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Suicide – Series of articles “How to treat the soul?” Part 4!

Approximately 800 thousand people commit suicide every year – 1 person every 40 seconds. It is the second most common cause of death among 15-29 year olds [1].
9th century sociologist E. Durkheim distinguished three types of suicide in his works – egoistic, altruistic and anomic.
Egoistic suicide is characteristic of people from a highly developed society and depends on the level of voluntariness – a person arbitrarily chooses to die due to his personal views/reasons. The weaker the religious tradition that condemns suicide, the weaker the influence of the family and the connection with society, the higher the number of people committing suicide.
Altruistic suicide – in contrast to egoistic suicide, is carried out when the connection with society is quite strong, but for various reasons a person feels like a burden to those around him and in his thoughts is convinced of the psychological pressure from society “you must die”. It happens in the environment of sick or old people, for example, from the past two centuries, we can mention the suicide of wives after the death of a husband or the suicide of servants after the death of a master, as a part of pathological mourning.
Anomic suicide is characteristic of a society in which major reforms and transformations take place, but a person is unable to adapt to them (new values, new roles) – usual causal relationships disappear, new ones appear. This type of suicide is characteristic of economic crises [2].
However, this classification only gives a general idea of ​​the motives for suicide. The real reasons why a person chooses to live or not are deeper.
60% of suicides are committed by people suffering from depression. 15-25% – drug and alcohol addicts. 3-10% – schizophrenic patients, their motivation for suicide is rooted in nightmares and hallucinations that command them to do it. Epilepsy patients are also at risk – during epileptiform excitement, behavior can be impulsive and spontaneous.
The suicidal behavior of a borderline personality (emotionally unstable) should also be singled out separately. In this case, suicide itself is a spontaneous reaction to stress and a temporary crisis: in 153 cases of incomplete suicides, 24% of people did it within 5 minutes of taking the action as suicide, and the remaining 70% within an hour. In people with a borderline personality structure, suicide attempts can be observed more often than real suicide, because it is not planned, although the risk of repetition is high [3; 4].
In the beginning of the 20th century, Z. Freud and K. Abrahams tried to explain the reasons for suicide even more deeply in their works. Suicidal behavior is aggression against one’s personality, losing an important object. In the concept of psychodynamic psychotherapy, there is a strong emphasis on the death of close people, separation from them or disappointment in them. During the development stages of psychotherapy, this object was also considered the image of the mother, which is stored in the memory since the newborn age, if painful experiences are associated with it. The first reaction to the lost object is hatred, arising from feelings – “I am bad because I was abandoned”. In later life, hatred is replaced by a feeling of guilt – “I was abandoned because I am bad”. But the most difficult thing is to give up the lost object. It retains a great value, therefore the person suffering from this loss begins to psychologically identify the lost object with himself, and the initial feeling of hatred is directed against himself, and the desire to kill another becomes a desire to kill himself. Suicidal behavior becomes a solution to this conflict, achieving both three goals – by killing oneself, the “other” is killed at the same time – and one’s own guilt against him has also been redeemed. So the main feelings that lead to suicidal behavior are hatred and guilt.

How to know?

In psychotherapy, there is the so-called pre-suicidal syndrome, the main features of which are suicidal fantasies, self-aggression and focusing attention on negative experiences – self-deprecating thoughts. Depressed people with a high risk of suicide are also characterized by a loss of interest in doctors and other people who care for them [5; 6]. Consequently, people with suicidal tendencies often become unable to help themselves and their fate depends on the ability of the people around them and loved ones to recognize warning signs and lend a helping hand.

Key signs of suicidal tendencies:

  • Signs of serious depression: persistent low mood, pessimism, anxiety, inner tension, hopelessness, despair, sleep disorders.
  • Increase or re-emergence of alcohol or drug use.
  • The person becomes impulsive or behaves risky.
  • A potential suicidal person sometimes openly expresses a desire to die or threatens suicide. It is also possible that he makes a suicide plan, gives his property to others, writes a legacy, unexpectedly buys a firearm, collects and researches information about poisons, medicines.
  • Suddenly becomes angry, easily irritated. [10]

TEST - Suicidality Risk Scale: C-SSRS.

