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Clinical aspects of suicidal behavior relevant to genetics
European Psychiatry 25 (2010) 257–259
Original article
Clinical aspects of suicidal behavior relevant to genetics A. Apter Schneiders Childrens Medical Center of Israel Sackler School of Medicine, University of Tel Aviv, 14 Kaplan St. Petah, 4202 Tikva, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 January 2010 Accepted 27 January 2010 Available online 4 May 2010
A major hindrance to determining the underlying biology of suicide is the heterogeneity of the phenotype. Not only are there various forms of self-harm and suicidal behaviors but even the finite act of dying by suicide can occur in multiple psychosocial contexts. Of all the different forms of fatal and nonfatal suicidal behaviors, the one that received the most attention is the aggressive impulsive type, which seems to occur in younger people and to cut across nosological entities, although its most classical expression occurs in borderline personality disorder. This focus should not obscure the fact that other forms of suicidal behavior such as those related to demoralization or wounded honor (narcissism) may well have different underlying genetic diatheses. ß 2010 Elsevier Masson SAS. All rights reserved.
Keywords: Genetics Adolescence Suicide
Psychiatric genetics has had immense problems with defining appropriate behavioral phenotypes for investigation. Not surprisingly, this is very true in the field of suicidal behavior. Ambiguous terms such as ‘‘suicidality’’, ‘‘Para suicide’’ and deliberate self-harm plague our discipline and the relationships between the various forms of suicidal behaviors (ideation, gestures, attempts, lethal attempts, and completed suicide) are not always what they seem to be. In addition, suicide and suicide attempts are frequently (80– 90%) associated with an Axis I disorder, most often depression, often complicated by other comorbid conditions. These psychiatric conditions have their own genetic vulnerabilities, which may be or not be related to suicidal impulses. The search therefore is for an underlying core, which underlies suicidal behavior which is common to most or all forms of suicidal behavior and is independent of the associated psychopathology. 1. Risk factors beyond psychopathology Suicidal behavior is associated with many kinds of risk factors but perhaps the most closely related to the basic construct of suicidal behavior are factors related to personality. My own experience has been based on work in three very different settings. (1) Psychological postmortem studies of adolescents (aged 18–21) who killed themselves while doing their compulsory military service in the Israel Defense Force (IDF). (2) Clinical work with suicidal adolescents in an adolescent psychiatric inpatient unit. (3) Work in the emergency room of a large general hospital as part of an epidemiological study of ‘‘Para suicide’’. E-mail address: [email protected]. 0924-9338/$ – see front matter ß 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2010.01.008
In attempting to organize this experience, I have developed the hypothesis that there are three sets of personality constellations that may underlie suicidality: narcissism, perfectionism and the inability to tolerate failure and imperfection combined with an underlying schizoid personality structure that does not allow the individual to ask for help and denies him the comforts of intimacy; impulsive and aggressive characteristics combined with an over sensitivity to minor life events. This sensitivity often leads to angry and anxious reactions with secondary depression. These subjects tend to use defenses such as regression, splitting, dissociation and displacement and to have suffered childhood physical and sexual abuse. There is often a history of alcohol or substance abuse and there appears to be a connection to an underlying disturbance of serotonin metabolism, which is genetic in origin. These patients may be characterized as suffering from ‘‘borderline’’ personality disorder; finally, there are those persons whose suicidal behavior is driven by hopelessness often related to an underlying depression. This hopelessness and depression usually result from mental illness such as affective disorder, schizophrenia, anxiety disorder and anorexia nervosa.
2. The narcissistic perfectionistic constellation The material for this conceptualization was derived principally from the clinical psychological postmortem studies we have been conducting in the IDF. Many of these suicides seemed to be very different from the patients seen on the adolescent unit or in the emergency room and, in fact, the vast majority had never been in contact with a mental health professional.
