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Suicide as a Message
Suicide as a Message KLAUS
W.
BERBLINGER,
M.D.
• Physicians appreciate the fact that contemplated, attempted and completed suicides occur on a continuum. The realized suicide comes first to medico-legal attention. Infonnation about suicidal intent may be communicated to relatives, clergymen, paramedical specialists and often to psychiatrists. On the other hand, the general physician and the non-psychiatric specialist are called upon to treat the after-effects of attempted self-destruction and may be confronted with hind- rather than insight in trying to understand suicidal motivation or etiology. It seems desirable to free the physician from such yeoman service and to enable him to enter the field of prevention. Since Silicide is not the outcome of one single, medical or psychiatric affliction, predictive clues must be gathered from a variety of sources, be they the familiarity with demographic studies, the acquaintance with psychiatric nosologies or an increased perceptiveness for individual, psychologic dynamics.
on the increase. In 1959, according to Hirsch,. it was the 11th most common cause of death on the North American continent. In Scotland, the suicide rate increased 5W between 1950 and 1960. Suicide before the age of 12 is relatively uncommon. Before the age of 30, nine times as many women as men attempt suicide, but over the age of 30, the ratio shows a drastic reversal. The young rarely communicate their suicidal intentions, while older people frequently do. t The suicide attempts of men are said to be more violent in character; however, this may be an accident of available means. 4 As suicide seems related to factors like old age, social isolation or mobility, Stengel lO states frankly that "no reliable criteria for Silicide have been established beyond its high incidence in depressive illness." Therefore, armed with such background material, the physician may prefer to view suicidal impulse, attempts and actual deaths in tenns of psychiatric syndromes or nosologies.
DE:\IOGRAPHIC STUDIES AXD SOCIAL BACKGROUND
PSYCHIATRIC ILLNESS AKD SUICIDE
INFOR:\IATION
Regardless of psychiatric nomenclature or classification, it is assumed that a mood of depression and suicide are closely linked. Ayd t says that, below the age of 30, it is the tense, deluded or hallucinated schizophrenic who commits suicide. Beyond this age, depressed. patients attempt to take their own lives. The peak of suicidal risk occurs during the depressive phase of manic-depressive psychosis and during the involutional fonn of melancholia. Warning against slighting the predominantly physical symptomatology of the involutionally depressed abound by now. It seems that this message has found acceptance and is reflected in a greater number of psychiatric referrals. Roth's' statement of encountering an increasing number of depressed patients as well as Ayd's' observation denote an enhanced psychiatric sophistication of the general physician. They also may be representative of a declining esteem for age and experience in the face of a prolonged life expectancy. Yet, Grinker's3
Major statistical surveys, sociologic correlations of incidence, sex, age, class, ethnic and religious distrihution with the presence of psychiatric illness are aptly summarized in a recent study by Hordern." The unavoidable shortcomings of such data lie in their extrapolation from mortality to morbidity and an implicit assumption that suicide in some way or another reflects the presence of mental or emotional illness. Many of these considerations must be of interest to the practicing physician but he will have to translate their significance and validity into the social context of his medical environment. During the last decade, Silicide seems to be From the Department of Psychiatry, University of California School of ~Icdicine and The Langley Porter Neuropsychiatric Institute, San Francisco, California. Read as part of the Symposium on "Clues to Suicide," at the annual meeting of the Academy of Psychosomatic Medicine, San Francisco, California, October 17-20, 1963.
