More On Conscious States and Suicide

“Did you remember all of that noise I was making in the bathroom?  I was trying to kill myself.”

The person I was talking with had been discharged from a hospital about two months ago.  He was admitted there because of an exacerbation of a mood disorder and possible psychosis. The main reason he was admitted from the emergency department was suicidal ideation. That is the most frequent indication for hospital admissions in the United States. Even then who does and does not get admitted is controversial. It is common for persons to be sent to the emergency department by their families or outlying facilities where there are legitimate concerns only have the patient deny the problem and get released from the hospital. There is a lot of drama involved because one of the decision points is whether or not suicidal person needs to be placed on legal hold and treated on an involuntary basis. This frequently leads to speculation about the true nature of what a person says or alternatively accepting "no suicidal thinking" at face value and dismissing them. 

I think it also highlights the significant limitations of interviewing people and adequately    understanding their conscious state. The best example is the rating scale approach which is really somebody’s idea of what the optimal interview questions might be to assess a suicidal person. The commonest depression checklist is the PHQ-9 (1).  Item 9 in the PHQ 9 involves suicidal thinking and the rating is as follows:

Thoughts that you would be better off dead, or of hurting yourself	0 – not at all
	1 - several days
	2 - more than half the days
	3 - nearly every day

Depending on where you practice clinics have different conventions about this item and how it needs to be approached. Any elevation usually leads to a more intensive assessment of suicide potential. That typically involves a clinical interview but also could involve the use of another checklist. It should be apparent that this item is a focused on the approximate frequency of suicidal thinking. It assumes that the patient can actually report this and that it is more significant than other metrics like the intensity of thinking. For example, is one extremely intense thought about suicide more significant and potentially lethal than thinking about it frequently but easily dismissing those thoughts? This is one of the basic limitations of any assessment of the person’s mental status. Clinical interviews and rating scales are very crude approximations of a person’s conscious state. Assessing someone’s potential for suicide is a clear example. There is also the notion of rating scales being “quantitative” measures and they are not. There is an entire field of research suggesting that these “measurements” lead to greater precision and I doubt that is true.

All of that brings me back to the first patient. Here he is somewhat annoyed that nobody seemed to realize on an inpatient psychiatric unit that he was trying to kill himself. At the same time he made every effort to conceal that fact while he was hospitalized. He only disclosed it months later after his mood and associated cognitive processes had stabilized. It reminds me that I also have talked with many people who were intent on killing themselves and presented themselves as being very well so that they could be discharged and attempt suicide. The popular literature is full of stories about people who reassured their families or appeared to be doing well only to carry out a planned suicide attempt. This is clearly a high risk conscious state that can escape detection and lead to very high risk attempt or death.

“The gun just went off.”

I talked to many survivors of gunshot wounds that were self-inflicted. In large trauma hospitals, psychiatrists are consulted by surgery services who have successfully treated the patient. The psychiatrists job is to assess the patient and determine whether or not they need further acute psychiatric care or they can be discharged home. I generally ask for a very detailed description of what happened including the type of firearm used, the time of day, the associated thought process, the overall psychiatric context, and the sequence of events just before the firearm goes off. The common explanation that I have heard is a recollection that someone was pointing a loaded gun at themselves and that at some point it "just went off". There is no recollection of a conscious effort to pull the trigger. Numerous secondary analyses are possible including that it is just a rationalization against self-harm or an attempt to avert psychiatric hospitalization. In keeping with the theme of this post - there is also a possibility that the patient’s conscious state at the time of the suicide attempt was so chaotic that it cannot be recalled or reconstructed. There is precedent for that state and that is delusional depression. If the patient is clearly delusional all of the usual deterrents like fear of dying, intense dislike of pain, not wanting to harm the family, and religious beliefs no longer apply. The standard risk analysis for suicidal thinking no longer applies. There is a delusional process with associated emotions that lead to very high suicide risk.

“I felt real bad about what happened 50 years ago and so I stabbed myself.”

The delusional process can be very subtle. Psychiatrists are typically taught to pay attention to hallucinations and classic forms of delusions. Those types of psychotic thinking are fairly obvious. In the case of depression and some forms of psychosis the delusion can be very subtle. An example might be feeling guilty about a trivial event from a long time ago. Everyone can relate to that kind of guilt or embarrassment but what if it is suddenly linked to the idea that death is preferred to the emotional burden of that trivial event. People in their 50s, 60s, and 70s could focus on events that happened when they were in middle school or high school that might start to disrupt their lives and lead to suicidal thinking. In the example given a severe suicide attempt occurred by self-inflicted stab wound over a trivial incident happening in the eighth grade. The patient was unable to recognize that this was a delusional thought process until the depression and psychosis had been adequately treated.

These examples all highlight how a person can go from being no risk at all for suicidal behavior to being at very high risk. The changes are subtle and they might not be apparent to the person experiencing them. The risk analysis models that are used are all linear and additive and do not capture the conscious states of people who become suicidal. The limited consciousness theories that we currently have would suggest that it is really not possible to experience the conscious state of another person in the transition to high suicide risk is probably a good example.  Even the best possible definition of empathy fails if the person cannot recognize the state that the psychiatrist is trying to reflect back to them. 

Time domain is another perspective on the fluidity of conscious states both in the case of suicidal thinking and substance use disorders. It is common for a person to describe themselves as becoming a person that they never wanted to be associated with both substance use disorders and suicidal thinking.  They are able to see those patterns in retrospect but not at the times they occur.   

It may be apparent that suicidal thinking can be a transition from a questionable belief to certainty. I listed a few of these beliefs in a previous post. A common one is “people would be better off without me”. In the early stages most people can examine that thought and conclude that it is at least partially false based on their relationships to the people in question and the assessment of their realistic value to those people. With time and continued emotional intensity any objective assessment of their value in relationships might diminish and disappear. At that point they are in a very high-risk state because they believe in the statement that “people would be better off without me”. Clinicians are often taught to ask about deterrence to suicidal ideation, but they are rarely taught to assess the degree of belief a person has in high-risk suicidal thinking.  There are non known ways to determine is a person who is delusional or quasi-delusional about suicidal thoughts is disclosing those thoughts or hiding them.

What can clinicians and patient do in these circumstances?  My previous posts suggests that an analysis of the thought patterns can be useful. I routinely review those ideas with people I see who have suicidal thoughts.  At some point the goal would be to see if talking about suicidal thoughts in this way would improve the level of resistance to these thoughts and make it less likely that people will act on them. I also believe that a public health message should discuss the same approach,  So far the only public health measure seems to be advice on calling suicide hotlines or crisis lines. 

I have had several people who I know as friends let me know that they have been able to analyze these thoughts on their own and come up solutions to contain these thoughts and get enough emotional distance from them to the point that they were no longer bothersome.  I know it can be done and encourage public health officials to take it to the next step.   

In closing, this post emphasizes a unique conscious state or states associated with suicidal ideation and suicide attempts. Nothing in this post should be construed as interview or treatment suggestions.  A more comprehensive understanding of  suicidal thinking and behavior requires more than a rating scale approach or risk factor analysis.

George Dawson, MD, DFAPA

References:

1.  PHQ-9 is copyrighted by Pfizer, Inc. Full rating scale is visible at many sites by searching on PHQ-9.  https://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+20219811