258
A. Apter / European Psychiatry 25 (2010) 257–259
2.1. Case material Jonathan was a 20-year-old officer when he killed himself. His father was a well-known figure in Israeli education: his mother operated a small business. The family was achievement oriented and had high moral standards. They believed in honesty, industriousness, helping one’s neighbor and public service. Their personal ideals stressed controlling one’s emotions and living up to high standards. The father was revered by his family and was regarded by all his family as a role model. Any conflict in the home was seen as a threat to the father’s authority and was suppressed. The mother was subservient to her husband in most matters. Jonathan’s early development was described by all who knew him as ‘‘excellent’’. As a child, he was intelligent, curious industrious and persistent. He was a natural leader and was popular with his teachers and peers. He was described as ‘‘slightly arrogant’’ but was always ready to help a weaker child. He became a senior leader in the scout movement and a camp councilor. Despite his popularity, however, Jonathan seems not to have had any close friends in whom he confided, suggesting difficulty with intimacy. In the army, Jonathan did very well and was chosen for the officers’ training course which he completed with flying colors. He was selected as an instructor for new recruits and was sent for advanced training. Here again, he did well apart from one foul-up for which he was reprimanded. He took this in his stride; and finished the course. His superior commended him for his ability to perform under stress. Jonathan was thrilled by his appointment as an instructor and told his father that he was determined to become the best instructor on the base. He became totally involved in his new duties, despite some difficulties as a teacher owing to his being over pedantic and somewhat naive, his platoon of trainees did rather well, although their overall performance rating was only average. Following the ceremony in which the new recruits received their berets and rifles, Jonathan went to his room and shot himself. Psychological postmortems of soldiers in the Israeli Defense Force (IDF) [1,8] have suggested that narcissistic and perfectionist patterns were common as were schizoid and avoidant traits. The IDF is for many Israeli youth a chance to prove their worth. For many, the military is a second chance to redeem earlier shortcomings or to confirm a sense of a competent identity. These features were often complicated by strong isolative traits, which seemed to be lifelong personality patterns and not related to stress or periods of depression. They were often termed them as being ‘‘very private’’ people. These subjects had much higher physical fitness ratings than the average Israeli solider, probably reflecting their also minimizing non-specific and subjective physical symptoms such as backache and flat feet and /or intensive training to reach high levels of fitness before conscription. Once these young men encountered perceived difficulty, shame related to their unrealistically high standards combined in many cases with an isolative style to prevent them turning to peers, officers or clinicians for help or support. As a result, even minor setbacks (to the external observer) could rapidly spiral into disaster as burgeoning anxious preoccupation, depressive rumination and withdrawal further interfered with the recruit’s ability to perform at the high levels he demanded of himself or to reach out to others, triggering a vicious cycle of isolative decompensation, with suicide as the only way out [8]. Recently, in a study of subjects with high lethality suicide attempts [9], we again found that problems of ‘‘self disclosure’’ were more significant in differentiating these people from low lethality attempters than was severity of depression. This constellation has not received much attention from biological investigators and has not been studied genetically but
the endophenotype here would probably be related to perfectionism and overachievement. 