorder singly or when comorbid with other mental disorders like major depressive disorder is effective in suicidal behavior [24, 40, 50]. Thus, the data indicate that the risk of suicide in panic disorder is substantial. As a consequence, clinicians should alert themselves to this preventable outcome and approach treatment with added caution.
Posttraumatic stress disorder (PTSD) is frequently associated with suicidal ideation and suicide attempts. Suicide is an important cause of death in veterans, and the risk for intentional death continues to be high many years after service [51]. Suicidal behavior is a critical problem in war veterans. Combat veterans are not only more likely to have suicidal ideation, often associated with PTSD and depression, but they are more likely to act on a suicidal plan [52]. Citizen soldiers (National Guard and Reserves) represent approximately 40% of the two million armed forces deployed to Afghanistan and Iraq. Twenty-five to forty percent of them develop PTSD, clinical depression, sleep disturbances, or suicidal thoughts [53]. Veterans reporting subthreshold PTSD were three times more likely to endorse these markers of elevated suicide risk relative to the veterans without PTSD [54]. They found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment [54]. Major depressive disorder cooccurs frequently with PTSD, and both disorders are linked to suicidal ideation. For the war veterans with depression symptoms, there is a strong relation between PTSD symptoms and suicidal ideation. According to these findings, when analyzing PTSD-diagnosed war veterans, depression symptoms of suicidal ideation must be taken into account [55]. Of those veterans diagnosed with PTSD, many have comorbid psychiatric disorders, typically major depressive disorder, substance use disorders, and other anxiety disorders [56]. Veterans with PTSD are also more likely to have social, occupational, and functional difficulties, including social isolation, frequent interpersonal altercations, and suicidal ideation [28]. PTSD and MDD occur together frequently, and both disorders have been separately linked to the increased risk of suicidal ideation [57, 58]. It is unclear, however, whether the combination of comorbid MDD and PTSD confers an increased risk for suicidal ideation beyond the risk presented by either diagnosis alone. Several studies of veteran samples have found that the combination of PTSD and MDD did not place individuals at greater risk for suicidal ideation than did a single diagnosis [54, 55, 59]. Conversely, Oquendo et al. [60] found that individuals with current MDD and comorbid PTSD were more likely to endorse suicidal ideation compared to those without a current PTSD diagnosis. In a different study, it was determined that among veterans with schizophrenia and schizoaffective disorder, there is an independent relation between comorbid PTSD suicidal ideation risk but no such risk could be detected for suicide attempt [61]. Suicide has huge effect on public health but despite efficient interventions, a great number of people with suicide risk cannot benefit from these interventions and lose their lives. Until now, a huge number of programs and strategies named as “suicide prevention” have been developed. Recent interventions about exercise give hope in the prevention of suicide thanks to its ease of application because exercise mitigates depression symptoms. Alleviating depression symptoms may provide lessened suicidal ideation and attempt but no study has so far indicated a direct relation between exercise and suicidal behavior. Davidson et al. [62] analyzed in veteran sampling a number of variables (sleep disorders, PTSD, and depression) that might be associated with suicidal risk. In this study, it has been emphasized that there may exist an indirect relation between exercise and suicide. It has also been suggested that exercise is also connected with low depression symptoms and a better sleep pattern, which might in effect lead to lower suicidal risk. A high prevalence of all types of violence is associated with the highest prevalence of depression and PTSD [63]. It is well established that intimate male partner violence (IPV) has a high impact on women’s mental health. Compared to women in control group, among women subjected to physical and psychological IPV, there is higher ratio of depression and anxiety disorders, PTSD, and suicidal ideation. Among women exposed to sexual abuse and sexual violence, there is high ratio of depression symptoms, physical/psychological abuse, and suicide attempt. In reality, PTSD on its own is quite hard to see. Depression symptoms are present either singly or codiagnosed with PTSD. Anxiety ratios are higher among women with comorbidite or abused women with depression symptoms. This may explain the high ratio of suicide attempts and anxiety among physically/psychologically abused women [64, 65]. Recovery from depressive symptoms, state anxiety, and posttraumatic stress disorder in women exposed to physical and psychological but not to psychological intimate partner violence alone. A metaanalysis with 50-article examining the relation among PTSD and past and present suicidal ideation and behavior has been conducted. There is no evidence showing that among PTSD patients there is a risk for completed suicide risk. A relation has been found among presuicide attempt and past and present suicidal ideation. Upon checking other psychiatric disorders (including depression), the relation between PTSD and suicide attempt has been examined but no sufficient data could be detected, but it was also reported that comorbidity depression and pretraumatic psychiatric state may have been a mediator. It is seen that a relation exists among various factors and PTSD and suicidal tendency [66]. In a different study, it was seen that among women patients with comorbid PTSD and drug addiction, suicide behavior varies according to drug addiction type and presence of preventive factors (for instance, worries about kids, will to live, and coping skill) [67]. Clinicians should be attentive to suicide risk in returned veterans and in women exposed to physical/psychological and psychological IPV. For future studies, assessing suicide risk in PTSD and identifying risk factors shall assist in better understanding the topic and preventing suicidal behavior.
Suicidal thoughts and behaviors, also known as suicidality, are a fairly neglected area of study in patients with obsessive-compulsive disorder. Patients with obsessive-compulsive disorder (OCD) have historically been considered at low risk for suicide, but recent studies are controversial. Torres et al. [68] found thirty-six percent of the patients reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide, and 10% presented current suicidal thoughts. The sexual/religious dimension and comorbid substance use disorders remained associated with suicidal thoughts and plans, while impulse-control disorders were associated with current suicidal thoughts and with suicide plans and attempts [68]. The risk of suicidal behaviors must be carefully investigated in OCD patients, particularly those with symptoms of the sexual/religious dimension and comorbid major depressive disorder, PTSD, substance use disorders, and impulse-control disorders [69]. Lester and Abdel-Khalek [70] reported that there is no relation between OCD and suicidal ideation but a relation between OCD and suicide attempt. However, there are certain limits such as the smallness of sampling group and failure to control depression. In a different study conducted with same research group in 2002, it was reported that there is a significant relation between OCD and suicidal ideation but again depression was not controlled in another study [71]. Obsessive-compulsive personality disorder is a factor increasing risk for nonfatal suicidal behavior independently of risk conferred by depressive disorders. For example, Diaconu and Turecki [72] reported that the comorbid obsessive-compulsive personality disorder depression group presented increased current and lifetime suicide ideation compared to the groups with depression alone or without depression, or personality disorders they also had increased history of suicide attempts which were often multiple attempts. OCD is associated with a high risk for suicidal behavior. Depression and hopelessness are the major correlates of suicidal behavior [73]. Suicidal behavior is not a common phenomenon in OCD, but among single patients in particular, accompanying depression, symmetry/order obsession, and compulsions are high risk factors for suicide [74]. In patients with OCD, risk factors for suicidal behavior have been left ignored when compared to other anxiety disorders. However, a high ratio as 10–27% was reported for suicidal behavior. This condition shows that OCD patients may commit suicide attempt at least once in their life [16]. Besides as in OCD assistance-seeking ratio is comparatively lower than assistance search in comorbid OCD, it becomes evident that in OCD patients assistance-seeking methods should be increased in suicide prevention strategies. Suicidality has been underestimated in OCD and should be investigated in every patient, so that appropriate preventive measures can be taken.