144
Volume V
SUICIDE AS A MESSAGE-BERBLINGER
careful research on depressive symptomatology fails to give unequivocal criteria for a connection between a depressive mood and suicidal propensity. Such an observation may increase the physician's diagnostic insecurity, and he may therefore rather rely on understanding communicative messages in predicting suicidal impulse or intent. SUICIDE AS A MESSAGE
Anterospectively, the most comprehensive summary of suicidal dynamics is contained in Menninger's" book on "Man Against Himself'; retrospectively, Shneidman's and Farberow's9 concept of a psychological autopsy tries to elucidate motives. Both elaborate on suicidal impulse and attempt at a time when they might have been prevented. They provide us with a dynamically predictahle cluster of potential suicides. Transposed into communication, suicide constitutes a message. It may represent a message to which no answer is expected, it may implicitly caB for a reply, and it may indicate that no solution seems possible. THE
~[ESSAGE
IS
TO WlIICH XO ANSWER
EXPECTED
Severely depressed people have one feeling in common: there are no choices, there is no way out. The "no exit" constellation is subjectively overpowering. Here, the suicidal message calls for /10 reply. These persons may proceed regardless of conscience restrictions. They are doomed, they know it, and they feel that they have no option of choice. In other words, the prevailing mood is sufficiently overwhelming to decide upon self-annihilation. l\'eedless to state that such persons often succeed. Their choice of means to destroy themselves may give clues to a particular illness or conflictual situation. If their psychiatric state is known, if they m'e under psychotherapeutic care, the risk is diminished, as clinical assessments point out.' From a diagnostic point of view, it behooves the physician not to underestimate somatic dysfunction in the absence of organic pathology, to elicit statements of mood in those patients who apparently seek his help for physical illness and to remember that in the older age group almost 70% are prone to give clues of their suicidal intent.~ Suicides in younger people may be prevented by recognition of a severe mental disease. The young schizophrenic may not readily divulge his suiMay-June, 1964
cidal intent. He may be driven by delusions of persecution or hallucinatory commands. His message of no choice or no alternative and his failure to ask for a "reply" can only be attenuated by the physician's general diagnostic acumen. In other words, should the doctor suspect such a disorder, he also would find himself alert to the catastrophe of self-destruction. THE MESSAGE IN HOPE OF A REPLY
Suicide, suicidal preoccupation or attempts can reflect difficulties in living, in other words, be the expression of personality problems. These may be vicariously described as character disorders, sociopathies or neurotic crises. They have in common that the suicidal gesture seems to ask for a reply. Such a response may be phantasied and encompass the possihle reactions of the survivors, it may be anticipatorily manipulative and intended to elicit compassionate counter-measures or it may read "if I am driven that far, what can I do?" Personality profile and situational contingency appear to be intertwined. Cutting across psychiatric classifications, such suicidal risks have in common: a low tolerance for fmstration, a heightened impulsivity and an inability to learn from experience. The more labile the affect, the more unpredictable will their actions be. The physician's task is relegated to the area of ansu:ering the gesture prior to its execution. This requires superior psychotherapeutic skill and awareness of relationship. The concept of inner directed aggression" does not suffice to explain all suicidal motivations in the group of personality disorders, neither does the concept of "death instinct" provide the clinician with immediate measures. He will have to rely on a subjective evaluation of those social and psychological forces that prompt and restrain suicidal drive. One might say that out of a number of precodified messages, suicide is an acknowledged signal in our culture. Telegraph services provide a number of coded messages for condolence or congratulation. The transmitted intent to threaten suicide caBs for a greater diversity in replying. Deciphering the suicidal message beyond conventional codification and its dissection into individual motivations remain the physician's task whenever he encounters a person with conHictual strivings. This leads us to a final message which may precede the suicide. 145
PSYCHOSO~IATICS
BILA:'\Z SELBSTMORD ("BALAl\CE SHEET SUICIDE")