3. The impulsive aggressive constellation 3.1. Case material Deborah had a history of multiple admissions to the adolescent unit, most of them being for suicidal behavior, including severe ideation, threats, gestures and some serious attempts which led her to be hospitalized in the intensive care unit (ICU). She had always been impulsive and displayed opposition from an early age. At about the age of 11, she developed anorexia nervosa probably as a result of her being an accomplished dancer in a ballet troop. With the onset of adolescence, she developed very severe bulimia which was complicated by severe disturbances in potassium metabolism. Her first admission to a psychiatric unit was occasioned by a suicide note, which she wrote to her teacher at school. On the unit, she was ‘‘an impossible patient’’. She was impulsive, dramatic and violent. She would smash plates and glasses and use the fragments to attack staff members and to cut herself. To revenge herself on the ward personnel, she would vomit into the nurses’ station and into the air conditioners. By the time she was 22, she had made over 100 suicide attempts. She would also abuse alcohol and indulged in shoplifting. She received all kinds of psychosocial and biological therapies but to no avail, although with age (she is now 25) there is some tempering of her emotional instability. Van Praag has conceptualized a personality constellation that is very relevant to suicide, especially in youth [10]. He has termed this ‘‘Serotonin-related anxiety/aggression stressor precipitated depression’’. This concept implies that there are certain individuals who when faced with relatively minor life stressors will react with anger and anxiety and then will develop a secondary depression which is often accompanied by suicidal behavior. There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among more mature adults [2–4]. Specifically, there is a more prominent role of impulsivity, substance abuse, and antisocial and other personality disorders in younger completed suicides [6]. Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior and have been the major focus of investigation in this field together with an accompanying hyper reactivity to stress. Impulsivity appears to be related to genes from the serotonergic system while hyper reactivity to stress is more relate to genes from the HPA system [7]. 4. Mental-illness demoralization—hopelessness constellation 4.1. Case material David, aged 18, came from a family with a distinguished military background. He was very shy at school with his peers but open with and dependent on his teachers. In retrospect, he appears to have had a poor self-image during his school years, with intermittent periods of depression, insomnia and weight loss. His teachers recommended that he see a psychologist but his parents refused. David enthusiastically looked forward to his army service, hoping that success here would redeem his low self-esteem. Significantly, he did not reveal any of his history in his preinduction screening and denied having any psychiatric or emotional difficulties. During the screening, the psychological interviewer noted that David seemed ‘‘slightly strange’’ but not sufficiently so as to warrant further psychiatric evaluation. On the basis of his pre-induction evaluation, David was found to be highly suitable for a combat unit. He applied to join an elite commando
A. Apter / European Psychiatry 25 (2010) 257–259
unit but was turned down by the unit psychologist for unspecified reasons. In the army, according to his officers, David did well in both basic and advanced combat training. Some of his comrades considered him ‘‘odd’’ but he was popular on the routine sociometric ratings. After advanced training, Davis was posted to a combat unit. He seemed to do well there but complained to his parents of being depressed, losing weight and being unable to cope. His parents alerted the unit mental health officer, who interviewed David. During the examination, David minimized his symptoms and denied experiencing any depression or suicidal thoughts but said he could not continue to serve in a front-line unit. After consulting a more experienced senior psychiatrist, the mental health officer diagnosed ‘‘adjustment reaction’’ and had Davis posted to a rear echelon. However, the prospect of reassignment made David feel like a ‘‘failure’’. Soon thereafter, he fatally shot himself. With the clarity of hindsight and the detailed postmortem accounts, David appears to have had an undiagnosed depression. The diagnosis was missed because of David’s desperate denial of difficulties in the service of unrealistic high internal standards and fear of failure. Although he was not really up to the rigors of a combat unit, David strove desperately but unsuccessfully to overfunction. It appears that almost any chronic or severe mental illness can lead to feelings of demoralization, hopelessness and a secondary depression that can lead to suicidal thoughts and behavior. In our own studies of hospitalized adolescents, BDI scores have always tended to be at least four to five times higher than that of controls irrespective of the diagnosis. Almost all serious psychiatric illnesses have high rates of suicide. Thus, many schizophrenic patients are depressed and suicidal, especially when they are young and have not been ill for a long time. The depression in schizophrenia may be