One of the more fascinating psychotic conditions in the medical
literature is known as Cotard’s syndrome, a rare disorder, usually
recoverable, in which the primary symptom is a “delusion of negation.”
According to researchers David Cohen and Angèle Consoli of the
Université Pierre et Marie Curie, many patients with Cotard’s syndrome
are absolutely convinced, without even the slimmest of doubts, that
they are already dead.
Some
recent evidence
suggests that Cotard’s may occur as a neuropsychiatric side effect in
patients taking the drugs aciclovir or valaciclovir for herpes and who
also have kidney failure.* But its origins go back much further than
these modern drugs. First described by the French neurologist Jules
Cotard in the 1880s, it is usually accompanied by some other
debilitating problem, such as major depression, schizophrenia, epilepsy
or general paralysis—not to mention disturbing visages in the mirror.
Consider the
case
of one young woman described by Cohen and Consoli: “The delusion
consisted of the patient’s absolute conviction she was already dead and
waiting to be buried, that she had no teeth or hair, and that her
uterus was malformed.” Poor thing—that image couldn’t have been very
good for her self-esteem.
Still, call me strange, but I happen to find a certain appeal in the
conviction that one is, though otherwise lucid, nevertheless already
dead. Provided there were no uncomfortable symptoms of rigor mortis
cramping up my hands, nor delusory devils biting at my feet, how
liberating it would be to be able to write like a dead man and without
that hobbling, hesitating fear of being unblinkingly honest. Knowing
that upon publication I would be tucked safely away in my tomb, I could
finally say what’s on my mind. Of course, living one’s life as though
it were a suicide note incarnate (yet remember this is precisely what
life is, really, and I would advise any thinking person to stroll by a
cemetery each day, gaze unto those fields of crumbling headstones
filled with chirping crickets, and ponder, illogically so, what these
people wish they might have said to the world when it was still humanly
possible for them to have done so ) is an altogether different thing
from the crushing, unbearable weight of an actual suicidal mind
dangerously tempted by the promise of permanent quiescence.
In considering people’s motivations for killing themselves, it is
essential to recognize that most suicides are driven by a flash flood of
strong emotions, not rational, philosophical thoughts in which the
pros and cons are evaluated critically. And, as I mentioned in last
week’s
column
on the evolutionary biology of suicide, from a psychological science
perspective, I don’t think any scholar ever captured the suicidal mind
better than Florida State University psychologist
Roy Baumeister in his 1990
Psychological Review article
, “Suicide as Escape from the Self.” To reiterate, I see Baumeister’s
cognitive rubric as the engine of emotions driving deCatanzaro’s
biologically adaptive suicidal decision-making. There are certainly
more recent theoretical models of suicide than Baumeister’s, but none in
my opinion are an improvement. The author gives us a uniquely
detailed glimpse into the intolerable and relentlessly egocentric
tunnel vision that is experienced by a genuinely suicidal person.
According to Baumeister, there are six primary steps in the escape
theory, culminating in a probable suicide when all criteria are met. I
do hope that having knowledge about the what-it-feels-like
phenomenology of ‘being’ suicidal helps people to recognize their own
possible symptoms of suicidal ideation and—if indeed this is what’s
happening—enables them to somehow derail themselves before it’s too
late. Note that it is not at all apparent that those at risk of suicide
are always aware that they are in fact suicidal, at least in the
earliest cognitive manifestations of suicidal ideation. And if such
thinking proceeds unimpeded, then keeping a suicidal person from
completing the act may be as futile as encouraging someone at the very
peak of sexual excitement to please kindly refrain from having an
orgasm, which is itself sometimes referred to as
la petite mort (“the little death”).
So let’s take a journey inside the suicidal mind, at least as it’s
seen by Roy Baumeister. You might even come to discover that you’ve
actually stepped foot in this dark psychological space before, perhaps
without knowing it at the time.
Step 1:
Falling Short of Standards
Most people who kill themselves actually lived better-than-average
lives. Suicide rates are higher in nations with higher standards of
living than in less prosperous nations; higher in US states with a
better quality of life; higher in societies that endorse individual
freedoms; higher in areas with better weather; in areas with seasonal
change, they are higher during the warmer seasons; and they’re higher
among college students that have better grades and parents with higher
expectations.
