Tag: suicide attempt

is suicide caused by psychological pain

by Midnight Demon, posted in suicide attempt

Since 1949, Edwin Shneidman has done extensive research in the field of suicidology.  He began his research by looking at suicide notes in the coroner’s office in Los Angeles (Shneidman, 1996).  During his intensive research, he came up with the term, “psychache” to refer to the mental pain, which, when intense, makes life so horrible and horrendous, that the sufferer can only think about suicide as the only option out of his/her misery.

Psychache can be defined as “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind (Shneidman, 1996).”  Risk factors associated with suicide are only relevant as far as they can relate to psychache (Shneidman, 1993, 2005).  Dr. Shneidman believes that the true cause of anyone’s thoughts of killing themselves derive from this “psychache.”

During my research for this paper, I concluded that literature concerning the cause for individuals to resort to suicide is sadly lacking.  Most of the assessment scales for determining suicide risk focus on basically, two concepts as proposed by Rosenberg  (1999), action based and affective based interventions. 

Action-based interventions can include items such as a “no suicide” contract, increase sessions or phone check-ins, and, if appropriate, hospitalization. 

Affective based interventions focus on feeling and thoughts that are behind the suicidal ideation. 

Attempts have been made by several researchers for implementing a framework for something close to a “standard” for treatment care that is not determined by litigation (Brown, Jones, Betts, & Wu, 2003; Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Kral & Sakinofsky, 1994; Rosenberg, 1999; Rudd, 1998; Rudd, Joiner, Jobes, & King, 1999; Sommers-Flanagan, Rothman, & Schenkler, 2000; Walker, Joiner, & Rudd, 2001).  Discussion of litigation is not the objective of this paper, so if the reader is interested, Brown et al (2003) would be the work to which one is referred.

The frameworks provided by these researchers have provided many useful scales in determining risk and lethality of suicide, but do not include the assessment of psychological pain.  In Range and Knott’s (1997) analysis of twenty assessment instruments, not one of the twenty examined includes an assessment of psychological pain.  One reason for this is the subjectivity on the individual’s emotions, thoughts, mental state, and experience (Kral & Sakinofsky, 1994).  According to Kral and Sakinofsky (1994), suicidologists are in general agreement that “predicting suicide for a given individual is that, like many human states, the suicidal state has a temporal, fluctuating dimension”.  They propose that the evaluation of psychache experience, the psychological state of the suicidal person, is the key to accurate risk assessment.

Psychache is subjective.  A person is not going to feel the exactly the same way for any length of time.  However, if the level of perturbation (mental anguish) increases in intensity for too long, the individual is going to feel a need to escape from the anguish and despair by any means necessary, including by not existing any more.  If suicide is seen as the only option, the only form of escape, lethality of a suicide attempt is high risk.  Kral and Sakinofsky (1994) have stated that treatment of perturbation will reduce lethality and treatment of lethality ideation will reduce perturbation as these two states can feed off one another (Kral & Sakinofsky, 1994). 

A scale to the assessment of suicide risk would be to have a scale of the person’s needs and current psychological pain.  Dr. Shneidman believes, as do I, that when psychache is intense, perturbation is intolerable, and one or more psychological needs are thwarted or blocked, suicide is seen as the only option of relieving the psychache (Shneidman, 1999).  He has based these needs on described by Henry Murray’s (1938) Explorations in Personality. Shneidman has developed 20 psychological needs.  These needs are weighted and the total sum is 100 (see table 1 for an example).