related to the fact that the young person feels that he is falling apart and becoming mentally ill and there is indeed evidence that suicidality and depression in these patients is related to good premorbid function, better insight, higher intelligence and preservation of cognitive function. About 10–15% of schizophrenics eventually commit suicide, usually in the initial stages of their illness. Most schizophrenic suicide victims are unmarried men who have made previous suicide attempts. At least two thirds of the suicides are related to depression and only a small minority to the psychotic symptoms such as command hallucinations. The suicide is often shortly after discharge and thus may be related to lack of social support. There has also been recent recognition of the very definite increased risk for suicide in girls with eating disorders [5]. A very
259
dangerous form of depression occurs in treatment resistant cases where the constant battle against gaining weight, on the one hand, and the constant social pressure to gain weight, on the other, becomes an intolerable burden. The diary of Ellen West, a famous anorectic patient who eventually killed herself, contained the following passages: ‘‘the most horrible thing about my life is that it is filled with continuous fear. Fear of eating but also fear of hunger and fear of fear itself. Only death can liberate me from this dread’’ and ‘‘since I am doing everything from the point of view of whether makes me thin or fat, all things lose their real value. It has fallen over me like a beast and I am helpless against it’’. 4.2. Conclusion Suicidal behavior is thus a many-faceted entity and is the final common pathway of many disparate genetic mechanisms. Thus far, genes for stress tolerance (the HPA axis) and genes for aggression and impulsivity (the serotonin system) seem to have the most promise for the genetics for ‘‘suicidality’’. It must be remembered, however, that these mechanism may account for only a certain subtype of a very heterogeneous entity and it is the task of clinicians to further delineate these phenotypes. References [1] Apter A, Bleich A, King RA, Kron S, Fluch A, Kotler M, et al. Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry 1993;50:138–42. [2] Apter A, Gothelf D, Orbach L, Weizman R, Ratzoni G, Har-Even D, et al. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. JAACAP 1995;34:912–8. [3] Brent DA, Johnson B, Bartle S, Bridge J, Rather C, Connolly MJ, et al. Personality disorder, tendency to impulsive violence, and suicidal behavior in adolescents. JAACAP 1993;32:69–75. [4] Brent DA, Johnson BA, Perper J, Connolly J, Bridge J, Bartle S, et al. Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents. JAACAP 1994;33:1080–6. [5] Bruch H. Eating Disorders. Obesity, Anorexia Nervosa, and the person within. New York: NY Basic Books; 1973. [6] Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. Relationships of age and Axis I diagnosis in victims of completed suicide: A psychological autopsy study. Am J Psychiatry 1996;153:1001–8. [7] Currier D, Mann JJ. Stress, genes and the biology of suicidal behavior. Psychiatr Clin North Am 2008;31:247–69. [8] King RA, Apter A. Psychoanalytic perspectives on adolescent suicide. Psychoanal Study Child 1996;51:491–505. [9] Levi Y, Horesh N, Fischel T, Treves I, Or E, Apter A. Mental pain and its communication in medically serious suicide attempts: An ‘‘impossible situation’’. J Affect Disord 2008;111:244–50. [10] Van Praag HM. Over the mainstream: Diagnostic requirements for biological psychiatric research. Psychiatr Res 1997;72:201–12.
Original article
Clinical aspects of suicidal behavior relevant to genetics A. Apter Schneiders Childrens Medical Center of Israel Sackler School of Medicine, University of Tel Aviv, 14 Kaplan St. Petah, 4202 Tikva, Israel
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 January 2010 Accepted 27 January 2010 Available online 4 May 2010
A major hindrance to determining the underlying biology of suicide is the heterogeneity of the phenotype. Not only are there various forms of self-harm and suicidal behaviors but even the finite act of dying by suicide can occur in multiple psychosocial contexts. Of all the different forms of fatal and nonfatal suicidal behaviors, the one that received the most attention is the aggressive impulsive type, which seems to occur in younger people and to cut across nosological entities, although its most classical expression occurs in borderline personality disorder. This focus should not obscure the fact that other forms of suicidal behavior such as those related to demoralization or wounded honor (narcissism) may well have different underlying genetic diatheses. ß 2010 Elsevier Masson SAS. All rights reserved.