Baumeister argues that such idealistic conditions actually heighten
suicide risk because they often create unreasonable standards for
personal happiness, thereby rendering people more emotionally fragile
in response to unexpected setbacks. So, when things get a bit messy,
such people, many of whom appear to have led mostly privileged lives,
have a harder time coping with failures. “A large body of evidence,”
writes the author, “is consistent with the view that suicide is
preceded by events that fall short of high standards and expectations,
whether produced by past achievements, chronically favorable
circumstances, or external demands.” For example, simply being poor
isn’t a risk factor for suicide. But going rather suddenly from
relative prosperity to
poverty
has been strongly linked to suicide. Likewise, being a lifelong single
person isn’t a risk factor either, but the transition from marriage to
the single state places one at significant risk for suicide. Most
suicides that occur in prison and mental hospital settings occur within
the first month of confinement, during the initial period of adjustment
to loss of freedom. Suicide rates are lowest on Fridays and highest on
Mondays; they also drop just before the major holidays and then spike
sharply immediately after the holidays. Baumeister interprets these
patterns as consistent with the idea that people’s high expectations for
holidays and weekends materialize, after the fact, as bitter
disappointments.
To summarize this first step in the escape theory, Baumeister tells
us that, “it is apparently the size of the discrepancy between
standards and perceived reality that is crucial for initiating the
suicidal process.” It’s the proverbial law of social gravity: the
higher your majesty is to start off with, the more painful it’s going
to be when you happen to fall flat on your face.
Step 2:
Attributions to Self
It is not just the fall from grace alone that’s going to send you on
a suicidal tailspin. It’s also necessary for you to loathe yourself
for facing the trouble you find yourself in. Across cultures, “self
blame” or “condemnation of the self” has held constant as a common
denominator in suicides. Baumeister’s theory accommodates these data,
yet his model emphasizes that the biggest risk factor isn’t chronically
low
self-esteem,
per se, but rather a relatively recent demonization of the self in
response to the negative turn of events occurring in the previous step.
People who have low self-esteem are often misanthropes, he points out,
in that while they are indeed self critical, they are usually just as
critical of other people. By contrast, suicidal individuals who engage
in negative appraisals of the self seem to suffer the erroneous
impression that other people are mostly good, while they themselves are
bad. Feelings of worthlessness, shame, guilt, inadequacy, or feeling
exposed, humiliated and rejected leads suicidal people to dislike
themselves in a manner that, essentially, cleaves them off from an
idealized humanity. The self is seen as being enduringly undesirable;
there is no hope for change and the core self is perceived as being
rotten.
This is why adolescents and adults of minority sexual orientations, who
grow up
gestating in a social womb filled with messages—both implicit and
explicit—that they are essentially lesser human beings, are especially
vulnerable to suicide. Even though we may consciously reject these
personal attributions made by an intolerant society, they have still
seeped in. If we extrapolate this to, say, Tyler Clementi as he was
driving towards the George Washington Bridge to end his own life in the
wake of being cruelly and voyeuristically outed over the Internet, I’d
bet my bottom dollar that he felt even the songs on the radio weren’t
meant for him, but for “normal people” more relatable to the singer and
deserving of the song’s message.
Step 3:
High Self-Awareness
“The essence of self-awareness is comparison of self with
standards,” writes Baumeister. And, according to his escape theory, it
is this ceaseless and unforgiving comparison with a preferred
self—perhaps an irrecoverable
self
from a happier past or a goal self that is now seen as impossible to
achieve in light of recent events—fuelling suicidal ideation.
This piquancy of thought in suicidal individuals is actually
measurable, at least indirectly by analyzing the language used in
suicide notes. One well-known “suicidologist,” Edwin Shneidman, once
wrote that, “Our best route to understanding suicide is not through the
study of the structure of the brain, nor the study of social
statistics, nor the study of mental diseases, but directly through the
study of human emotions described in plain English, in the words of the
suicidal person.” Personally, I feel a bit like an existential
Peeping Tom in reading strangers’ suicide notes, but it’s a
longstanding cottage industry in psychological research. Over the past
few decades alone, nearly 300 studies on suicide notes have been
published. These cover a broad range of research questions, but because
they tend to yield inconsistent findings, they have also painted a
confusing picture of the suicidal mind.
This is especially the case when trying to reveal people’s
motivations for the act. Some who commit suicide may not even be aware
of their own motivations, or at least they have not been completely
honest in their farewell letters to the world. A good example comes
from University of Manchester sociologist Susanne Langer and her
colleagues’
report in a 2008 issue of
The Sociological Review
. The researchers describe how the suicide note written by one young
man was rather nondescript, mentioning feelings of loneliness and
emptiness as causing his suicide, while, in fact, “his file contained a
memo inquiring about the state of an investigation regarding sexual
offences the deceased had been accused of in an adjacent jurisdiction.”