Table 1

 

Murray Need Form

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________
Subject: ____________________Sex: _______Age: ______Rater:________Date:_______

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________

_____   ABATEMENT          The need to submit passively; to belittle oneself.

_____  ACHIEVEMENT      To accomplish something difficult; to overcome.

_____  AFFILIATION         To adhere to a friend or group; to affiliate.

_____  AGGRESSION         To overcome opposition forcefully; fight, attack.

_____  AUTONOMY           To be independent and free; to shake off restraint.

_____  COUNTERACTION                       To make up for loss by retrieving; get even

_____  DEFENDANCE        To vindicate the self against criticism or blame

_____  DEFERENCE           To admire and support, praise emulate a superior

_____  DOMINANCE          To control, influence, and direct others; dominate

_____  EXHIBITION           To excite, fascinate, amuse, entertain others

_____  HARMAVOIDANCE          To avoid pain, injury, illness, and death.

_____  INVIOLACY                        To protect the self and one’s psychological space.

_____  NURTURANCE       To feed, help console, protect, nurture another.

_____  ORDER                     To achieve organization and order among things and ideas

_____  PLAY                                    To act for fun; to seek pleasure for its own sake.

_____  REJECTION             To exclude, banish, jilt, or expel another person.

_____  SENTIENCE             To seek sensuous, creature-comfort experience.

_____  SHAME-AVOIDANCE       To avoid humiliation and embarrassment

_____  SUCCORANCE       To have one’s needs gratified; to be loved

_____  UNDERSTANDING                        To know answers; to know the hows and whys.

100

(Shneidman, 1999; used with permission)
References:

 

Brown, G. S., Jones, E. R., Betts, E., & Wu, J. (2003). Improving suicide risk assessment in a managed care environment. Crisis, 24(2), 49-55.

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.

Kral, M. J., & Sakinofsky, I. (1994). Clinical model for suicide risk assessment. Death Studies, 18, 311-326.

Murray, H. A. (1938). Explorations in personality. New York: Oxford University Press.

Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21(1), 25-58.

Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.

Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.

Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.

Shneidman, E. (1996). The suicidal mind: Oxford University Press.

Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 147-149.

Shneidman, E. S. (1996). Suicide as psychache.New York and London: New York University Press.

Shneidman, E. S. (1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29(4), 287-294.

Shneidman, E. S. (2005). How I read. Suicide and Life-Threatening Behavior, 35(2), 117-120.

Sommers-Flanagan, J., Rothman, M., & Schenkler, R. (2000). Training psychologists to become competent suicide assessment interviewers: Commentary on Rosenberg’s(1999) suicide prevention. Professional Psychology: Research and Practice, 31(1), 99-100.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.

Copyright 2013, Collerone, G

suicide paper, V1

by Midnight Demon, posted in suicide attempt

“You will not fail to see that I am suffering under a depression of spirits which will [not fail to] ruin me should it be long continued” -Edgar Allan Poe {{Jamison, 1993 #18}.    

Depression, left untreated, eventually leads to suicide.  In the United States, suicide is the 11th leading cause of death, accounting for approximately 30,000 deaths with an age adjusted rate of 10.7 per 100,000 persons (Gaynes et al., 2004).  Most clinicians have seen suicidal patients throughout their careers.  Researchers have reported that professional psychologists has a 1:5 or 1:7 chance of losing a client to suicide; for psychologist trainees, a 1:6 ratio has been reported.  To date, there is no known formalized training program for beginning or experienced clinicians designed to teach suicide assessment skills, nor is there a recognized model for treating suicidal thoughts and feelings in a systematic way (Rosenberg, 1999).  Furthermore, the current literature fails to accurately define what it meant by “suicide ideation” or “suicide attempt”.  O’Carroll et al describes in their research how one clinician can say to the other that they have hospitalized a client due to suicide attempt.  The other clinician often wonders what that means.  Does that mean the client actively attempted deliberate self-harm warranting medical attention, attempted self-harm but did not warrant medical attention, or ideated a plan for an attempt and was intent on acting on that plan.  Eg pg 238 on senate asking the question and responding.  Reasons for intent, how many came to the hospital how many didn’t, how many died.  Basic terms are not uniform among clinicians (O’Carroll et al., 1996). 