Keywords: Genetics Adolescence Suicide
Psychiatric genetics has had immense problems with defining appropriate behavioral phenotypes for investigation. Not surprisingly, this is very true in the field of suicidal behavior. Ambiguous terms such as ‘‘suicidality’’, ‘‘Para suicide’’ and deliberate self-harm plague our discipline and the relationships between the various forms of suicidal behaviors (ideation, gestures, attempts, lethal attempts, and completed suicide) are not always what they seem to be. In addition, suicide and suicide attempts are frequently (80– 90%) associated with an Axis I disorder, most often depression, often complicated by other comorbid conditions. These psychiatric conditions have their own genetic vulnerabilities, which may be or not be related to suicidal impulses. The search therefore is for an underlying core, which underlies suicidal behavior which is common to most or all forms of suicidal behavior and is independent of the associated psychopathology. 1. Risk factors beyond psychopathology Suicidal behavior is associated with many kinds of risk factors but perhaps the most closely related to the basic construct of suicidal behavior are factors related to personality. My own experience has been based on work in three very different settings. (1) Psychological postmortem studies of adolescents (aged 18–21) who killed themselves while doing their compulsory military service in the Israel Defense Force (IDF). (2) Clinical work with suicidal adolescents in an adolescent psychiatric inpatient unit. (3) Work in the emergency room of a large general hospital as part of an epidemiological study of ‘‘Para suicide’’. E-mail address: [email protected]. 0924-9338/$ – see front matter ß 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2010.01.008
In attempting to organize this experience, I have developed the hypothesis that there are three sets of personality constellations that may underlie suicidality: narcissism, perfectionism and the inability to tolerate failure and imperfection combined with an underlying schizoid personality structure that does not allow the individual to ask for help and denies him the comforts of intimacy; impulsive and aggressive characteristics combined with an over sensitivity to minor life events. This sensitivity often leads to angry and anxious reactions with secondary depression. These subjects tend to use defenses such as regression, splitting, dissociation and displacement and to have suffered childhood physical and sexual abuse. There is often a history of alcohol or substance abuse and there appears to be a connection to an underlying disturbance of serotonin metabolism, which is genetic in origin. These patients may be characterized as suffering from ‘‘borderline’’ personality disorder; finally, there are those persons whose suicidal behavior is driven by hopelessness often related to an underlying depression. This hopelessness and depression usually result from mental illness such as affective disorder, schizophrenia, anxiety disorder and anorexia nervosa.
2. The narcissistic perfectionistic constellation The material for this conceptualization was derived principally from the clinical psychological postmortem studies we have been conducting in the IDF. Many of these suicides seemed to be very different from the patients seen on the adolescent unit or in the emergency room and, in fact, the vast majority had never been in contact with a mental health professional.
258
A. Apter / European Psychiatry 25 (2010) 257–259
2.1. Case material Jonathan was a 20-year-old officer when he killed himself. His father was a well-known figure in Israeli education: his mother operated a small business. The family was achievement oriented and had high moral standards. They believed in honesty, industriousness, helping one’s neighbor and public service. Their personal ideals stressed controlling one’s emotions and living up to high standards. The father was revered by his family and was regarded by all his family as a role model. Any conflict in the home was seen as a threat to the father’s authority and was suppressed. The mother was subservient to her husband in most matters. Jonathan’s early development was described by all who knew him as ‘‘excellent’’. As a child, he was intelligent, curious industrious and persistent. He was a natural leader and was popular with his teachers and peers. He was described as ‘‘slightly arrogant’’ but was always ready to help a weaker child. He became a senior leader in the scout movement and a camp councilor. Despite his popularity, however, Jonathan seems not to have had any close friends in whom he confided, suggesting difficulty with intimacy. In the army, Jonathan did very well and was chosen for the officers’ training course which he completed with flying colors. He was selected as an instructor for new recruits and was sent for advanced training. Here again, he did well apart from one foul-up for which he was reprimanded. He took this in his stride; and finished the course. His superior commended him for his ability to perform under stress. Jonathan was thrilled by his appointment as an instructor and told his father that he was determined to become the best instructor on the base. He became totally involved in his new duties, despite some difficulties as a teacher owing to his being over pedantic and somewhat naive, his platoon of trainees did rather well, although their overall performance rating was only average. Following the ceremony in which the new recruits received their berets and rifles, Jonathan