The more compelling studies on suicide notes, in my view, are those
that use text analysis programs enabling the investigators to make
exact counts of particular kinds of words. Compared to fake suicide
notes, real suicide notes are notorious for containing first-person
singular pronouns, a reflection of high self-awareness. And unlike
letters written by people facing involuntary death, such as those about
to be executed, suicide note writers rarely use inclusive language
such as plural pronouns, such as “us” and “we.” When they do mention
significant others, suicide note writers usually speak of them as being
cut off, distant, separate, not understanding, or opposed. Friends and
family, even a loving mother at arm’s length, feel endless oceans
away.
Step 4:
Negative Affect
It may seem to go without saying that suicides tend to be preceded
by a period of negative emotions, but, again, in Baumeister’s escape
model, negative suicidal emotions are experienced as an acute state
rather than a prolonged one. “Concluding simply that
depression
causes suicide and leaving it at that may be inadequate for several
reasons,” he writes. “It is abundantly clear that most depressed people
do not attempt suicide and that not all suicide attempters are
clinically depressed.”
Anxiety—which can be experienced as guilt, self-blame, threat of
social exclusion, ostracism and worry—seems to be a common strand in
the majority of suicides. As I mentioned in last week’s post, we may
very well be the only species for which negative social-evaluative
appraisals can lead to shame-induced suicide. It’s not without
controversy, but the most convincing data from studies with nonhuman
animals suggest very strongly that we are the only species on the face
of the earth able to take another organism’s perspective in judging the
self’s attributes. This is owed to an evolutionary innovation known as
“theory of mind” (literally, theorizing about what someone else is
thinking about, including what they’re thinking about
you ;
and, perhaps more importantly in this case, even what you’re thinking
about you) that has been both a blessing and a curse. It’s a blessing
because it allows us to experience pride, and a curse because it also
engenders what I consider to be the
uniquely human, uniquely painful emotion of shame.
Psychodynamic theorists often postulate that suicidal guilt seeks
punishment, and thus suicide is a sort of self-execution. But
Baumeister’s theory largely rejects this interpretation; rather, in his
model, the appeal of suicide is loss of consciousness, and thus the
end of psychological pain being experienced. And since cognitive
therapy isn’t easily available—or seen as achievable—by most suicidal
people, that leaves only three ways to escape this painful
self-awareness: drugs, sleep and death. And of these, only death,
nature’s great anesthesia, offers a permanent fix.
Step 5:
Cognitive Deconstruction
The fifth step in the escape theory is perhaps the most intriguing,
from a psychological perspective, because it illustrates just how
distinct and scarily inaccessible the suicidal mind is from that of our
everyday cognition. With cognitive deconstruction, a concept
originally proposed by social psychologists Robin Vallacher and Daniel
Wegner, the outside world becomes a much simpler affair in our
heads—but usually not in a good way.
Cognitive deconstruction is pretty much just what it sounds like.
Things are cognitively broken down into increasingly low-level and
basic elements. For example, the
time perspective
of suicidal people changes in a way that makes the present moment
seem interminably long; this is because, “suicidal people have an
aversive or anxious awareness of the recent past (and possibly the
future too), from which they seek to escape into a narrow, unemotional
focus on the present moment.” In one interesting study, for example,
when compared to control groups, suicidal participants significantly
overestimated the passage of experimentally controlled intervals of
time by a large amount. Baumeister surmises, “Thus suicidal people
resemble acutely bored people: The present seems endless and vaguely
unpleasant, and whenever one checks the clock, one is surprised at how
little time has actually elapsed.”
Evidence also suggests that suicidal individuals have a difficult
time thinking about the future—which for those who’d use the threat of
hell as a deterrent, shows just why this strategy isn’t likely to be
very effective. This temporal narrowing, Baumeister believes, is
actually a defensive mechanism helping the person to cognitively
withdraw from thinking about past failures and the anxiety of an
intolerable, hopeless future.
Another central aspect of the suicidal person’s cognitive
deconstruction, says Baumeister, is a dramatic increase in concrete
thought. Like the intrusively high self-awareness discussed earlier,
this
concreteness is often conveyed in suicide notes.