European, and in particular German psychiatric literature speaks of "Bilanz-Selbstmord." 1\0 adequate translation is available. The term denotes suicide on rational grounds, as the person has logically drawn a balance sheet of his assets and liabilities and from there on has decided that dying is better than living. Here, self-destruction is not regarded as the result of a disordered mind or emotional upheaval, but rather the outc'Ome of purposeful reasoning. There is little doubt that our culture sanctions such deaths when it provides intelligence officers with cyanide capsules in order to escape revelation of secrets or torture. The aspect could be.extended and encompass the physician who has carcinomatosis and knows that his economic assets are greater in death than in life. The message that "ultra posse nemo obliganlr" is convincing even to those who do not subscribe to Latin logics. Yet physicians are bound by the mores of their culture. To alleviate suffering and to prolong life remains their principal function. In each instance, we may assign suicidal impulse to categories. We will react individually and account for success and failure in preventing suicide. In order to avoid an impression that the phenomenon of self-destruction can easily be pigeonholed, the illustration of a completed suicide may be permitted. It cuts across lines of social constellation, psychiatric disorder and intellecnlal awareness as a dilemma beyond other alternatives. A 30 year old military officer found himself I:onfTOntt'd with the' accusation of antisocial conduct. His superiors preferred psychiatric to judicial stigma and sent him for psychotherapy. M. was a professional man of considerable achit'wments, married and the father of three children. His sodaI background rt'vealecl upward mobility, his psychiatric pidure could be defined as schizoid, and he was openly aware of the consequences of his conduct or bt'havior. After threl' st'ssions with a psychiatrbt he strongly professecl to have adequate internal controls. Tht' samt' day his superior officer informed the psychiatrist of renewecl delinquent conduct, disappearance from duty and several houTS later that the patit'nt had mmmitted suicide by carhon monoxide inhalation. During the last interview the patient had givt'n no indication of psychotic disturbancc nor was he dt'pressed or overtly agitatecl. Hc had previouly resisted the physician's suggestion to make contact with his wife or family, had refused him direct communication with his su146
perior officers and deniecl additional difficulties. A hbtory of anotht'r suidde attempt was known to hi~ psychiatrist, yet the physician had no medic.11 or legal means to insist upon closer supervision. In retrospect, the man committed suicide to avoid expulsion from the service, to spare hi~ family shame, while consciously rcc'ognizing his compulsively antisocial behavior. The "clues" wert> present and con~ist ed of a previous suiddal attempt, a personality disorder and social pressures, and one may aceuse the psychiatrist of misjudging tht' state of treatment relationship. Yet, this unfortunatt' patient illustrates those liabilities of doctor-patient relationship that are preclicatecl upon inadequate communication. Ultimately, the message that has not been receivecl nor understood will not be answ('f(>(l. This ohserver is inclined to call this a "balance sheet suicide" yet is mindful of the patient's con~iderable psychopathology. However, had he not been in a particularly exposed social position he might well hav(' sustained existence and life.
This pessimistic annotation is offered not for the sake of distracting from social consciousness or psychiatric awareness, but to alert the physician to human empathy. Be such empathy inntitive or may it have been acquired during one's own experience in life, a truly preventive goal of psychological medicine must go beyond the signals of immediate danger. We should not only fmstrate our patients' wish to die, but teach them how to live. REFERENCES
1. Ayd, F.: Suicide, a hazard in depression. ]. Neuropsychiat., 2:52 (Supp!.) 1962. 2. Capstick. A.: Recognition of emotional disturbance and the prevention of suicide. Brit. Med. J., 1:1179, 1960. 3. Crinker, Roy, and others: The Phenomena of Depressions. New York: Hoeber, 1961. 4. Hirsch, J.: Suicide. Ment. Hyg. 43:516, 1959. 5. Hordern, A.: Depressive states: A pharmacotherapeutic study. (In press). 6. Mennin~er, Karl: Man Against Himself. New York; Harcourt Brace, 1938. 7. Muncie, Wendell: Dt'pression, or depressions? Canad. PSljch. Ass. ]., Vo!. 8, No.4 (July-Aug.) 1963. 8. Roth, M. and Morrissey, J. D.: Problems in the diagnosis and dassification of mental disorders in old a~e: with a study of cast' material. J. Ment. Sci., 98:66, 1952. 9. Shneidman, Edwin S., and Farberow, Norman L., Editors: Clues to Suicide. New York: Blakiston Div., McCraw-Hili Book Co., 1957. 9a. Norman L. Farberow and Shneidman, Edwin S., Editors: The Cry for Help. New York: Blakiston Div., McCraw-Hill Book Co., 1961. 10. Stt'ngel, E.: Old and new trends in suicide research. Brit. ]. Med. PSljchol., 33:283, 1960. 11. Watts, C. A. H.: The problem of suicide in ~en t'ral practice. Proc. ROIj. Soc. Med., 54:264, 1960. Volume V
W.
