Back in town, but my harddrive is still being repaired, so I’m a little hampered bloggingwise.
I don’t know if it was motivated by this post of mine or not, but Roger at Limited Inc. has an interesting post up entitled “Suicidal Ideation.” I’m gonna have to get hold of the Psychiatry article he discusses. In one respect, though, I think Roger is, perhaps, mistaken about his announced topic.
Roger says:
I don’t hold myself out as an entire model of normality, but still, my own experience is derived from the main, and my own experience is that suicide is and always has been one of the normal ‘ideations’ in the longue duree of my experience. It takes on all the technicolor of any object of repeated reflection: at time it is a comfort, sometimes it is a threat, sometimes it is a silly melodrama, sometimes an inevitability. I find this all pretty normal. Now, there are probably human beings out there who don’t think of killing themselves, or who think much less frequently than I do. But it is hard to image that someone committed in some vague way to the arts doesn’t have a lively dialogue going with a suicide double at some point or another.
I agree that all this is “pretty normal.” But this sort of thinking about suicide is not what is meant by “suicidal ideation”; at least, it’s not how I use the term, and I don’t think it’s how psychiatrists use it, either. I offer this uninformed opinion based on my reading of a single book, which I’ve mentioned before here: David Healy’s Let Them Eat Prozac. Suicidal ideation is not what occurs when one’s circumstances make self-destruction appear to be, temporarily at least, a rational solution. If the contemplation of suicide is a “comfort” or a “silly melodrama”, then suicidal ideation is not taking place. As I (and Healy, I think), suicidal ideation consists of intense and overwhelming momentary urge to kill oneself in a particular way, usually accompanied by very concrete, near-hallucinatory visualizations of oneself performing that particular act. (It’s helpful here to remember the root of the word “idea”: the Greek idein, meaning “to see”.)
Spend a few hours with someone who’s afraid to be alone because when she is she’s overwhelmed by visions of herself cutting her own wrists, and you’ll know what I’m talking about.
Healey offers a number of very vivid descriptions of what suicidal ideation is like, and they are worth quoting at length:
[The patient] had “forced obsessional suicidal thoughts consisting of intense and obsessive wishes to kill herself and described by [her] as ‘uniquely bad.’ She felt ‘death would be welcome.’ She also felt like jumping out of her skin, but had no signs of motor restlessness.” . . . As [her psychiatrist] later put it, he’d seen patients who were suicidal before, but never anything quite like this.
(LTEP, p.43)
Two weeks later [the patient] made a suicide attempt that did not appear to be a call for help. When interviewed after the suicide attempt, she made it clear that she had been having frequent severe suicidal ruminations, that she felt unreal, and that she had a belief she could neither fight nor control her suicidal impulses.
(LTEP, p.44)
(Re a woman with multiple personality disorder): She began to self-mutilate, planned lethal overdoses, and put a loaded gun to her head. One of her internal personalities began to shout at her to commit suicide.
(LTEP, p. 44)
One option in this kind of situation is to undertake an Amytal interview, using the barbiturate to relax the person in the hope that his barriers to the disclosure of sensitive information drop. Following an injection of Amytal, Alan was asked to imagine himself in the front garden of his house. . . . Alan was then walked up to his front door and asked to ring the bell and see who answered.
. . .
But another, quite unexpected story unfolded. While being walked around his house, Alan began to discuss fantasies of killing himself before coming to the hospital. . . . [H]e . . . described getting the sharpest serrated cutting knives in the house and contemplated deeply cutting his wrists. He described fantasies of holding the earth wire [ground wire], commonly at that time attached to the pipes of the cold tap under the sink in the kitchen, while at the same time plunging a steel knife into a nearby line socket. There were other suicidal thoughts. . . . He was visibly upset. He insisted that these thoughts were out of character.
(LTEP, pp. 47-48)
Over the weekend, Joanna had dreams of slitting her throat open and bleeding to death in the bed beside her partner. These dreams woke her at 3AM and left her frightened and unable to get back to sleep. The same dream recurred on three successive nights.
. . .
That night alone in her house was one of the worst of her life. She felt things were watching her. She checked behind doors in case there was anything there. . . . She suddenly decided she should go out and throw herself in front of a car or train. It was as if there was nothing out there apart from the vehicle she was going to throw herself under. She didn’t think of her partner or child. This lack of feeling ate away at her later. When our biology changes, we change, but even in the midst of a high fever, when everything was unreal, she still knew she loved her daughter. Now she felt nothing.All her anxiety vanished once the thought of death crystallized in her mind. Putting an end to herself, even in this violent way, seemed a way to solve her anguish and pain. She was, in fact, on her way out the door to kill herself when the phone rang. It was as if a hypnotic trance was broken.