The statements can be answered with “yes” (1 point) or “no” (0 points) [7].
During the last month:
  • Have you wanted to die?
  • Have you had thoughts of committing suicide? (if the answer to this question is affirmative, then proceed to questions 3, 4, 5, 6; if negative, proceed immediately to question 6)
  • Do you think you might commit suicide?
  • Have you had thoughts about how to commit suicide?
  • Have you started to develop a detailed plan and were you going to implement it?
  • Have you ever done something to kill yourself? (if yes – how long ago was it? More than a year ago/ 3 months-year/ within the last 3 months?
A concise interpretation by summing up affirmative answers: from 3 points (inclusive) there is a risk of suicide.

Suicide Panacea!

The first thing to do if you notice suicidal tendencies is to seek psychiatric help. If you have observed suicidal tendencies in any of your relatives, colleagues, friends, etc., you should offer inpatient psychiatric treatment and persuade them to undergo treatment. When the problem is serious and severe, it should be understood that sincere discussions about life and suggestions to go and have a good time with friends will not help, here you need professional help.
Unfortunately, in today’s society there is still a prejudice that being treated by a psychiatrist or in a psychiatric hospital is something shameful that could threaten one’s reputation or social life. Taking care of your own and other people’s life and health can never be shameful. As well as the legislation of our country, confidentiality is guaranteed to patients – it is forbidden to disclose any information about the patient’s health to other persons without the patient’s consent to the doctor, even on certificates and sick sheets the diagnosis must not be indicated [11]. We know as much about each patient’s problems as he tells us about himself.
Patients receive inpatient treatment voluntarily. But it should be added that in acute cases, when a person is aggressive towards himself and openly threatens suicide or tries to do so, it is possible to provide psychiatric help even without his consent, which was established by Article 68 of the “Law on Medical Treatment of the Republic of Lithuania”. This is possible in cases where a person
  • 1) has threatened or is threatening, tried or is trying to cause bodily harm to himself or another person, or has behaved or behaves violently towards other persons, and the medical practitioner determines that the patient has a mental health disorder, the possible consequences of which could be serious bodily harm to the patient himself or to another person;
  • 2) has shown or is showing an inability to take care of himself or the persons under his care and the medical practitioner determines that the patient has a mental health disorder, the possible consequences of which could be an imminent and serious deterioration of the person’s health.
A full course of treatment for acute conditions in a psychiatric hospital usually lasts a few weeks, and in state institutions it is fully paid for from budget funds. After discharge, the patient is usually given recommendations for further outpatient treatment, if necessary. Inpatient treatment takes place according to the doctor’s plan. A more suitable drug is sought for each patient. The spectrum of drug effects is different, so the effectiveness of the treatment depends on how openly the patient is able to tell the doctor about his feelings. Cooperation and interaction in the “doctor-patient” relationship is the determining factor in the healing process, however, during inpatient treatment, it is important to reject the doctor-psychiatrist as a person who has more experience and knowledge on how to prevent other people’s emotional crises and suicidal tendencies – it was initiated professional standards and treatment principles [12].
When it comes to treating suicidal tendencies in detail, it depends on the reasons. Most suicides are due to severe depression. In such cases, it is very important to start drug therapy as soon as possible (antidepressants, mood stabilizers) simultaneously with psychotherapy with the aim of reducing self-aggressiveness and the tendency to condemn oneself. After the mood background stabilizes and depression remission is achieved and consolidated (which usually takes half a year), antidepressants are canceled, but psychotherapy must be continued. In general, the duration of treatment, which gives a long-term effect, is approximately one to two years [8]. Of course, it is important to differentiate depression from other mental illnesses. In cases of schizophrenia, it is important to constantly, continuously use the prescribed medications, even though in the case of this disease, especially in the remission of episodic schizophrenia, depression also develops and then it is also necessary to treat it. If suicidal tendencies occur in alcohol and drug addicts, addiction treatment is started. Replacement therapy and the Minnesota program give good results. When remission is achieved, individual psychodynamic psychotherapy should be continued to strengthen the results.
Authors: Alina Kuznetsova, resident doctor in psychiatry, Psychiatrist Pēteris Zālītis

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