Generalized anxiety disorder (GAD) is a chronic general disease among adult population but it is comparatively a less understood clinical state. Clinicians may have knowledge about the characteristics of GAD such as over anxiety, anxiety, and hypervigilance, but such symptoms may fall short in distinguishing GAD from other psychiatric disorders, because in the course of several mental diseases these symptoms are frequently observed. Interestingly enough, despite the changes in diagnosis criteria, prevalence predictions for GAD are quite consistent among epidemiologic studies. It is predicted that among general population, lifelong prevalence is 5% (DSM-III and/or DSM-IV-R criteria). GAD is common in different levels among gender, ethnics, and social groups. Among age 40 and above women, in addition to high ratio as 10%, in the cases applying to primary care service, GAD is 8%. Again in the first primary care service, GAD is the most widely diagnosed anxiety disorder. GAD’s age of onset is different than other anxiety disorders. Prevalence ratios are low among teenagers and young adults but age is a remarkably triggering effect. Women are, compared to men, at higher risk. GAD is more frequent among unemployed housewives with chronic medical diseases [75]. GAD is frequently associated with accompanying depression, other anxiety, and somatoform disorders [76]. Weak family relations, codiagnosed C group personality disorders in stressful life events and codiagnosed Axis 1 disorders, are the increasing factors of GAD’s effects [77]. GAD is quite prevalent all over the world but the relation between GAD and suicidal behavior has not been investigated. There are a limited number of studies on this topic. In another study, it was detected that there is a relation between impairment and suicidal ideation and GAD [29]. Zimmerman and Chelminski [78] found that depressed patients with GAD had higher levels of suicidal ideation when compared to patients with depression only. In future studies, analyzing the impact of GAD on suicidal behavior may be illuminating on the potential risk factors.
Life-long prevalence of social anxiety disorder is 13%, which is a quite high ratio among general public. Not only it leads to a major loss of ability but it is often associated with increased suicide ratios and codiagnosed drug abuse; but the relation between social anxiety disorder and suicidal behaviors has not been analyzed adequately so far. The characteristics of patients with social anxiety disorder are that they unrealistically fear that others will constantly and persistently criticize their acts. Social anxiety disorder usually springs up during puberty and it really emerges for the first time after age 25 [79]. Rates of social anxiety disorder were highest among women and persons who were younger, less educated, single, and of lower socioeconomic class. SAD is a common illness often followed by comorbid MDD and alcohol dependence. SAD with comorbid MDD predicts a substantially elevated risk of alcohol dependence and suicide-related symptoms, stressing the need for early SAD detection [80]. It has been reported that despite the high frequency of suicidal ideation among patients with anxiety disorder, the level of suicide attempt is low. Furthermore, the data show that in social anxiety disordered cases, the ratio of lifelong suicide attempt is 12–18% but this condition is associated with codiagnosed depression symptoms [81]. It is also reported that 69% of patients with social anxiety disorder are afflicted with other lifelong comorbid mental disorders and with the occurrence of social anxiety usually, they are added into clinical picture. Once contrasted with people having no mental disorder, uncomplicated social anxiety disorder is found to be connected with increased suicidal ideation, financial dependency, and having sought medical treatment. Nonetheless, no connection was established between social anxiety disorder and suicide attempt and psychiatric treatment. It has been reported that in social anxiety disorder there is elevated suicide attempts, but these cases are surprisingly comorbid cases. In the absence of comorbidity, social anxiety disorder is still a problem that spoils the functionality, but patients rarely seek psychiatric treatment; hence large numbers of cases cannot be examined well by the clinicians [82]. The effect of anxiety disorder alone on suicide behavior has not yet been established but when social anxiety disorder’s chronic course and adverse impact on functionality are considered, particular attention needs to be paid in the assessment of patients in this group.
Comparison of the suicidal behaviors of the specific anxiety disorders is given in Table 1.
\n\t\t\t\tSpecific anxiety disorders\n\t\t\t | \n\t\t\t\n\t\t\t\tSuicide ideation \n\t\t\t | \n\t\t\t\n\t\t\t\tSuicide attempt\n\t\t\t | \n\t\t\t\n\t\t\t\tCompleted suicide\n\t\t\t | \n\t\t
Panic disorder | \n\t\t\t++++ | \n\t\t\t++++ | \n\t\t\t? | \n\t\t
Posttraumatic stress disorder | \n\t\t\t+++ | \n\t\t\t+++ | \n\t\t\t? | \n\t\t
Obsessive-compulsive disorder | \n\t\t\t+/? | \n\t\t\t? | \n\t\t\t? | \n\t\t
Social anxiety disorder | \n\t\t\t? | \n\t\t\t? | \n\t\t\t? | \n\t\t
Generalized anxiety disorder | \n\t\t\t? | \n\t\t\t? | \n\t\t\t? | \n\t\t
Simple phobia | \n\t\t\t? | \n\t\t\t? | \n\t\t\t? | \n\t\t
Specific anxiety disorders and suicidal behaviors
Strong evidence: ++++, Evidence: +++, No clear evidence +/?, No data: ?
Anxiety disorders, when accompanied with other comorbid mental disorders, may affect the course and treatment of disease. Comorbid conditions may occasionally lead to diagnostic ambiguity, and in a number of cases, multiple comorbid mental disorder may accompany the present clinical picture. In a research conducted by Sanderson et al. [83], it was reported that among 70% of patients with anxiety disorder, there is minimum one additional Axis 1 diagnosis. In present study, the highness of comorbidity ratio draws attention. However, once considered that current diagnosis systems are largely consisting of joint symptom clusters, these ratios appear to be exaggerated predictions. Nevertheless, mental disorder comorbidity is considered negative for the natural course of illness by implying additional kinds of dysfunction depending on whether it is a disorder of mood, substance abuse, or personality [84, 85]. These three are the most common comorbid disorders.
The potential association between anxiety disorders and suicidal ideation rendered mixed results. In the researches, positive findings between anxiety and suicidal ideation may be connected to accompanying depression. In patients diagnosed with anxiety disorder not positing mood disorder story, there was no increased risk for suicidal ideation. On the other hand, in a recent study, it has been reported that among anxiety disordered cases not accompanied with mood disorder, there is an increased risk for suicidal ideation [86]. Nonetheless, in current research, subsyndromic depression symptoms have not been excluded, which puts the findings of research open to discussion. Traditionally, research on suicide has emphasized relationships with mood disorders, psychotic disorders, and some personality disorders. Although certain features of anxiety have been incorporated into models of suicide, anxiety-related conditions such as severe psychic anxiety, agitation, and panic have typically been examined as predictors of suicidal behaviors only to the extent that they overlap with mood disorders. Sareen et al. [16] in their 3-year long monitoring studies probed into the relation between anxiety and mood disorder–diagnosed cases and lifelong suicide ideation and suicide attempt, and they found out that in the presence of an anxiety disorder not positing a mood disorder story, there is a significant relation between lifelong suicidal ideation and suicide attempt. However, the main limitation of their study is that while analyzing particular anxiety disorders, probable mixing factors (syndromal depressive symptoms, etc.) have not been excluded. Despite this, there is fairly strong evidence that even subthreshold depressive symptoms are associated with increased psychosocial impairment, higher rates of comorbid substance use problems, and greater risk for future syndromal depressive episodes [87]. Further, studies provide strong evidence for an additive and interactive relative risk conveyed by cooccurring anxiety and depression. Consequently, comprehensive suicide assessment plans are strongly recommended when evaluating or treating individuals with an anxiety disorder, and especially individuals with comorbid anxiety and depressive disorders [88].