BERBLINGER,
M.D.
• Physicians appreciate the fact that contemplated, attempted and completed suicides occur on a continuum. The realized suicide comes first to medico-legal attention. Infonnation about suicidal intent may be communicated to relatives, clergymen, paramedical specialists and often to psychiatrists. On the other hand, the general physician and the non-psychiatric specialist are called upon to treat the after-effects of attempted self-destruction and may be confronted with hind- rather than insight in trying to understand suicidal motivation or etiology. It seems desirable to free the physician from such yeoman service and to enable him to enter the field of prevention. Since Silicide is not the outcome of one single, medical or psychiatric affliction, predictive clues must be gathered from a variety of sources, be they the familiarity with demographic studies, the acquaintance with psychiatric nosologies or an increased perceptiveness for individual, psychologic dynamics.
on the increase. In 1959, according to Hirsch,. it was the 11th most common cause of death on the North American continent. In Scotland, the suicide rate increased 5W between 1950 and 1960. Suicide before the age of 12 is relatively uncommon. Before the age of 30, nine times as many women as men attempt suicide, but over the age of 30, the ratio shows a drastic reversal. The young rarely communicate their suicidal intentions, while older people frequently do. t The suicide attempts of men are said to be more violent in character; however, this may be an accident of available means. 4 As suicide seems related to factors like old age, social isolation or mobility, Stengel lO states frankly that "no reliable criteria for Silicide have been established beyond its high incidence in depressive illness." Therefore, armed with such background material, the physician may prefer to view suicidal impulse, attempts and actual deaths in tenns of psychiatric syndromes or nosologies.
DE:\IOGRAPHIC STUDIES AXD SOCIAL BACKGROUND
PSYCHIATRIC ILLNESS AKD SUICIDE
INFOR:\IATION
Regardless of psychiatric nomenclature or classification, it is assumed that a mood of depression and suicide are closely linked. Ayd t says that, below the age of 30, it is the tense, deluded or hallucinated schizophrenic who commits suicide. Beyond this age, depressed. patients attempt to take their own lives. The peak of suicidal risk occurs during the depressive phase of manic-depressive psychosis and during the involutional fonn of melancholia. Warning against slighting the predominantly physical symptomatology of the involutionally depressed abound by now. It seems that this message has found acceptance and is reflected in a greater number of psychiatric referrals. Roth's' statement of encountering an increasing number of depressed patients as well as Ayd's' observation denote an enhanced psychiatric sophistication of the general physician. They also may be representative of a declining esteem for age and experience in the face of a prolonged life expectancy. Yet, Grinker's3
Major statistical surveys, sociologic correlations of incidence, sex, age, class, ethnic and religious distrihution with the presence of psychiatric illness are aptly summarized in a recent study by Hordern." The unavoidable shortcomings of such data lie in their extrapolation from mortality to morbidity and an implicit assumption that suicide in some way or another reflects the presence of mental or emotional illness. Many of these considerations must be of interest to the practicing physician but he will have to translate their significance and validity into the social context of his medical environment. During the last decade, Silicide seems to be From the Department of Psychiatry, University of California School of ~Icdicine and The Langley Porter Neuropsychiatric Institute, San Francisco, California. Read as part of the Symposium on "Clues to Suicide," at the annual meeting of the Academy of Psychosomatic Medicine, San Francisco, California, October 17-20, 1963.
