NM, a 34-year-old married woman, was videotaped pilfering small bills and change from the cash register at work. She was confronted with the evidence by her boss who told her that the police had been notified. Filled with shame, visibly distraught, she panicked. NM fled her workplace and drove straight home where she grabbed one of her husband’s hunting rifles with the intent of shooting herself in the head. When the gun bucked, the bullet shattered her humerus instead. She survived. Interviewed in the intensive care unit (ICU), NM said, “I really wanted to die and I still do. How will I face everyone when they learn what I’ve done?”
In true suicide, individuals desire immediate death. The acts they have committed and survived—or intend to commit—are potentially lethal, and they have taken no one else into confidence in discussing why death is a reasonable goal. The fact that they have not shared their plans or have not succeeded in killing themselves does not mean they are unambivalent about dying. As with NM, their actions are often impulsive. It is good clinical practice to assume that suicidal thinking or behavior in response to an acute event could prove—if effectively executed—a permanent solution to a temporary problem. Assessment can then focus on identifying remediable factors forcing the self-annihilatory fantasy or act.
Building on Gardner and Cowdry’s work,2 Jacobs and Bostwick have proposed eight scripts describing motives commonly underlying suicidal behavior. Among these motives are revenge, manipulation, shame, altruism, panic, and command hallucinations.3 Eliciting the narrative underlying the attempt or wish not only makes sense of what might otherwise appear senseless but also suggests interventions that could alleviate the suicidal urge.
Shneidman’s three-dimensional formulation of a suicidal crisis can aid in teasing out the contributors to a suicidal state.4 The three dimensions of his model are press, perturbation, and pain, dated terms that nonetheless correspond beautifully to contemporary stress-diathesis models.5 The first, press, is equivalent to diathesis, risk factors that by definition are longstanding, essentially immutable, indicative of general increased susceptibility. These include a personal or family history of affective illness, a family history of suicide, a personal history of previous attempts, active alcohol abuse or dependence, advanced age (particularly in men), and chronic, poorly managed pain. The second dimension, perturbation, is synonymous with stress, in the form of the recent onset of a noxious stimulus such as an acute depressive episode, acute pain, acute psychosis, acute loss of a significant relationship. The operative word is “acute,” superimposed upon the chronic backdrop implied in press. Finally, the third element is pain, a term encompassing the suicidal individual’s agonized mental state. Shneidman coined the word “psychache” to convey the unbearable emotional torment assailing suicidal individuals, a torment, a psychological torture they will do literally anything to escape.6 In his formulation, when press, perturbation, and pain are simultaneously operating at a fever pitch, their synergy yields a serious suicidal crisis.
Rudd makes the important observation that risk factors, by their nature static and enduring, afford little insight into whether a suicidal crisis is imminent. In line with Shneidman’s crisis model, he points out the fluid nature of intent and motivation for suicide, and calls for the assessment of warning signs indicating immediate risk. Warning signs are understood to relate to near-term danger—measured in minutes, hours, days—that rapidly evolve as the elements coalesce into an event, a suicide attempt.7,8 In NM’s case she has reacted to a potent trigger, an accusation of thievery, with instant panic. Her visible distress is a warning sign, as is her flight with only one intention: to lay her hands on the gun she needs to extinguish the shame and fear flooding her consciousness. Her tunnel vision is also a warning sign. It goaded her into seeing killing herself as the only possible alternative she had to her psychache.
It is critical to recognize that if the patient survives long enough, two of the three “p’s” can be mitigated, either through psychosocial or pharmacological interventions. Helping patients explore and understand what is behind their crises may aid them, both by giving voice to suicidal feelings that ebb when transformed into cognitions and by identifying problems that—once addressed—lose their power to fuel a deadly escape. For example, NM tells a sympathetic listener that she believes she will inevitably be incarcerated “for years, for decades for my crime.” Her distress dissipates upon learning that the police plan only to charge her with a misdemeanor, and the punishment for a first offender will likely be minimal.
While much is made of depression’s role in suicidal crises, definitive treatment of depressive episodes—if present—cannot be accomplished in the short term. However, judicious deployment of anti-psychotic or anxiolytic medication can nearly immediately mute the emotional upheaval of psychache. Likewise opiates or other analgesics may vanquish unbearable pain. Indeed medication administration may make it possible for an initially incoherent patient to become calm enough to tell their story.
In a case-control study, Shekunov and colleagues reviewed eight suicide attempts made by inpatients while hospitalized on Mayo Clinic medical or surgical units. They found cases differing from controls in that the former were more likely both to have psychiatric histories and to have had inpatient psychiatric consultation prior to the attempt. The agitation, impulsiveness, and disinhibition of delirium have long been known to raise the risk of self-injurious behavior in hospitalized patients.9 For hyperactive delirious states, close observation and neuroleptic medication can prevent quasi-suicidal acts. They also found that such remediable conditions as pain, anxiety, and insomnia were present in all attempters.7 They emphasized that attention to these issues in all patients constitutes both good medical practice and potential suicide prevention. Ultimately addressing what can be changed holds real promise of defusing the combustibility of a suicide crisis.