Clinical and epidemiological studies have provided convincing evidence that comorbid anxiety disorders are relatively prevalent among patients with bipolar disorder (BD), found in up to 65% of cases [89]. Henry et al. [90] studied 318 inpatients including bipolar I and found that 24% had at least one lifetime anxiety disorder and 11% of the patients had more than one such disorder. Comorbidity of anxiety disorders may be associated with greater suicidality, substance abuse, resistance to pharmacological treatment, and poor outcome [91-93]. Altındag et al. [94] studied 70 outpatients including bipolar I and found that 27.1% had at least one lifetime anxiety disorder, and most common anxiety disorders in this sample were obsessive-compulsive disorder (12.8%) and specific phobia (12.8%), followed by panic disorder (5.7%). Anxiety disorder comorbidity appears to be associated with greater number of hospitalizations, psychotic symptoms, and suicide attempts in patients with bipolar disorder type I. Bipolar subjects with anxiety disorders were younger, had earlier age at onset of illness, and were overrepresented by female subjects and those with earlier onset illness compared to those without anxiety disorder [95]. Panic disorder, which also confers an independent risk of suicide and psychiatric comorbidity, in general has been found to amplify suicidality in mood-disordered patients [96]. The presence of comorbid panic disorder in individuals with bipolar disorder may confer an increased risk of suicide risk. Some papers’ reviewed have conflicting conclusions but the majority of papers support an increased risk. Future research should study specific bipolar subgroups, focus on anxiety and panic symptoms rather than diagnosis, and look at the role of specific pharmacological treatment in patients with comorbid mood and anxiety disorders. Among anxiety disorders, only social phobia (SP) was significantly associated with history of suicide attempt in BD. In other words, SP is an important risk factor for suicidal behavior in BD [97]. Suicide takes significantly different forms within different stages of behavioral bipolar disorder. Suicide attempts and suicidal ideation have been found to be most closely connected to the depressive periods of disease. Severity of despair and depression are the key indicators of risk for all stages [98]. Previous studies have shown a significant relationship between suicide ideation and mixed depression. The rates of mixed depression among bipolar and nonbipolar depressive suicide attempters were much higher than previously reported among nonsuicidal bipolar II and unipolar depressive outpatients, suggesting that suicide attempters come mainly from mixed depressives with predominantly bipolar II base. Irritability and psychomotor agitation were the strongest predictors of suicide attempt [99]. Although anxiety may be a modifiable suicide risk factor among bipolar patients, anxiety disorder comorbidity has not been highlighted as critical in identification of high-risk individuals nor has its treatment been integrated into suicide prevention strategies. Although lifelong anxiety disorders are related to past suicide attempts, current comorbid anxiety disorders are found to be connected to suicidal ideation. In anxiety disordered individuals, suicidal ideation is a risk factor for suicide behaviors in future. The early onset of polar disorder and frequent appearance of rapid cycling and mixed periods constitute great risk for suicidal behavior. All in all, both bipolar disorder and anxiety disorder bear risks for suicidal behavior. In the presence of comorbid anxiety disorders, suicide behavior risk may gain even further impetus in bipolar disorder cases. To put differently, anxiety disorders (social anxiety disorder at most) may play active role in developing suicidal ideation and suicide attempt among bipolar disordered cases [100]. In the presence of comorbid anxiety disorders in bipolar disordered cases, patients must be attentively monitored against suicidal risk. Further studies shall contribute to better comprehending suicide behavior in bipolar disorder patients with anxiety disorder.
The high prevalence of comorbid drug abuse in anxiety disorders is attributed to patients’ relief seeking in alcohol and/or drugs for alleviating the emotional stress they cope with (self-medication). Regardless of the high ratios of alcohol and drug use in anxiety disorders, self-medication has been discussed in limited numbers of studies. Likewise although in mood disorders there is high frequency of alcohol and drug abuse, there is a limited body of research on this domain. The use of alcohol and drugs to relieve affective symptoms is common among individuals with mood disorders in the general population [101]. Comorbid specific mood and anxiety disorders and specific drug use are widely common in American society. Among women in particular comorbid psychiatric disorders may lead to critical use of illegal drugs. In present study, it was reported that among female cases diagnosed with comorbid mood and anxiety disorder, in comparison to postdrug-alcohol addicted men, medical prognosis of disease is affected more negatively [102]. Among cases with anxiety disorder self-medication has been associated with accompanying mood disorders, drug abuse, anxiety, suicidal ideation, and increased risk for suicide attempt. Even after controlling sociodemographic and psychiatric variances self-medication remained to be related to suicidal ideation and increased risk for suicide attempt. Bolton et al. [103] reported that individuals with anxiety disorders who self-medicate their symptoms with alcohol or drugs may be at increased risk for mood and substance use disorders and suicidal behavior. In this study covering a wide sampling of society, self-medication prevalence varied between 7.9% (social phobia and speech subtype) and 35.6% (GAD). Multivariate analyses put forth that self-medication is independently related to lifelong suicidal ideation and attempts and also to an increased comorbid mood disorder and drug abuse tendency. Alcohol use disorders and suicidal ideation cooccur, yet few studies have investigated the risk and protective factors that influence their comorbidity. The comorbidity between alcohol use disorders and suicidal ideation is characterized in young women by cooccurring psychopathology, drinking to cope, and negative life events [104].
Among schizophrenic patients, there is a considerably high ratio of suicidal behavior. It is particularly noteworthy that among schizophrenic cases with suicide attempt story and suicidal ideation in the past, there is also comorbid OCD. Also the ones with suicide story are significantly higher in patients with OCD-schizophrenia than in patients with non-OCD schizophrenia. Compulsive symptoms were significant predictors of suicide attempt among patients with schizophrenia [105]. The obsessive-compulsive symptoms may account for the emergence of suicidality in patients with OCD-schizophrenia. In schizophrenia suicidal ideation has been auspicated with depressive mood, anxiety, low self esteem, negative disease perceptions, negative assessments of the self and others, and daily alcohol consumption. The frequency of coping with audio hallucinations and delusions has no connection with suicidal ideation but distress caused by positive symptoms was found to be related to suicidal ideation [106]. Affective dysfunction, including distress in response to hallucinations and delusions, was a key factor associated with suicidal ideation in individuals with psychotic relapse.
In elderly persons with major depressive disorder, coexisting generalized anxiety disorder or panic disorder is associated with more severe symptoms and poorer short-term treatment outcomes. De Luca et al. [107] found evidence that comorbid generalized anxiety disorder or panic disorder is associated with a greater decline in memory in late-life MDD and suicidal ideation. The clinical correlates of comorbid anxiety and depression in a sample of older patients with major depression. In elderly patients with anxious depression, psychosocial support and suicidal ideation should be assessed [108]. Anxiety symptoms are the frequent comorbids of old-age depression; hence MDB comorbid with subsyndromal anxiety symptoms is termed as “anxious depression.” In reality, MDD is generally comorbid with specific anxiety disorders but there is no definite information on the frequency, diagnosis, clinical course, and treatment approaches for anxiety disorders among elderly group. It is acknowledged that specific anxiety disorders, anxiety disorders comorbid with MDD, are less common among the elderly. Still, in aged people with anxious depression, particularly in complex cases comorbid with chronic physical disease, there is a heightened risk for suicidal ideation, disability, and poor prognosis. Standard pharmacotherapy could be sufficient for depression but among many older people with anxious depression. Standard pharmacotherapy on its own may fail to be sufficient. There are a number of psychosocial treatments but they are not specific for old-age anxious depression. However, psychosocial interventions may be a major constituent in the treatment of these patients [109]. In the elderly group, ratios of completed suicide are significantly higher than the other age groups, thus in preventing old-age suicides, the elderly cases diagnosed with “anxious depression” must be studied attentively.
Suicidal ideation and behavior have been associated with a variety of neurological illnesses. There are important linkages between suicidal ideation and behavior and neurological conditions, including epilepsy, multiple sclerosis, and amyotrophic lateral sclerosis [110]. Anxiety disorders are common in patients with multiple sclerosis, but are frequently overlooked and undertreated. Korostil and Feinstein [111] studied 140 outpatients including multiple sclerosis and found that 35.7% had at least one lifetime anxiety disorder, and most common anxiety disorders in this sample were panic disorder (10%) and obsessive-compulsive disorder (8.6%), followed by generalized anxiety disorder (18.6%). Subjects with an anxiety disorder were more likely to be female, have a history of depression, drink to excess, report higher social stress, and have contemplated suicide. Risk factors include being female, a comorbid diagnosis of depression, and limited social support. Clinicians should evaluate all multiple sclerosis subjects for anxiety disorders, as they represent a treatable cause of disability in multiple sclerosis. The studies have observed a strong relationship between coronary artery disease (CAD) and psychiatric disorder, notably depression, anxiety, and panic attacks. A significant positive relation was observed between CAD and lifelong prevalence of suicide attempts. Suicide attempts were found to be connected with major depression and comorbid anxiety disorder but no relation was detected between suicide attempts and anxiety singly. At the end of logistic regression analysis, the relation between suicide attempt and CAD continued after making correction for depression and anxiety. In a different saying, CAD is an independent risk factor more powerful than depression for suicide behavior [112]. Acne is a common disease in adolescence with female preponderance. It could cause poor self-esteem and social phobia. Previous studies based on questionnaires from several thousands of adolescents showed that acne is associated with major depression and suicide [113, 114]. However, the gender- and age-specific risk of depression and suicide in patients with acne remain largely unknown. The risk is additive in women with acne. Similar additive risk of suicide was noticed in women with acne. In recently, Yang et al. [115] reported that acne and gender, independently and jointly, were associated with major depression and suicide. Special medical support should be warranted in females with acne for the risk of major depression and suicide. It has been demonstrated that a correlation exists between an extensive scope of physical diseases and increased ratios of suicide. As the studies on particular topic are examined, it surfaces that medical diagnoses alone are not sufficient causes to lead a person to suicide. Comorbid mental disorders are equally responsible in the development of suicide. It is thus important to train the clinicians on identifying not only physical symptoms but mental symptoms too and the ways to determine their effects on the treatment and the course of disease. To have a lifesaving effect, particular attention to crisis periods, stages of physical illness, and postdischarge period should be monitored attentively on accounts of being risk-posing periods for suicide behavior. It is thus obviously crucial to monitor physically sick patients to stay alert against suicide behavior.