144
Volume V
SUICIDE AS A MESSAGE-BERBLINGER
careful research on depressive symptomatology fails to give unequivocal criteria for a connection between a depressive mood and suicidal propensity. Such an observation may increase the physician's diagnostic insecurity, and he may therefore rather rely on understanding communicative messages in predicting suicidal impulse or intent. SUICIDE AS A MESSAGE
Anterospectively, the most comprehensive summary of suicidal dynamics is contained in Menninger's" book on "Man Against Himself'; retrospectively, Shneidman's and Farberow's9 concept of a psychological autopsy tries to elucidate motives. Both elaborate on suicidal impulse and attempt at a time when they might have been prevented. They provide us with a dynamically predictahle cluster of potential suicides. Transposed into communication, suicide constitutes a message. It may represent a message to which no answer is expected, it may implicitly caB for a reply, and it may indicate that no solution seems possible. THE
~[ESSAGE
IS
TO WlIICH XO ANSWER
EXPECTED
Severely depressed people have one feeling in common: there are no choices, there is no way out. The "no exit" constellation is subjectively overpowering. Here, the suicidal message calls for /10 reply. These persons may proceed regardless of conscience restrictions. They are doomed, they know it, and they feel that they have no option of choice. In other words, the prevailing mood is sufficiently overwhelming to decide upon self-annihilation. l\'eedless to state that such persons often succeed. Their choice of means to destroy themselves may give clues to a particular illness or conflictual situation. If their psychiatric state is known, if they m'e under psychotherapeutic care, the risk is diminished, as clinical assessments point out.' From a diagnostic point of view, it behooves the physician not to underestimate somatic dysfunction in the absence of organic pathology, to elicit statements of mood in those patients who apparently seek his help for physical illness and to remember that in the older age group almost 70% are prone to give clues of their suicidal intent.~ Suicides in younger people may be prevented by recognition of a severe mental disease. The young schizophrenic may not readily divulge his suiMay-June, 1964
cidal intent. He may be driven by delusions of persecution or hallucinatory commands. His message of no choice or no alternative and his failure to ask for a "reply" can only be attenuated by the physician's general diagnostic acumen. In other words, should the doctor suspect such a disorder, he also would find himself alert to the catastrophe of self-destruction. THE MESSAGE IN HOPE OF A REPLY
Suicide, suicidal preoccupation or attempts can reflect difficulties in living, in other words, be the expression of personality problems. These may be vicariously described as character disorders, sociopathies or neurotic crises. They have in common that the suicidal gesture seems to ask for a reply. Such a response may be phantasied and encompass the possihle reactions of the survivors, it may be anticipatorily manipulative and intended to elicit compassionate counter-measures or it may read "if I am driven that far, what can I do?" Personality profile and situational contingency appear to be intertwined. Cutting across psychiatric classifications, such suicidal risks have in common: a low tolerance for fmstration, a heightened impulsivity and an inability to learn from experience. The more labile the affect, the more unpredictable will their actions be. The physician's task is relegated to the area of ansu:ering the gesture prior to its execution. This requires superior psychotherapeutic skill and awareness of relationship. The concept of inner directed aggression" does not suffice to explain all suicidal motivations in the group of personality disorders, neither does the concept of "death instinct" provide the clinician with immediate measures. He will have to rely on a subjective evaluation of those social and psychological forces that prompt and restrain suicidal drive. One might say that out of a number of precodified messages, suicide is an acknowledged signal in our culture. Telegraph services provide a number of coded messages for condolence or congratulation. The transmitted intent to threaten suicide caBs for a greater diversity in replying. Deciphering the suicidal message beyond conventional codification and its dissection into individual motivations remain the physician's task whenever he encounters a person with conHictual strivings. This leads us to a final message which may precede the suicide. 145
PSYCHOSO~IATICS
BILA:'\Z SELBSTMORD ("BALAl\CE SHEET SUICIDE")