David Rudd has provided a conceptual framework based on clinical summaries and assessment tasks consistent with existing standards of care but not dependent on psychotherapeutic orientation.  This framework is divided into three categories: practical skills, self-image, and interpersonal relationship (Rudd, 1998). 

One of the essential goals to achieve treatment success is to emphasize psychodynamic approaches to developmental issues and the therapeutic relationship.  A strong therapeutic alliance is essential to positive outcome treatment with a depressed client (Klein et al., 2003).

Several studies have noted a difference between single and multiple attempters (Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Rudd, Joiner, Jobes, & King, 1999; Walker, Joiner, & Rudd, 2001).  It has been postulated that previous suicide attempts sensitize one to subsequent suicide-related thoughts and behaviors.  These individuals with a history of multiple attempts display behavioral and cognitive styles distinct from those of non-multiple attempters. There is also evidence that crisis intensity is related to negative life events for non-multiple attempters but not for multiple attempters (Walker et al., 2001). These same authors have stated that clients fall into three types of groups when assessing suicidality: suicide ideators, single attempters, and multiple attempters (Joiner et al., 1999).

The difference between them is the elevated risk in multiple attempters because of type, chronicity, and severity of psychopathology.  The authors also go on to define seven domains of factors in assessing suicide risk.  These are:

1. Previous suicidal behavior

2. Nature of current suicidal symptoms

3. Precipitant stressors

4. General symptomatic presentation, including hopelessness

5. Impulsivity and self-control

6. Other dispositions (e.g. history of abuse, environmental factors, substance abuse, etc)

7. Protective factors (e.g. suicidal writing, social support)

A history of previous suicidal behavior is an important domain for risk assessment.

In addition to these domains, the authors have narrowed down two main factors to summarize suicidal symptomatology risk: “resolved plans and preparation” and “suicidal desire and ideation”.

     Resolved plans and preparation is defined as the following symptoms: a sense of courage to make and attempt, a sense of competence to make an attempt, availability of means to and opportunity for attempt, specificity of plan for attempt, preparations for attempt (seeking gun, pills, etc), duration of suicidal ideation, and intensity of suicidal ideation.  Their view is that if the client shows such symptoms, they are in pernicious, moderate risk.

     The suicidal desire and ideation factor defines the following symptoms: reasons for living, wish to die, frequency of ideation, wish not to live, passive attempt, desire for attempt, expectancy of attempt, lack of deterrents to attempt, and talk of death and/or suicide.  These symptoms are clinically noteworthy but are considered minimal risk, unless the client has had previous suicidal attempts (Joiner et al., 1999).

References:

Gaynes, N. B., West, S. L., Ford, C. A., Frame, P. S., Klein, J., & Lohr, K. (2004). Screening for suicide risk in adults: A summary of the evidence for the United States preventative services task force. Annuals of Internal Medicine, 140(10), 822-835.

Jamison, K. R. (1993). Touched with fire.New York: Free Press Paperbacks. p.18

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.

Klein, D. N., Santiago, N., Vivian, D., Schwartz, J. E., Vosisano, C., Blalock, J., et al. (2003). Therapeutic alliance in depression treatment: Controlling for prior change and patient characteristics. Journal of Counseling and Clinical Psychology, 71, 997-1006.

O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the tower of babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237-252.

Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.

Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.

Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.

perception

by Midnight Demon, posted in suicide attempt

Had a visit with my primary doc today and it went well. I got what I needed and now just need to settle for the month of what ifs until next month. We discussed the paper I sent him and agreed that though my intention was clear with him, his staff was a moron in handling it. Instead of getting the point of what my pain was meaning to me, they just focused on the small suicide part and disregarded everything else in the paper, which pissed me off. I had given this to my neurologist and my psychiatrist and if there was any suicidal warning in the paper, I think the white coats would have been thrown at me in a heart beat. But this is what it is, CYAM (Cover Your Ass Medicine). My neurological condition ignored and I am again just a mentally ill patient.