Several review articles have noted the relative paucity of “thinking
words” in suicide notes, which are abstract, meaningful, high-level
terms. Instead, they more often include banal and specific
instructions, such as, “Don’t forget to feed the cat,” or “Remember to
take care of the electric bill.” Real suicide notes are usually
suspiciously void of contemplative or metaphysical thoughts, whereas
fake suicide notes, written by study participants, tend to include more
abstract or high-level terms (“Someday you’ll understand how much I
loved you” or “Always be happy”). One old study even found that genuine
suicide notes contained more references to concrete objects in the
environment—physical things—than did simulated suicide notes.
What this cognitive shift to concrete thinking reflects, suggests
Baumeister, is the brain’s attempt to slip into idle mental labor,
thereby avoiding the suffocating feelings that we’ve been describing.
Many suicidal college students, for example, exhibit a behavioral
pattern of burying themselves in dull, routine academic busywork in the
weeks beforehand, presumably to enter a sort of “emotional deadness”
which is “an end in itself.” When I was a suicidal adolescent, I
remember reading voraciously during this time; it didn’t matter what it
was that I read—mostly junk novels, in fact—since it was only to
replace my own thoughts with those of the writer’s. For the suicidal,
other people’s words can be pulled over one’s exhausting ruminations
like a seamless glove being stretched over a distractingly scarred
hand.
Even the grim, tedious details of organizing one’s own suicide can offer a welcome reprieve:
When preparing for suicide, one can finally cease to
worry about the future, for one has effectively decided that there will
be no future. The past, too, has ceased to matter, for it is nearly
ended and will no longer cause grief, worry, or anxiety. And the
imminence of death may help focus the mind on the immediate present
Step 6:
Disinhibition
We’ve now set the mental stage, but it is of course the final act
that separates suicidal ideation from an actual suicide. Baumeister
speculates that behavioral disinhibition, which is required to overcome
the intrinsic fear of causing oneself pain through death, not to
mention the anticipated suffering of loved ones left behind to grieve,
is another consequence of cognitive deconstruction. This is because it
disallows the high-level abstractions (reflecting on the inherent
“wrongness” of suicide, how others will feel, even concerns about
self-preservation) that, under normal conditions, keep us alive.
A recent theoretical
analysis
by University of Rochester psychiatrist Kimberly Van Orden and her
colleagues sheds some additional light on this component of behavioral
disinhibition. These authors point out that while there is a
considerable number of people who want to kill themselves, suicide
itself remains relatively rare. This is largely because, in addition to
suicidal desire, the individual needs the “acquired capability for
suicide,” which involves both a lowered fear of death and increased
physical pain tolerance.
Suicide hurts,
literally. One acquires this capability, according to these authors’
model, by being exposed to related conditions that systematically
habituate the individual to physical pain. For example, one of the best
predictors of suicide is a nonlethal prior suicide attempt.
But a history of other fear-inducing, physically painful experiences
also places one at risk. Physical or sexual abuse as a child, combat
exposure, and domestic abuse can also “prep” the individual for the
physical pain associated with suicidal behavior. In addition, heritable
variants of impulsivity, fearlessness and greater physical pain
tolerance may help to explain why suicidality often
runs in families.
Van Orden and her coauthors also cite some intriguing evidence that
habituation to pain is not so much generalized to just any old suicide
method, but often specific to the particular method used to end one’s
own life. For example, a study on suicides in the U.S. military branches
found that guns were most frequently associated with Army personnel
suicides, hanging and knots for those in the Navy, and falling and
heights were more common for those in the Air Force.
So there you have it. It’s really not a pretty picture. But, again, I
do hope that if you ever are unfortunate enough to experience these
cognitive dynamics in your own mind—and I, for one, very much have—or if
you suspect you’re seeing behaviors in others that indicate these
thought patterns may be occurring, that this information helps you to
meta-cognitively puncture suicidal ideation. If there is one thing that
I’ve learned since those very dark days of my suicidal years, it’s that
scientific knowledge changes perspective. And perspective changes
everything.
Everything.
And, as I mentioned at the start, always remember: You’re going to
die soon enough anyway; even if it’s a hundred years from now, that’s
still the blink of a cosmic eye. In the meantime, live like a
scientist—even a controversial one with only an ally or two in all the
world—and treat life as a grand experiment, blood, sweat, tears and
all. Bear in mind that there’s no such thing as a failed experiment—only
data.
Source:
http://blogs.scientificamerican.com/bering-in-mind/2010/10/20/being-suicidal-what-it-feels-like-to-want-to-kill-yourself/