A comprehensive metaanalysis to identify the proportions of comorbid personality disorders (PD) across the major subtypes of anxiety disorders has not previously been published. Friborg et al. [85] reported that the rate of any comorbid PD was high across all anxiety disorders. The findings reveal that Group C personality disorders are two times more common compared to Group A and B personality disorders, and within Group C personality disorders, the highest ratio was seen in avoidant PD, followed alternately by obsessive-compulsive and the dependent personality disorder. In cases where personality disorders are codiagnosed with anxiety disorders, the course and treatment response of the disease may alter. It has, for instance, been reported that in social anxiety disorder where PTSD provides a heterogeneous clinical picture, there is a high ratio of comorbid with avoidant PD. Except early onset, avoidant PD rendered insignificant or minor impacts on social anxiety disorder. No relation could be established between gender or length of anxiety disorder and personality disorder comorbidity. Patients with social phobia (61%) and generalized anxiety disorder (49%) were most often diagnosed with a personality disorder. Patients with simple phobia were rarely diagnosed with a personality disorder (12%) [83]. In a different study, it has been illustrated that present or lifelong panic disorders are related with borderline, avoidant, and dependent personality disorders; social anxiety disorder connected with avoidant personality disorder; and obsessive-compulsive disorder associated with obsessive-compulsive and avoidant personality disorders. In anxiety disorders comorbid with personality disorders, unlike anxiety disorders with no personality disorder, there has been a more chronic course, increased suicidal behavior, and low level of functionality [116]. The relationship between cooccurring personality disorders and anxiety disorders (panic disorder with or without agoraphobia, social phobia, and generalized anxiety disorder) was examined, taking into account the effect of major depression. Generalized anxiety disorder, social phobia, and major depression were positively associated with the occurrence of one or more personality disorders, whereas panic disorder with agoraphobia was not associated [117]. The effect of comorbid personality disorders in obsessive-compulsive disorder is unclear. Baer and Jenike [118] in their research covering 96 OCD adult patients detected that in patients with mixed personality disorder, the length of OCD is longer compared to the ones with no OCD. The authors argued that the impacts of personality disorders on behavior and life style can be secondary OCD. The studies indicate that most individuals with OCD have comorbid personality disorders (PDs), particularly from the anxious cluster. However, the nature and strength of this association remains unclear, as the majority of previous studies have relied heavily on clinical populations. Personality pathology is highly prevalent among people with OCD who are living in the community and should be routinely assessed, as it may affect help-seeking behavior and response to treatment [119]. Latas and Milovanovic [120] in a recent study proved that in anxiety disorder cases, personality disorders exhibit quite a high prevalence as 35% in posttraumatic stress disorder, 47% in panic disorder with agoraphobia and generalized anxiety disorder, 48% in social phobia, and 52% in OCD. In anxiety disorder cases, the highest ratio (39%) was found in Group C personality disorders. Also in samplings with personality disorders, high ratio of anxiety was detected particularly among borderline personality disorder cases. It is agreed that borderline personality disorder is a high risk factor for recurrent suicidal behavior. Personality disorders comorbid with anxiety disorder display a number of clinical outcomes such as suicide risk and more severe and less treatable anxiety disorders, thereby clinicians should place particular emphasis on identifying potential personality disorders in patients with anxiety disorder. Further studies should focus on the causes and risk factors for suicidal behavior particularly in patients with anxiety disorders comorbid with personality disorders.
The basic principles of treatment of anxiety disorders in major depression involve longer treatment and higher doses than are usually required for major depression. The impact of psychosocial disability and severity of depressive symptoms can be ameliorated with appropriate treatment. Screening for depressive symptoms as well as administering an appropriate therapy seems the best way to prevent suicide attempts [121]. Newer treatments, such as the combination of psychotherapy and pharmacotherapy, may prove to be of greatest benefit for individuals with comorbidity of anxiety disorders in psychiatric disorders [122]. For the recent 25 years, much progress has been made in the treatment of five specific anxiety disorders such as social phobia, obsessive-compulsive disorder, generalized anxiety disorder, and posttraumatic stress disorder. Placebo-controlled evidences suggest that pharmacological and psychological treatments offer substantially effective solutions [21, 123]. Treatment of anxiety disorders involve antidepressants (selective serotonin reuptake inhibitors (SSRI) mostly) and cognitive behavioral therapy. Among patients diagnosed with mood disorder and comorbid anxiety disorders, it is advisable to administer higher doses of SSRI [124]. Besides, a long-term discussion has been going on about the use of SSRIs (paroxetine, fluoxetine, and citalopram) which, as some argue, may have a triggering/stipulating effect on adult suicides since 1991 and children since 2002. Apter et al. [125] stated that paroxetine taking adult patients with major depression are at higher risk for suicidal ideation and behavior, and the same authors also claimed that there was no attempt in OCD and social phobia cases. In sync with this finding, the benefits of sertraline outweigh its potential risks in suicidal behavior among OCD patients, and OCD’s effects are, in contrast to its effects in major depression, further positive [126]. In younger patients diagnosed with major depression, the risk of suicidal behavior uncovered with treatment is even higher. It is suggested that the rise in suicidal ideation and attempt parallel to the use of antidepressants is more risky for children and teenagers [21, 123]. Rickels et al. [127] in their two randomized controlled studies reported the positive effects of long-released venlafaxine on GAD. Among children and teenagers major depression and in GAD patients with venlafaxine, there might be a stage between suicidal behaviors and hostile behaviors. Antidepressant drugs play a vital role in the treatment of anxiety disorders and preventing suicidal behaviors among adult patients. Selective serotonin reuptake inhibitors are the first-line pharmacological treatment for these disorders, and that newer serotonin and norepinephrine reuptake inhibitors show significant promise, especially for comorbid cases. In the treatment of anxiety disorders, cognitive behavior therapy (CBT) can be applied in combination with pharmacotherapy or independently. For instance, in the treatment of panic disorder, CBT aims to control agoraphobic symptoms in panic disorders comorbid with agoraphobia, to inhibit adverse effect of medicine deduction and treatment and prevention of panic attacks. Not much study has been made on the effects of CBT applications in anxiety disorders on suicidal behavior, but when anxiety disorder cases are successfully treated with CBT there is likelihood to witness fewer ratios of suicide [128]. When anxiety disorders are comorbid with depression, disease symptoms are likely to be more severe; hence symptom severity should be taken into account while making treatment plan. Particularly speaking, patients diagnosed with panic disorder, PTSD, and comorbidity of anxiety disorders in major depression bear higher risks for suicide. The cases bearing potential risks for suicide should be kept and monitored under strict scrutiny by clinicians. In order to assess and monitor these patients, there is a need for relevant measurement tools of which reliability and validity tests have been confirmed. In suicide behavior treatment studies among anxiety disorders, ethic limitations have restricted the participation of individuals with acute suicidal tendency. In relevant studies, the lowness of suicidal behavior and restricted volume of samplings inhibited a precise detection of the real effect of treatments. As we consider the fact that various factors interact in the emergence of suicidal behavior, it is probable that drug effect may be regulated in the same way with the interactions among such factors. The fact that no treatment study manages to equally control the risk factors among treatment groups makes it hard to identify the causal factors in suicide-relevant cases. Furthermore, in the analysis of SSRIs, short-term risks alone were examined; hence it is a requirement to detect long-term risks and create future-oriented study designs with wider databases and closer monitoring procedures. There is a need for more research to develop a guideline/protocol exclusively for suicide prevention in patients with anxiety disorders.