went to his room and shot himself. Psychological postmortems of soldiers in the Israeli Defense Force (IDF) [1,8] have suggested that narcissistic and perfectionist patterns were common as were schizoid and avoidant traits. The IDF is for many Israeli youth a chance to prove their worth. For many, the military is a second chance to redeem earlier shortcomings or to confirm a sense of a competent identity. These features were often complicated by strong isolative traits, which seemed to be lifelong personality patterns and not related to stress or periods of depression. They were often termed them as being ‘‘very private’’ people. These subjects had much higher physical fitness ratings than the average Israeli solider, probably reflecting their also minimizing non-specific and subjective physical symptoms such as backache and flat feet and /or intensive training to reach high levels of fitness before conscription. Once these young men encountered perceived difficulty, shame related to their unrealistically high standards combined in many cases with an isolative style to prevent them turning to peers, officers or clinicians for help or support. As a result, even minor setbacks (to the external observer) could rapidly spiral into disaster as burgeoning anxious preoccupation, depressive rumination and withdrawal further interfered with the recruit’s ability to perform at the high levels he demanded of himself or to reach out to others, triggering a vicious cycle of isolative decompensation, with suicide as the only way out [8]. Recently, in a study of subjects with high lethality suicide attempts [9], we again found that problems of ‘‘self disclosure’’ were more significant in differentiating these people from low lethality attempters than was severity of depression. This constellation has not received much attention from biological investigators and has not been studied genetically but
the endophenotype here would probably be related to perfectionism and overachievement. 3. The impulsive aggressive constellation 3.1. Case material Deborah had a history of multiple admissions to the adolescent unit, most of them being for suicidal behavior, including severe ideation, threats, gestures and some serious attempts which led her to be hospitalized in the intensive care unit (ICU). She had always been impulsive and displayed opposition from an early age. At about the age of 11, she developed anorexia nervosa probably as a result of her being an accomplished dancer in a ballet troop. With the onset of adolescence, she developed very severe bulimia which was complicated by severe disturbances in potassium metabolism. Her first admission to a psychiatric unit was occasioned by a suicide note, which she wrote to her teacher at school. On the unit, she was ‘‘an impossible patient’’. She was impulsive, dramatic and violent. She would smash plates and glasses and use the fragments to attack staff members and to cut herself. To revenge herself on the ward personnel, she would vomit into the nurses’ station and into the air conditioners. By the time she was 22, she had made over 100 suicide attempts. She would also abuse alcohol and indulged in shoplifting. She received all kinds of psychosocial and biological therapies but to no avail, although with age (she is now 25) there is some tempering of her emotional instability. Van Praag has conceptualized a personality constellation that is very relevant to suicide, especially in youth [10]. He has termed this ‘‘Serotonin-related anxiety/aggression stressor precipitated depression’’. This concept implies that there are certain individuals who when faced with relatively minor life stressors will react with anger and anxiety and then will develop a secondary depression which is often accompanied by suicidal behavior. There is now substantial evidence that suicide in younger people is a somewhat different phenomenon than among more mature adults [2–4]. Specifically, there is a more prominent role of impulsivity, substance abuse, and antisocial and other personality disorders in younger completed suicides [6]. Impulsivity and aggression are likely to be involved in the genetics of suicidal behavior and have been the major focus of investigation in this field together with an accompanying hyper reactivity to stress. Impulsivity appears to be related to genes from the serotonergic system while hyper reactivity to stress is more relate to genes from the HPA system [7]. 4. Mental-illness demoralization—hopelessness constellation 4.1. Case material David, aged 18, came from a family with a distinguished military background. He was very shy at school with his peers but open with and dependent on his teachers. In retrospect, he appears to have had a poor self-image during his school years, with intermittent periods of depression, insomnia and weight loss. His teachers recommended that he see a psychologist but his parents refused. David enthusiastically looked forward to his army service, hoping that success here would redeem his low self-esteem. Significantly, he did not reveal any of his history in his preinduction screening and denied having any psychiatric or emotional difficulties. During the screening, the psychological interviewer noted that David seemed ‘‘slightly strange’’ but not sufficiently so as to warrant further psychiatric evaluation. On the basis of his pre-induction evaluation, David was found to be highly suitable for a combat unit. He applied to join an elite commando
A. Apter / European Psychiatry 25 (2010) 257–259