European, and in particular German psychiatric literature speaks of "Bilanz-Selbstmord." 1\0 adequate translation is available. The term denotes suicide on rational grounds, as the person has logically drawn a balance sheet of his assets and liabilities and from there on has decided that dying is better than living. Here, self-destruction is not regarded as the result of a disordered mind or emotional upheaval, but rather the outc'Ome of purposeful reasoning. There is little doubt that our culture sanctions such deaths when it provides intelligence officers with cyanide capsules in order to escape revelation of secrets or torture. The aspect could be.extended and encompass the physician who has carcinomatosis and knows that his economic assets are greater in death than in life. The message that "ultra posse nemo obliganlr" is convincing even to those who do not subscribe to Latin logics. Yet physicians are bound by the mores of their culture. To alleviate suffering and to prolong life remains their principal function. In each instance, we may assign suicidal impulse to categories. We will react individually and account for success and failure in preventing suicide. In order to avoid an impression that the phenomenon of self-destruction can easily be pigeonholed, the illustration of a completed suicide may be permitted. It cuts across lines of social constellation, psychiatric disorder and intellecnlal awareness as a dilemma beyond other alternatives. A 30 year old military officer found himself I:onfTOntt'd with the' accusation of antisocial conduct. His superiors preferred psychiatric to judicial stigma and sent him for psychotherapy. M. was a professional man of considerable achit'wments, married and the father of three children. His sodaI background rt'vealecl upward mobility, his psychiatric pidure could be defined as schizoid, and he was openly aware of the consequences of his conduct or bt'havior. After threl' st'ssions with a psychiatrbt he strongly professecl to have adequate internal controls. Tht' samt' day his superior officer informed the psychiatrist of renewecl delinquent conduct, disappearance from duty and several houTS later that the patit'nt had mmmitted suicide by carhon monoxide inhalation. During the last interview the patient had givt'n no indication of psychotic disturbancc nor was he dt'pressed or overtly agitatecl. Hc had previouly resisted the physician's suggestion to make contact with his wife or family, had refused him direct communication with his su146
perior officers and deniecl additional difficulties. A hbtory of anotht'r suidde attempt was known to hi~ psychiatrist, yet the physician had no medic.11 or legal means to insist upon closer supervision. In retrospect, the man committed suicide to avoid expulsion from the service, to spare hi~ family shame, while consciously rcc'ognizing his compulsively antisocial behavior. The "clues" wert> present and con~ist ed of a previous suiddal attempt, a personality disorder and social pressures, and one may aceuse the psychiatrist of misjudging tht' state of treatment relationship. Yet, this unfortunatt' patient illustrates those liabilities of doctor-patient relationship that are preclicatecl upon inadequate communication. Ultimately, the message that has not been receivecl nor understood will not be answ('f(>(l. This ohserver is inclined to call this a "balance sheet suicide" yet is mindful of the patient's con~iderable psychopathology. However, had he not been in a particularly exposed social position he might well hav(' sustained existence and life.
This pessimistic annotation is offered not for the sake of distracting from social consciousness or psychiatric awareness, but to alert the physician to human empathy. Be such empathy inntitive or may it have been acquired during one's own experience in life, a truly preventive goal of psychological medicine must go beyond the signals of immediate danger. We should not only fmstrate our patients' wish to die, but teach them how to live. REFERENCES
1. Ayd, F.: Suicide, a hazard in depression. ]. Neuropsychiat., 2:52 (Supp!.) 1962. 2. Capstick. A.: Recognition of emotional disturbance and the prevention of suicide. Brit. Med. J., 1:1179, 1960. 3. Crinker, Roy, and others: The Phenomena of Depressions. New York: Hoeber, 1961. 4. Hirsch, J.: Suicide. Ment. Hyg. 43:516, 1959. 5. Hordern, A.: Depressive states: A pharmacotherapeutic study. (In press). 6. Mennin~er, Karl: Man Against Himself. New York; Harcourt Brace, 1938. 7. Muncie, Wendell: Dt'pression, or depressions? Canad. PSljch. Ass. ]., Vo!. 8, No.4 (July-Aug.) 1963. 8. Roth, M. and Morrissey, J. D.: Problems in the diagnosis and dassification of mental disorders in old a~e: with a study of cast' material. J. Ment. Sci., 98:66, 1952. 9. Shneidman, Edwin S., and Farberow, Norman L., Editors: Clues to Suicide. New York: Blakiston Div., McCraw-Hili Book Co., 1957. 9a. Norman L. Farberow and Shneidman, Edwin S., Editors: The Cry for Help. New York: Blakiston Div., McCraw-Hill Book Co., 1961. 10. Stt'ngel, E.: Old and new trends in suicide research. Brit. ]. Med. PSljchol., 33:283, 1960. 11. Watts, C. A. H.: The problem of suicide in ~en t'ral practice. Proc. ROIj. Soc. Med., 54:264, 1960. Volume V