Traditionally, anxiety disorders have not been viewed as independent risk factors for suicidal behavior, and therefore assessment of anxiety disorders has not been particularly emphasized in clinical enquiries, and suicide screening tools specific anxiety disorders (e.g., generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder) may be independently associated with suicidality, to which they particularly contribute when they are comorbid with bipolar disorder, personality disorders, depression, schizophrenia, and substance use disorders. Despite methodological issues, these findings should prompt clinicians to evaluate more specifically the impact of anxiety disorders on suicidal behavior, particularly when they are comorbid. Further research into treatment of anxiety disorders in relation to preventing suicide is required.
I offer thanks to our team for suggesting that we write a book about anxiety disorders and suicide.
The manufacture/fabrication of all men- made objects made up of metals/alloys involve the process of solidification at same stage. It processes of phase change, a liquid phase giving way to a solid phase. In metals and alloys, however, solidification involves the formation of crystals, a crystalise solid exhibiting regularity in atomic spacing over a considerable distance [1]. This is dissimilar from a process involving glasses and polymers. However, even in the case of metal/alloy, when crystals are deposited as a consequence of solidification from the melt, though, there exist certain extents of internal symmetry, there are certain irregular external forms and shapes. This tendency can be attributed to the uneven growth rates throughout the process of solidification and the constraints in the growth process during the last stages of freezing. In the ordinary general case, the solidified grain or cell representing the structure of the solid is a normal crystalline unit formed in the cast structure. However, under the specific case of eutectic freezing, the solidified cell consists of two separate crystal structures with the simultaneous growth of separate phases [2].
The most important practical applications of the process of solidification is found in the production of castings. Indeed, casting can be defined as liquid metal forming. The process consists of introducing the liquid metal of appropriate composition into the mould effecting its solidification under controlled conditions of cooling, pouring, etc. to obtain the desired cast structure [3, 4]. A molten metal has a viscosity which is about one-twentieth of the corresponding solid. Thus, instead of spending, high energy, overcoming the high flow of stresses of a solid to shape if by adopting bulk metal forming operations of forging, extrusion, rolling, etc. a liquid metal with essentially zero shear stress is required to be handle. A detailed study of the process of solidification, therefore, enables one to know and hence control the microstructure of the casting that decides is microstructural properties.
The process of freezing of a solid from its melt is accompanied by to very important phenomena which decides the intrinsic properties of the resultant casting. At the first instance, freezing is associated with volume contractions as a consequence of the development of a more closely packed solid [5]. At the same time a reduction in the molecular motion is experienced when the randomly moving molecules in the liquid phase generate the nuclei that finally grow into the solid phase. Latent heat of crystalization is liberated at the solid/liquid interface. This liberated heat energy markedly affects the rate and mode of crystal growth. The general fall of temperature to give way to freezing causes a lowering of the solubility of the alloying elements in the melt. Solute atoms are rejected at the solid–liquid interface. The solubility of the alloying elements is further affected as a result of the changed composition of the alloy grossly affecting the final structure of the solidified melt.
Where the casting process is the last stage of fabrication or it has to be followed by further mechanical working, solidification possesses pay an important role in deciding the microstructure of the product and hence its final structure related properties. In this respect, two distinct cases can be considered:
One of the major problems concerning the process of casting involves the local variation of the resultant microstructure leading to compositional variations. The above is illustrated in Figure 1.
Schematic presentation of alloy properties as influenced by its position in the melt.
As seen in Figure 1, the dendritic arm spacing (
Heavy reduction through mechanical working is not a very efficient method of modifying the edge cast structure. Any initial heterogeneously develop structure, due to the adoption of a faulty solidification process has some tendencies to persist. Therefore, it can be said with authority, any effective control of product quality must be exercised during the process of solidification itself.
The process of solidification comprises of successive stages of Nucleation and Growth. Whether, freezing is directional or adopts a discrete fashion, throughout the melt, depends on these two factors. In this regard, the location and relative rate of Nucleation and Growth hold the keys to the casting characteristics.
Any phase change has to get initiated by the emergence of the new phase at some instant of time. Likewise, when a solid phase emerges out of the liquid metal/alloy, it begins with the appearance of Nuclei. These are the cluster of atoms which come together during their course of random motion in the melt and can be termed as the embryonic crystals. These embryonic crystals permit further sitting at atoms on their surfaces which causes the growth of the solid phase. However, many of the nuclei again disappear in the melt, the clustered atoms again moving randomly in the melt. Only those nuclei which are stable and meet the thermo-dynamic requirements, allow growth to take place on their surfaces.
Nucleation can take place in two ways.
The coming together of the randomly moving atoms, from within the melt to form the embryonic crystals, the Nuclei, is known as Homogeneous Nucleation. These are smaller zones of higher density, formed by the ordered cluster of atoms [6]. Mahata et al. have conducted experiments to understand homogeneous nucleation in solidification of aluminium by molecular dynamics simulation [7]. They are of the opinion that there are many methods like X-ray scattering [8] etc., to monitor solid to liquid transformation. However, these methods are limited by several factors that make it difficult to study Homogeneous Nucleation in pure metals.
The precipitation of the group of atoms as the embryonic fresh phase in the melt, is subjected to a change in the free energy. The total free energy change comprises of two components, VOLUME FREE ENERGY CHANGE and INTERFACE FREE ENERGY CHANGE. Thus, a thermodynamic set of conditions is set up for the formation of the Nuclei and for the Nuclei to be stable and not to dry–out prematurely, these thermodynamic conditions have to be met with.
Thermodynamically, when a solid comes out as a liquid, there is a negative free energy change in the system. This change of free energy is directly proportional to the new volume(solid) transformed. Thus, for a spherical solid particle formed in a liquid,
Thermodynamically, when a new interface is generated due to the emergence of a solid from a liquid, there is a gain of free energy at the interface created. This free energy gained is gained is proportional to the surface area of the solid particle created. For the same sphere, as considered above, with a radius of
The volume free energy change and the interfacial free energy change are both presented graphically in Figure 2. The Figure 2 also depicts the overall free energy change as a consequence of the two components when the solid volume is created in the melt.
Change of free energy (volume and interface) as a consequence of the creation of solid phase.
As seen in the Figure 2, for small values of
From the above it follows, homogeneous nucleation conditions are not favourable at the beginning for the stability of the nuclei as considerable undercooling is necessary for homogeneous nucleation to be effective. In the practical case of casting in a foundry, however, the melt need not be supercooled to make the homogeneous, stable nuclei form to start the solidification process. This is because, in the practical melt in the foundry, solidification processes are initiated by heterogeneous nucleation.
For heterogeneous nucleation, the initial interface for growth is provided by a foreign particle [9]. This foreign particle can be provided from outside or formed in the melt itself. The impurities, foreign particles or even the mould wall (the subtstate) can provide for a part of the surface energy required for nucleation. It is a known fact that less activation energy (free energy barrier) is required for nucleation. Therfore, the presence of the substate as mentioned above reduced the free energy barrier and can be very helpful in creating more growth capable nuclei. This is known as heterogeneous nucleation which need less activation energy than homogeneous nucleation [10]. This second phase to act as a nucleus, however, must be capable of being wetted by the melt forming low contact angles and also it must have some structural affinity with the crystalline solid to be formed on it. This second phase could be any one or any combination of the following:
impurities in the metal
the wall of the mould
deliberately added particles to encourage a particular mode of crystallisation
Once the heterogeneous nuclei meet the growth conditions, growth occurs on them. After a certain lapse of time, when the temperature of the melt is lowered, the homogeneous nuclei become stable, and more solid may get deposited on them. At the same time, fresh nucleation may occur generating further stable nuclei. These fresh nuclei may be of the same phase as the first nuclei or of a different phase.