(LTEP, pp. 183-184)
Rule of thumb: Anyone who begins with the thought: “My life is hopeless, things will never get better, maybe I’d be better off killing myself”, and then ponders the best method, is not experiencing this kind of ideation. The ideation occurs when the vision of doing oneself in a specific way pops into the mind unbidden.
I’m engaging in untrammelled speculation here, but it seems to me that the possibility of having these kinds of experiences indicates that there is a self-destruction routine hardwired in our brains, and that that routine can be triggered in a variety of ways. Healey offers substantial evidence that Prozac is unique among known drugs in being able to provoke this kind of experience (in a small minority of those who take it), and that both the ideation and the attempts can occur in the absence of anything we’d ordinarily call depression. Prozac-induced suicidals more frequently describe their state of mind as agitated, restless, even manic, than as despondent or hopeless. Seems to me that Prozac, in fact, offers us a means of studying how that autodestruction mechanism is neurally encoded and how it is triggered. With ample financial incentives for volunteers, close monitoring of subjects, and dosage increases in very small and slow increments, it should be possible to put together a reasonably safe study. Can’t see that there’s much money to be made at it, though, so it’ll probably never happen.
Comments 5
Alan, admittedly, the extreme end - a sort of suicidal possession - is definitely beyond the everyday variety. But I do wonder if all suicide attempts match up to the instances that you list. I’d have to look this up, but I’d be surprised if people less prepared, whose scenarios are less graphic and demanding, don’t commit suicide. If one attempts suicide without these extreme manifestations, would the psychiatrist still talk about suicidal ideation?
In the film, the Bridge, there were obviously people who attempted it who had that sort of stuck in the groove record playing in their heads. But, on the testimony of the survivors, there were others who dealt with suicide as a possibility pretty openly, for a pretty long time, in ways that don’t seem so manic.
Posted 11 Jul 2007 at 8:57 pm ¶“If one attempts suicide without these extreme manifestations, would the psychiatrist still talk about suicidal ideation?”
No.
Posted 12 Jul 2007 at 6:08 am ¶Well, Alan, if thoughts of suicide of no matter what type aren’t sufficient to create suicidal ideation, I stand corrected. But I think that my mistake is common. I went and looked up some psych texts on Google books. Rita Sommers-Flanigan’s Clinical interviews, and suicidal ideation is continually used, there, to designate that thought of suicide, down to the rating of intensity. For instance, when assessing suicidal intent, Sommers-Flanigan places as the lowest level “Mild: suicidal ideation but no specific or concrete plans exist. Few risk factors are present.†That seems to be what I am talking about. On the other hand, she writes “Severe: Suicide ideation is frequent and intense. Plan is specific and lethal, means are available, and nearby resources are few…†All of which seems to signal that there is a difference between suicidal ideation and the planning you are talking about. Of course, there is another lower level of “wishing to die†in a sort of vague way, but in other books I’ve scanned – for instance, Julio Licino and Ma Li Wong’s Biology of Depression, they define suicidal ideation like this: “Suicidal ideation represents a more diffuse and mild aspect of suicidality, which includes thinking about suicide. This can be of varying degrees of intensity and severity. Suicidal ideation is considerably more difficult to characterize precisely. In addition, the relationship between suicidal ideation and neurobiological factors associated with suicide completion remains unclear.â€(289)
Posted 12 Jul 2007 at 8:06 am ¶I stand corrected about the use of the term. I stand by what I said about there being a “hardcoded self-destruct mechanism” in the human CNS, and that Prozac can trigger it in the absence of any other symptoms of depression.
Posted 12 Jul 2007 at 1:36 pm ¶Alan, on that, I’d be inclined to agree with you. I’m curious, though, why you don’t relate that in any way to the Freudian death drive.
Posted 12 Jul 2007 at 8:31 pm ¶Trackbacks & Pingbacks 2
[...] While writing this cheery post, my heart began to sing; and I felt like increasing the lightheartedness by letting the world know the song that I was singing. To my dismay, I discovered that the lyrics to Loudon Wainwright III’s immortal “Suicide Song” aren’t available anywhere on the Internet. (For you youngsters, Loudon is Rufus’s dad.) To remedy this situation, I dragged my LPs out of storage, and even got my old turntable to work; so appreciate this labor of love. [...]
[...] The item most closely related to things I’ve been blogging about recently is a link to a NYT article claiming that a new study refutes the alleged link between SSRIs and suicide. [...]
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