unit but was turned down by the unit psychologist for unspecified reasons. In the army, according to his officers, David did well in both basic and advanced combat training. Some of his comrades considered him ‘‘odd’’ but he was popular on the routine sociometric ratings. After advanced training, Davis was posted to a combat unit. He seemed to do well there but complained to his parents of being depressed, losing weight and being unable to cope. His parents alerted the unit mental health officer, who interviewed David. During the examination, David minimized his symptoms and denied experiencing any depression or suicidal thoughts but said he could not continue to serve in a front-line unit. After consulting a more experienced senior psychiatrist, the mental health officer diagnosed ‘‘adjustment reaction’’ and had Davis posted to a rear echelon. However, the prospect of reassignment made David feel like a ‘‘failure’’. Soon thereafter, he fatally shot himself. With the clarity of hindsight and the detailed postmortem accounts, David appears to have had an undiagnosed depression. The diagnosis was missed because of David’s desperate denial of difficulties in the service of unrealistic high internal standards and fear of failure. Although he was not really up to the rigors of a combat unit, David strove desperately but unsuccessfully to overfunction. It appears that almost any chronic or severe mental illness can lead to feelings of demoralization, hopelessness and a secondary depression that can lead to suicidal thoughts and behavior. In our own studies of hospitalized adolescents, BDI scores have always tended to be at least four to five times higher than that of controls irrespective of the diagnosis. Almost all serious psychiatric illnesses have high rates of suicide. Thus, many schizophrenic patients are depressed and suicidal, especially when they are young and have not been ill for a long time. The depression in schizophrenia may be related to the fact that the young person feels that he is falling apart and becoming mentally ill and there is indeed evidence that suicidality and depression in these patients is related to good premorbid function, better insight, higher intelligence and preservation of cognitive function. About 10–15% of schizophrenics eventually commit suicide, usually in the initial stages of their illness. Most schizophrenic suicide victims are unmarried men who have made previous suicide attempts. At least two thirds of the suicides are related to depression and only a small minority to the psychotic symptoms such as command hallucinations. The suicide is often shortly after discharge and thus may be related to lack of social support. There has also been recent recognition of the very definite increased risk for suicide in girls with eating disorders [5]. A very
259
dangerous form of depression occurs in treatment resistant cases where the constant battle against gaining weight, on the one hand, and the constant social pressure to gain weight, on the other, becomes an intolerable burden. The diary of Ellen West, a famous anorectic patient who eventually killed herself, contained the following passages: ‘‘the most horrible thing about my life is that it is filled with continuous fear. Fear of eating but also fear of hunger and fear of fear itself. Only death can liberate me from this dread’’ and ‘‘since I am doing everything from the point of view of whether makes me thin or fat, all things lose their real value. It has fallen over me like a beast and I am helpless against it’’. 4.2. Conclusion Suicidal behavior is thus a many-faceted entity and is the final common pathway of many disparate genetic mechanisms. Thus far, genes for stress tolerance (the HPA axis) and genes for aggression and impulsivity (the serotonin system) seem to have the most promise for the genetics for ‘‘suicidality’’. It must be remembered, however, that these mechanism may account for only a certain subtype of a very heterogeneous entity and it is the task of clinicians to further delineate these phenotypes. References [1] Apter A, Bleich A, King RA, Kron S, Fluch A, Kotler M, et al. Death without warning? A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry 1993;50:138–42. [2] Apter A, Gothelf D, Orbach L, Weizman R, Ratzoni G, Har-Even D, et al. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. JAACAP 1995;34:912–8. [3] Brent DA, Johnson B, Bartle S, Bridge J, Rather C, Connolly MJ, et al. Personality disorder, tendency to impulsive violence, and suicidal behavior in adolescents. JAACAP 1993;32:69–75. [4] Brent DA, Johnson BA, Perper J, Connolly J, Bridge J, Bartle S, et al. Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents. JAACAP 1994;33:1080–6. [5] Bruch H. Eating Disorders. Obesity, Anorexia Nervosa, and the person within. New York: NY Basic Books; 1973. [6] Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. Relationships of age and Axis I diagnosis in victims of completed suicide: A psychological autopsy study. Am J Psychiatry 1996;153:1001–8. [7] Currier D, Mann JJ. Stress, genes and the biology of suicidal behavior. Psychiatr Clin North Am 2008;31:247–69. [8] King RA, Apter A. Psychoanalytic perspectives on adolescent suicide. Psychoanal Study Child 1996;51:491–505. [9] Levi Y, Horesh N, Fischel T, Treves I, Or E, Apter A. Mental pain and its communication in medically serious suicide attempts: An ‘‘impossible situation’’. J Affect Disord 2008;111:244–50. [10] Van Praag HM. Over the mainstream: Diagnostic requirements for biological psychiatric research. Psychiatr Res 1997;72:201–12.