 

After my appt I really didn’t know what to do with myself. I came home and had something to eat as I hadn’t eaten anything all day. My foot was sore from walking around and felt like I was walking on hot pokers. I debated on taking something but decided against it because I didn’t want to be sleepy.  Tonight the show Perception is on and I can’t wait to watch it but it is a few hours away. This show has found meaning to me with the parallels of the main character’s struggle with schizophrenia and my own battles with psychosis. I too have the main voices and the ones that come along just to haunt me.

 

I tried writing on my suicide attempt paper but it really did not hold my attention for long. I seem to have lost my writing ability for this for now. I ended up editing it a little bit trying to make it make sense a little more. My hopes of it being a sequel to my other paper have been dashed, as it is already so long there is no way I can introduce the lyrics now.  Plus I have not felt strongly about this song in a long time so trying to get the juices flowing has been slow and uneventful. I wish I could turn and write the paper like I did the other but I had more to go on with the other than with this one. It has turned painfully personal and I just cannot let the human element of this new paper die with just what I have written. My experiences, though I do not know if they are valuable, have been injected into this and I can’t seem to remove them without taking away from the paper. Now I find myself writing about every attempt I have made in my life and the consequences of those actions.  I don’t know if that is what people want to read about but I write about the aftermath and how it felt after each failed attempt.  Maybe I have just given up on trying again and that is why it has been so long since I have attempted again. True I feel like the biggest failure in the world knowing this but how can I not. This is deeply personal talking about the lowest point in my life and wanting to end it all and then by some grace, still be forced to live on afterwards because of some kind of divine intervention. Of the many attempts I have tried, only 1 was medically serious to warrant a hospitalization. The others were not so serious but did lead me to another hospitalization. Since the age of sixteen I have had close to 30 hospitalizations. Most have been involuntary as I posed a danger to myself and it is law to hospitalize for that reason. I just wonder why I have survived this long. Am I suicidal if I don’t attempt and just plan? We can go into the whole what makes a person a suicidal ideator vs an attempter but most would agreed prevention lies in before the attempt not after. We hear stories about suicides and their survivors but what you don’t hear at all is about the attempter that survived. These truly are the ones that need the most attention to but because their world is so private no one really knows. Unless someone survives a shotgun wound or emmolation or hanging attempt, you often don’t see the scars of attempters. True those that slice their wrist leave scars but most do survive to eventually tell their tale. There are countless overdoses every year that get under reported or if successful get ruled as accidental poisonings rather than suicides mostly to either spare the family the “shame” or because there was no clear indication that the poisoning was intentional. Most people believe that unless there is a suicide note, it is not a suicide because he or she wouldn’t do that. I would say that the majority of people who attempt and fail feel too ashamed to admit what they have done and so cover their asses by saying it was an accident or just a foolish impulse but for those that succeed we will never know.