The growth process is conceived as the sitting of further atoms on the stable nuclei which brings in the growth of individual crystal or a general growth in the mass of the solid as solidification proceeds the latent heat of crystallisation is liberated at the solid–liquid interface. Zones of thermal supercooling are generated in the liquid pool. Also, with the lowering of temperature the solubility of an alloying element in the liquid melt decreases. As a consequence, the solute is rejected at the solid–liquid interface. The equilibrium freezing temperature of the alloy is continuously altered and a phenomenon known as constitutional supercooling, takes place. Both thermal and constitutional supercooling obstruct growth and alter the growth pattern.
Nucleation does not take place randomly in the metal/alloy melt throughout the liquid because in the actual case of solidification, and uniform lowering of temperature throughout the melt cannot be obtained. There exist a thermal gradient between the cool mould wall surface exposed to the ambience and the interior of the solidifying melt that would eventually form the casting. Therefore, in the practical case, nucleation is initiated at the mould surface and the growth of the solid phase proceed being directed towards the centre of the casting. This growth takes place in a preferred crystallographic direction as dictated by the characteristic of the solidifying crystal. For an example, in a cubic crystal the preferred crystallographic direction is <001>. With the aid of the temperature gradient, the grains oriented favourably grow at a faster rate than the others.
With the lapse of time, depending on the no of effective nuclei and the initial growth rate setup by the initial temperature gradient, the growth of the crystals in the lateral direction gets obstructed. This is because the laterally growing crystals impinge into each other restricting growth of the neighbouring crystals. Also any growth of any crystal ahead of the others, into the high temperature melt is inhibited due to the unfavourable temperature conditions. Such a situation gives rise to planar or plane front growth where in a seemingly plane interface proceeds into the melt causing growth [11]. The interface is plane macroscopically whereas in actual, it is a terraced structure microscopically. This is a typical condition leading to the formation of columnar grains which is often observed in cast ingots. These columnar grains grow in a direction opposite to the direction of heat-flow. This is illustrated in Figure 3.
Schematic presentation of planar growth giving rise to columnar dendrite.
The occurrence of planar growth giving rise to a columnar structure involves thermal condition present in Figure 4.
Schematic presentation of the thermal condition for plane front growth.
It is assumed, a positive temperature gradient exists at the solid–liquid interface. Here, the liberated latent heat of crystallisation is not enough to reverse the temperature gradient due to the freezing; i.e., a situation is not created when some pockets in the inside of the melt, away from the interface, are at relatively lower temperature. This situation is favoured at slow cooling rates which ensure a stiff and positive temperature gradient. Under these conditions only, the interface assumes the shape of a seemingly plane surface a columnar grain-structure is favoured.
The thermal conditions get grossly distributed when sufficient accumulation of the liberated latent heat of crystallisation at the interface is experienced. The liberated heat now disturbs the thermal gradient. Though there is a positive thermal gradient due to the cold mould surface, the local evolution of latent heat produces a reverse temperature gradient at the interface. This is illustrated in Figure 5. Where a zone of thermal super cooling indicating pulls in the melt at the interface or adjacent to it at temperatures lower than the equilibrium temperature are witnessed. Obviously, growth does not occur due to the general advancement of the plane-front but by preferential growth processes in these undercooled pulls in the melt.
Schematic presentation of generation of thermal undercooling.
The planar growth pattern is disturbed as the minimum temperature in the liquid melt is not witnessed at the interface. Plane-front growth is hindered and growth occurs by other means. Depositions of further atoms on the surface of the nuclei may occur in regions of greater under cooling in preference to the interface. The thermal super cooling greatly influences the final structure of the solidified melt.
Constitutional supercooling in an alloy is best illustrated in Figure 6.
Phase diagram of a typical binary alloy.
The Figure 6 presents the solidification and hence the phase changes in a simple binary alloy of ‘A’ and ‘B’. Let us consider the alloy of Co. The initial alloy deposited from Co has a composition confirming to ‘C1’. Obviously, ‘C1’ has a composition pertaining to ‘B’ which is less than that of the original alloy ‘Co’. Therefore, as ‘C1’ is formed, the residual liquid gets slightly enriched in ‘B’. Thus, as solidification proceeds ‘B’ is continuously rejected into the liquid. This rejection occurs at the solid–liquid interface throughout the process of freezing. A constitutional gradient is, thus, created in the liquid, solute ‘B’ being continuously rejected at the interface. The concentration of ‘B’ is maximum at the interface and gradually diminishes as one goes towards the interior of the liquid melt. This compositional variation is presented in Figure 7(a). The change of composition brings in a corresponding change in the equilibrium freezing temperature of the alloy as presented in Figure 7(b). Each composition on the solute distribution curve has its corresponding equilibrium freezing temperature as it depends on the corresponding composition of an alloy.
Schematic presentation of rejection of solute at the interface (7(a)) and change of equilibrium temperature (7(b)) as a consequence of the solute accumulation.
The relationship between the actual (existing) temperature gradient in the melt and the equilibrium freezing temperature as a consequence of alterations in the composition of the alloy-melt, is illustrated in Figure 8.
Schematic presentation of constitutional supercooling as a consequence of solute rejection at the interface and the resultant alternation in the equilibrium freezing temperature.
Figure 8 clearly illustrates, before the actual (existing) temperature falls considerably for growth to occur, there, is a pool of melt where considerable supercooling can be witnessed at points farther within the melt. In this pool of supercooled liquid conditions are more favourable for freezing than at the interface. This condition is referred to as constitutional super-cooling.
Alloys having Eutectic composition or containing appreciable amounts of eutectic constituents, undergo eutectic freezing. The alloy of eutectic composition solidifies at a single temperature to precipitate a mixture of two phases
Alternate laminates of the two,
Rod-like or globular solids of apparently discontinuous phase in the matrix of the other phase.
It is the extent of undercooling and its relative location in the melt that immensely influence the mode of growth of the crystal in a solidifying melt. As suggested earlier, it can be a thermal undercooling or a constitutional undercooling. Different extents of undercooling may be found in a band of liquid adjoining the interface or even in the inside of the melt depending on the following:
Temperature gradient in the melt,
The equilibrium freezing temperature and
The nucleation temperature (which will also be dictated by heterogeneous nucleation)
Depending on the extent of under cooling growth can be Dendritic Growth, Cellular Growth or growth due to independent nucleation.
Dentric crystalline growth takes place on solidification of a metal/alloy melt when the liquid–solid interface moves into supper cooled liquid at a temperature lower than that of the interface. This is illustrated in Figures 5 and 6 wherein the thermal supercooling or the constitutional supercooling, as the case may be, generate pools in the liquid melt with temperature less than that at the interface. To understand dendritic growth it is important to realise that any protuberance on the solid face may tend to be stable and act as a centre for further growth in preference to other locations due to undercooling. The general advancement of the interface is retarded by the liberated lateral heat of crystallisation or by a solute barrier, but the local growth centres have the possibilities to grow into the zones of supercooling. This gives rise to dendritic growth. This is characterised by commercial alloys forming solid-solutions. It can be emphasised, under rapid solidification conditions non equilibrium condition of solid –liquid interface influence the dendritic characteristics to a great extent [12].
Primary axis of the dendrite is a result of preferred growth at the edge or corner of an existing crystallite. The projection develops into a needle, an then into a plate following the general direction of heat flow. This growth direction is usually associated with a particular crystallographic direction. Again, lateral growth of the primary crystal, needle or plate, is restricted by the liberation of latent heat of crystallisation or solute accumulations that had earlier restricted the growth of the original interface. However, the secondary or tertiary branches may grow by a similar mechanism that helped the formation of the primary stem. This is presented in Figure 9 which depicts the branch like dendritic growth.
Schematic diagram showing the growth of a typical dendritic arm.
This unidirectional dendritic growth produces columnar dendritic structure.
In a pure metal dendritic growth is detected by interrupted freezing and decantation (once a portion freezes, it is separated from the liquid, i.e., the liquid is decanted from the freezing crystal). On the other hand, in alloys dendritic growth is revealed by the characteristic cored structure. Coring is resulted from the differential freezing processes. The centre of the dendrites are deficient in solute which are rejected to the interdendritic zone, as explained earlier.