killer bees, 10-dec-10

by Midnight Demon, posted in suicide attempt

The past three days I have been thinking about what to write on here.  My topic was going to be about the killer bees and how they always seem to come out when I want to go to sleep.  The bees aren’t real. It is just this buzzing sensation I get because of the nerve damaged caused by a disc fragment in my spinal nerves.  I have been living with this condition, called Cauda Equina Syndrome (CES for short), for the past 9 ½ years. I actually got it twice. The second time was in 2006. I had it easier the second time around because I knew what to look for and how to get the proper care as well as what I knew to expect.  That helps big time as the first go round didn’t go well.  I was only 25 yrs old when I got it. My leg gave way one night, 12 hrs after seeing my chiropractor and got worse in the next 72+ hrs since then.  I had seen a doc the Monday as I could barely put any weight on my left leg and all the doc did was give me pain meds and a pain shot. He didn’t tell me about warning signs or nothing.  A couple days later I was to have an appointment with my psychiatrist, but by then the damage had spread to my right leg and I could feel my toes on either foot. I had foot drop in both, but the worse was my left where most of the damage was. I couldn’t walk at all.  She wanted me to call an ambulance right away but because of the current detours, I couldn’t be 100% sure I would end up at MGH so I decided to wait for my friend to come home and take me.  I was at her house anyway and didn’t have the key to lock up, plus she had 2 dogs so I didn’t want to leave the house open to them or have an incident where they attacked the EMT’s.  I know I added more time to the clock, but I didn’t want to go to some rinky dink hospital and then be forced to go to MGH in worse condition.  All this time, I just thought I needed some good PT and pain meds and I would be good as new. I couldn’t be more wrong.  Soon after I had my MRI (after being in the ER 12+ hrs and being up for 24), the radiology tech’s face was ghastly.  He said that I shouldn’t move.  I wanted to tell him, “buddy, if I could walk, do you really think I would be in this wheelchair???”  3 hrs later I was in the OR. My L4-L5 disc had ruptured. It was the size of an almond compressing my cauda equina nerves.   It took me a week just to wiggle my toes a little bit.  I had to learn how to walk again, which is probably fine if you are a kid. You can fall easily and not worry about doing damage. If I fell, I was afraid I was u going to end up back in the OR.  I had to wear orthotics called AFO’s to keep my feet where they were supposed to be while walking.  I had a long recovery.  In 3 months I was using just a cane to get around. I still have the walker.  I hope it continues to collect dust but you never know.  I was still having back pain all throughout this.  It wasn’t until my doc put me on oxycontin that I really got better.  I am off it now for reasons I won’t go into, but it really saved my life. I doubt I would be able to work 40+ hrs a week now if I hadn’t been on it. It helped me heal and push through the pain so I could get well.

Six months into recovery, the nerve pain started.  My foot and left side of my leg from the outside burned something fierce. This lead to another wonderful med, Neurontin or gabapentin as its generic name is known.  Some people cannot tolerate this med and have had bad side effects. My system loved it and it has worked wonderfully.  With a high dose at night, I was almost pain free most of the day. Now, not so much.  I never thought much about the difference between brand name and generic, but with this med, there is a huge difference.  Once dose is usually all I need (on brand name). Generic I need a slightly higher dose to get me the same relief.  But the one thing it doesn’t change is my sleep.  This nerve pain is not something to mess with.  I have some nights where not even the bed sheets can touch me. Other nights, just before drifting off, the deep pins and stabbing begins, jolting me upright.  It drives me crazy because unless I take the gaba, I will be in pain. The side effect is that it takes me a long time to wake up after dosing. Sometimes I need at least 10-12 hrs of sleep to sleep it off or my brain is just foggy.  With my job, I need to be able to be places early in the morning so I can’t take it every night like I need to. Plus with me taking it with my other meds, it really knocks me out.

I have been having a lot of suicidal thoughts over the past few years. I have written so many wills and good bye letters that I know one day I will just end my life. Most of it is because of this pain I deal with every day and I’m not really talking about the physical pain. Mental pain is with me every day, every second. There is no escaping from it and there is no drug I can take to relieve it. I have a high pain tolerance. I just realized over the past few days that because I take ativan, I don’t seem to get the recurrent thoughts of suicide in my head as much. I think most of it is because of my physical pain caused by CES and the downfalls of having to keep track of things that no other “normal” person would think of, stressing me more than I realize.  How many people do think when the last time they urinated or had a bowel movement. If I don’t keep track it could be a week before I had a BM or significant long hrs since my last void that I am going to have an accident or a leak, well mostly a leak. I only had one accident and it was my fault as I should have gone to the bathroom before going home but I thought I would make it and I didn’t. Now I know that I can’t ignore those signals anymore and it stresses me out.

Working long hours and days does help with the depression. It keeps the thoughts out that lead to planning and contemplating when I will and how I will kill myself. I know that I will someday and have already begun to do so. Maybe this will be my last writing before I die to tell you what really goes through the suicidal mind up until death.