Dendritic growth may be associated by crystals growing independently on independently formed nuclei, elsewhere in the melt depending on the preventing thermal conditions. This independently growing crystal within the melt has an interface on its periphery. Thus, it is capable of growing in all directions generating an approximately equiaxial grain. With a less marked undercooling, when the undercooling is not enough to form dendrites, cellular growth may still take place. Thus, cellular growth precedes dendritic growth. The cellular substructure is produced as a cluster of hexagonal rods. These rods grow into the liquid and reject solute on their boundaries at the respective interfaces. After a certain level of undercooling is achieved by both thermal and the constitutional means, cellular growth gives way to dendritic growth. This proceeds by the preferential development of some of the cells. This intermediate, rod like structure is also referred to as Fibrous Dendrites.
As shown in Figure 10 when the temperature gradient is very shallow or the rate of freezing is very rapid, the undercooling achieved may be sufficient to promote nucleations at points in the melt,
Schematic representation of the influence of undercooling on the growth pattern and grain morphology.
distant from the main interface. In such an eventuality, the nuclei are free to grow in all directions on their periphery. An equiaxial grain structure, is thus, produced by independent nucleations. Figure 10, thus, exhibits the effect of increased undercooling (with the creation of different temperature gradient) on the mode of growth. It also shows the growth pattern with this different temperature gradients existing in the melt in the growth direction away from the mould wall into the interior of the liquid-melt.
Three factors have major influence on the casting structure.
The alloy constitution (composition) decides whether the structure will be of a simple phase or eutectic grains or both. The alloy composition also indicates the tendency of the alloy to respond to constitutional supercooling. The extent of constitutional supercooling is certain to influence the growth pattern that decides the crystallographic morphology of the casting.
The thermal conditions to which the liquid melt/alloy is exposed during solidification, refer to both, the rate of cooling and the temperature distribution in the solidifying melt. This is also related to the thermal properties of the melt as well as that of the mould. Obviously, the above would influence the cast structure by dictating the mode of growth.
The inherent nucleation and growth conditions in the melt are decided by the presence of foreign particles as well as the solute present in the melt. These solute atoms could be present as trace impurities or may be due to deliberate additions to influence nucleation. Obviously, these will influence/modify the possibilities of nucleation and growth, influencing the cast structure.
To elaborate the above we take help of Figures 11 and 12.
Effect of temperature gradient variations on the extent of undercooling that influence the crystal structure.
Effect of liquidus temperature profile on extent of supercooling and crystal structure.
The alloys considered in these figures form a continuous range of solid solutions. The Figures 11 and 12 illustrate the mode of crystallisation and hence the structure of the casting, as governed by the interaction of temperature and compositional gradients in the liquid.
Figures 11 and 12 depict the effect of temperature gradient and that of liquidus temperature profile, respectively on the structure of the casting. Initially when the melt is at higher temperature the existing temperature gradient is stiff [Ti (in Figure 11)] planar growth is encouraged and columnar grain structure is favoured. This is assisted by a slow cooling rate. This continues till the temperature gradient is sufficiently shallow to generate considerable undercooling which disturbs planar growth and growth proceeds adopting other modes, as explained earlier. Figure 12 clearly indicates, with a given temperature gradient the alterations of equilibrium temperature profile, which could be due to the alterations in the solute concentration, undercooling is witnessed with liquidus profile TE (ii), with the liquidus profile TE (i) and the given temperature gradient ‘T’, undercooling is not witnessed and growth proceeds by plane-front growth giving rise to columnar grain structure. From the above, it can be concluded that columnar growth is promoted under stiff temperature gradients. Columnar growth is also favoured at slow cooling rates because of the following:
slow cooling rates establish low rate of nucleation in comparison to the growth rates, allowing growth to overtake nucleation.
As seen in Figure 13 when the cooling rates are slow the solid rejected at the interface get sufficient time to migrate into the melt interior, away from the interface. The equilibrium temperature is altered.
Change in equilibrium temperature profile as a consequence of solute concentration crystal variation.
It changes from TE (ii) to TE (i) (Figure 13). This is parallel to a situation as in Figure 12 when with TE (i) the extent of undercooling are negligible or absent. Such a situation promotes columnar growth.
In a foundry the various local factors like the extent of superheat, the extent of heterogeneous nucleation, the mould characteristics, etc. decide the variations in the thermal gradient (G) and the rate of cooling (R). Needless to say, the ratio G/R forms an important parameter to decide the mode of growth and the consequence of structure development.
Figure 14 illustrates that as the G/R ratio progressively changes from a high to a low volume the effect of undercooling becomes more and more pronounced. Columnar, plane-front growth gradually gives way to independent nucleation.
Schematic presentation of G/R ratio influencing the effect of undercooling and the resultant structure.
During freezing the thermal conditions prevailing in the melt continuously change. Thus separate structural zones as shown in Figure 15 are encountered in the solidifying melt.
Schematic presentation of critical changes in the G/R ratio during freezing and its influences on the different structural zones.
These zones are consequences of the continuously changing G/R ratio in the melt. Assuming of a lower value of the G/R ratio with the lapse of time results in the increasing extents of undercooling which are instrumental in the separable structural zones as preserved in Figure 15. The above can be made more clear with the aid of Figures 16 and 17.
Variation of undercooling with alteration in the thermal gradient showing different grain morphology.
Variation of undercooling with alternation in the thermal gradient showing different grain morphology.
Both Figures 16 and 17 provide for an explanation of the mixed structure in a solidifying casting on the basis of the prevailing thermal conditions. To start with, as presented in Figure 16, the temperature gradient is stiff. Solidification initially occurs under this marked thermal gradient. This is often sufficient to cause columnar dendritic growth in the outermost region and adjacent to the mould wall as shown in Figure 16 in this central zone (in some cases, throughout the entire solidifying melt) the temperature gradient is shallow (Figure 17).
This shallow gradient generates excessive undercooling. Here solidification proceeds by widespread nucleation, the rate of nucleation being very high. Independent nucleation occurs in the interior of the melt. These nuclei, without any barrier for growth across their periphery, grow into equiaxed grains. To be more specific, initially the temperature gradient is stiff. The rate of cooling is low, G/R assume high values. Initial solidification, thus, occur under a marked temperature gradient which is sufficient to cause columnar dendritic growth in the outermost layer. Gradually ‘G’ decreases, i.e., the temperature gradient becomes shallow and ‘R’ the rate of cooling increases as a consequence of increasing extents of undercooling. The shallow temperature gradient in the casting and the increasing extents of undercooling in the melt give rise to the formation of independent nucleation in the melt interior forming equiaxed grains, being free to grow on their unhindered periphery.
Schematically the practical, ideal cast structure can be presented as in Figure 18.
Schematic presentation of a theoretical grain structure of the casting.
Although, the above refers to alloys forming solid solutions, analogous changes occur in alloys subject to eutectic freezing. The Figure 18 shows small dendrites (equiaxed) in the outermost surface because of chilling effects at the cold mould wall.
Two further factors, other than the thermal and constitutional undercooling, also influence the cast structure particularly concerning the formation of equiaxed crystals. These are:
Crystal multiplication is a consequence of the fragmentation of dendritic arms in the columnar zone due to local factors like thermal fluctuations and change in growth rates, etc. Also the nuclei formed on the inside of the mould wall may get washed off when further metal is being poured into the mould. Some of these detached nuclei may vanish being unstable, while some may get transported to favourable sides in the liquid and grow into equiaxed grains.
Turbulence during pouring
Thermal convective currents between the hot central portion and the relatively cooler surface region,
Gravitational separation due to the difference in densities between the solid and the liquid. In general the fragmented dendrules in the melt tend to go to the bottom of the melt due to density differences between the solid dendrules and the surrounding liquid melt. The only exception is ‘Be’. Here the density of the liquid is higher than that of the solid.
To sum up the formation of the equiaxed zone consisting of equiaxed grains, is promoted by the following:
Heterogeneous nucleation in situ
Crystal multiplication and
Transportation of crystallites by gravity or by mass movement into the interior of the melt
Obviously, the above form certain factors which influence the crystallographic morphology of the casting.
For a casting to be produced, it is essential that appropriate technique to be adopted for the liquid metal to be fed into the mould cavity. It is an issue inviting special considerations since the viscosity of the melt increases with drop of temperature making its flow sluggish and time taking which may result in considerable solidification prior to the completion of the feeding process. Also, the metal/alloy shrink on solidification producing solidification shrinkages in the casting which are discontinuities in the casting. For a healthy casting production ample facilities must be made be made available for compensating for these shrinkage. On these considerations, we can take the case of a pure metal which solidifies at a constant temperature or even alloys having a narrow freezing range. In these cases, three are clearly defined interfaces between the solidified region and the ‘still-liquid’ region. Any solidification contraction has the liberty to be compensated by the ‘still-liquid’ melt adjacent to it. If sufficient liquid metal is available the process of compensation of the physical contraction continues by the general lowering of the free liquid surface resulting in the production of a sound casting with no solidification shrinkages. The supply of liquid metal is accomplished by the provision of liquid metal reservoir known as feeder head or riser.
However, in many cases the case is not as simple. A clearly defined solid/liquid interface does not exist. Solidification takes place through a zone simultaneously. Even in certain cases the solidification zone may extend throughout the melt entirely. In these zones crystals at different stages of growth can be seen with the residual low melting point liquid. The alloy is in a pesty zone or in a mushy stage. Contraction sites are dispersed in the casting making feeding of these contraction sites a very difficult and even impossible, for the production of sound casting.
Under these conditions, liquid metal is fed ink the contraction sites in three successive stages.
In the early stages, growing crystal bodies are suspended in the liquid. Free movement of the liquid across the crystals is possible. Thus, any contraction can be easily compensated by a feeder head with the general lowering of the free liquid surface.
Here, after some lapse of time, the grains grow to certain extent and form contact among themselves forming a network of solid. Liquid movement becomes confined to intergranular channels. These channels get diminished continuously. Frictional resistance to the liquid movement in these channels increases. It becomes considerably difficult for the liquid to reach the solidification sites that undergo contraction. Thus, feeding for compensating the contractions becomes progressively difficult.
Now the final stages of solidification have reached. The intergranular channels are completely blocked by the growing crystals. Thus, isolated pockets of liquid are generated which solidify independently. The resultant contractions cannot be fed from external sources. These are always with long freezing range and cool under shallow temperature gradients. The shrinkage defects in these alloys persist resulting in spatter porosities distributed in the entire castings, even extending to the casting surface.
An external feeder head, known as the riser, is employed to compensate for the solidification shrinkages so that a sound casting results. For successful functioning of the riser the principle of directional solidification is employed. It is also known as progressive solidification in which solidification starts farthest from the riser and proceeds into the riser so that any side of shrinkage has an unfailing supply of liquid metal. The successful functioning of the riser must ensure the following:
Riser should be the last one to solidify in the casting system. This means throughout the process of solidification the riser must have liquid metal for feeding during freezing.
Freezing must start farthest from riser and continue through the casting towards the riser.
There must be a continuous path of feeding the liquid metal from the riser to the solidifying site.
The cooling rate of the casting need to be controlled for this purpose. The cooling rate on the other hand can be controlled by controlling the pouring temperature of the metal, pouring rate, promoting differential cooling by use of chills, differential heating by addition of exothermic materials, use of padding, etc. The temperature gradient and cooling rate are very important consideration in a solidifying melt. It is opined [13, 14] by setting up an appropriate temperature gradient and cooling rate by selecting the necessary pouring rate and temperature the cast structure can be controlled and the casting upgraded. A fine grain structure can be, thus, obtained by proper selection of the pouring rate and temperature. These fine grained structure can enhance the ability of the casting to inhibit the slide of the dislocations. This can result in the increase of yield strength and the ultimate strength of casting. These measures stiffen the temperature gradient assisting the setting up of a path feeding from the riser to the contraction sites in the mould.
Though, no two alloys have identical feeding characteristics, on the basis of the major contrasts of solidification they can be put under three categories.
This group of alloys freeze with marked skin formation. These have of obvious short (narrow) freezing zone. These include Low carbon steels, Brasses, Aluminium Bronzes, Aluminium Copper, etc.
In these group of alloys progressive or directional solidification measures can be easily achieved. Sound castings can be obtained with proper feeding from the feeder head. However, the casting yield may suffer sometimes as the feeder head has to be finally discarded.
These are alloys with long feeding ranges. These include Medium and High carbon steels, Nickel based alloys, Gun metals, Mg alloys, Complex Al alloys, etc.
In these alloys solidification proceeds simultaneously in much of the casting, even in the entire casting. All the three stages of freezing can be clearly witnessed as explained earlier. In the third and last stage of freezing widespread porosity may occur. In such castings of alloys progressive solidification is very less unless heavy chilling is used to disturb the thermal gradient. The chilling induces very sharp temperature gradient and help formation of a sound casting by setting up of narrow freezing zones. However, the casting feeding in these alloys is not always based on directional solidification. Efforts are made to follow measures such that concentration of porosity is not localised but distributed in the casting. To achieve the above mentioned disperse porosity measures have to be adopted for equalisation of cooling rates over the entire zone instead of going for a sharp temperature gradient. These disperse micro pores could be more acceptable than concentrated porosities [15].
These are the alloys which show expansion on freezing. These include Grey Cast Iron. In the Gr III hypoeutectic Grey Cast Irons freezing is initiated with the growth of austenite dendrites. Contraction on freezing occurs much like the other alloys with considerable freezing range. Then the eutectic freezing begins. Graphite precipitates out of the solid. Interdendritic liquid gets enriched with carbon. The solidification of this austenite-graphite eutectic is accompanied by volume expansion. A positive pressure is caused. In a completely rigid mould this expansion makes it virtually self-feeding. In practice, however, the positive pressure tends to cause mould-wall-movement. This movement increases the mould dimensions and sets up a tendency for contraction giving rise to an increase in the internal porosity.
To sum up, in the Gr.I alloys feeding by risers is easy. In the Gr.2 alloys feeding by riser is helped by ensuring directionality in solidifications and in the Gr.III alloys, in the contraction stage all the three stages of bulk feeding and interdendritic feeding stages may be encountered.
As mentioned earlier the temperature gradient in a casting system can be made stiff from a shallow one by adopting several means. This is illustrated in Figures 19 and 20 [16].
Shallow temperature gradient showing extensive pasty zone.
Effect of stiff temperature gradient on pasty zone (narrow zone of crystallisation).
A stiff temperature gradient can reduce the extent of pasty zone with the associated advantages in setting of directionality in solidification. On the other hand, a shallow temperature gradient can be set up and extensive pasty zone resulting in simultaneous freezing in an extended zone in the melt and help distribution of micropores.
Casting of a metal/alloy is a manufacturing process in which the liquid metal/alloy Is poured into a pre-formed mould. The liquid solidifies in the mould and the solidified liquid, known as the casting, is finally retrieved from the mould. In the whole process of producing the casting, the solidification processes play a major role in deciding the cast structure which dictate the structure related properties of the casting and decide its end-use. Throughout the entire process of solidification the metal/alloy shrink, generating discontinuities in the casting in the form of shrinkage cavities. These have to the compensated for by the supply of liquid metal from a liquid-metal-reservoir, known as the feeder-head or the riser. For efficient functioning of the riser it is desirable to ensure directionality in solidification by shaping of the necessary thermal gradient ‘G’ and the rate of cooling ‘R’. Infact the ratio ‘G/R’ plays a very important role in deciding the cast structure when it changes from a high value to a low value with the lapse of time. It decides the mode of growth which can be planar, cellular dendritic or growth due to independent nucleation and dictates the consequent development of the cast structure. The extent of superheat in the melt, the extent of heterogeneous nucleation, the mould characteristics, etc. Setup the required ‘G/R’ ratio. External factors like the pouring rate and pouring temperature can be altered suitably to vary the ‘G/R’ ratio such that the desire cast structure can be obtained.
IntechOpen publishes different types of publications
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