Jonathan E. Prousky, ND, MSc, MA

Naturopathic Perspective

The first several minutes of the 2006 documentary, The Bridge,¹ features what appears to be a rather idyllic day in San Francisco. The sky is blue and the Golden Gate Bridge is filled with sightseers and commuters. Among them is a man wearing a burgundy hat, green T-shirt, and jeans. He looks to be in his 60s or perhaps early 70s. The man approaches the rails of the bridge, seems to ponder for a moment, then brings his legs over the rails to the other side. He stands facing outward and balances himself while holding onto the railing with his hands, pauses for a couple of seconds, and then jumps. You see the man falling forward, with his body horizontally positioned as he plummets to his death. This suicide is so harrowing to watch, and yet I have often wondered: what must have been going on in this man’s life to result in such a tragic decision? What must it be like to be in that state of Existenz² – a boundary situation placing one at their personal limits – and then choosing death because life had become so tormenting and insurmountable?

The aim of this paper is to illuminate some of the phenomenology of suicide and, in so doing, to provide the practicing clinician with a better understanding of what suicidal people might be experiencing when they are at their personal limits. I will also describe salient risk factors that we clinicians should be attentive to when trying to provide a lifeline to vulnerable patients.

Psychache

When thinking about why people die by suicide, I am struck by the darkness, hopelessness, and unending frustration that these people must have experienced. My words cannot in any manner describe the painful and hellish existence that each of them must have endured prior to deciding that death was their best and only option. This kind of unrelenting psychological pain, known as psychache, is characterized by general psychological and emotional pain that reaches an intensity so intolerable that killing oneself seems like a viable option.³ It is considered to be an introspective, dysphoric experience that is sustained by unattainable or unmet psychological needs.^3,4

While unremitting psychache is intellectually understandable, it is difficult for most people to comprehend having impulses strong enough to end one’s life – impulses that would have to yield so much more power compared to the usual momentum that matter-of-factly (albeit, mostly unconsciously) sustains life and keeps it going. Is a complete lack of self-love to blame? Does it come down to having such abject self-loathing and self-hatred that utter annihilation makes sense? Sometimes I have even had the thought that suicide might be the ultimate act of fearlessness, since before killing oneself, the person would have the complete realization that his or her life will end, ie, consciously entering into the unknown abyss of death. Most of the time, however, just thinking about death terrifies people, and the ensuing anxiety about death drives both maladaptive and adaptive behaviors.

From an existential perspective, inner conflict arises “between awareness of inevitable death and the simultaneous wish to continue to live” (p.276).⁵ To alleviate the impact of this potentially terrifying reality, most people “erect defenses against death awareness” that can be maladaptive because of “failed death transcendence,” and which result in clinically apparent maladjustment (p.276).⁵ Is the actual act of suicide the ultimate in maladaptive death transcendence? I have no idea, and yet the awareness of death can also be a life-sustaining force, as noted by Yalom in this beautifully written, yet simple prophetic passage: “…although the physicality of death destroys man, the idea of death saves him” (p.30).⁶

When people purposely end their lives, their confrontation with death is not the least bit life-sustaining. Why not? Research has looked at this issue closely, and has determined that a myriad of factors –  personality factors, cognitive factors, social factors, and adverse life events – play a role in a person’s ability to die by suicide, or rather, in the psychology of suicide. Over the next several paragraphs, I will highlight the many factors that contribute to suicidal behavior, as described in more detail by O’Connor and Nock in their comprehensive review article.⁷

Risk Factors & Adverse Life Events

It is commonly known that having a mental disorder, or having a history of mental disorder diagnoses, is a risk factor for suicide. And yet, the mere presence and/or history of having mental disorders does not explain why people die by suicide. There are personality factors that do increase suicidality, but few are known to be reliably responsible for the actual action of suicide. Hopelessness, for instance, is considered a risk factor for suicidal ideation, but having this mindset does not predict suicide attempts or deaths. Self-reported impulsivity, on the other hand, is associated with suicide attempts, with impulsive-aggression possessing the strongest link to suicide attempts. Another personality factor, “socially prescribed perfectionism” (ie, holding the belief that other people hold unrealistically high expectations of you), is associated with suicide attempts, and becomes even more of a risk factor when “socially determined beliefs are internalized as self-criticism” (p.4).⁷ There are other personality dimensions – eg, low extraversion and high neuroticism – that increase the risk of suicide, and which describe socially disconnected people who are also highly sensitive to distress.

With respect to cognitive factors, there are numerous thought processes that contribute to suicidality and perhaps to suicide attempts as well. One such factor is cognitive rigidity, which happens when a person lacks the ability to flexibly alter decision-making such that suicide remains a highly viable option. Brooding rumination characterizes someone who cannot stop dwelling on his symptoms, and this too is a potential risk factor for suicide. Another cognitive factor – thought suppression – describes the paradoxical increase in distress and suicidality that happens to vulnerable people when they try to suppress their unwanted thoughts. There is even something known as autobiographical memory biases that describes people who cannot recall specific personal memories; this in turn diminishes their present ability to have positive thoughts about the future while also limiting effective problem-solving. Not feeling a sense of belonging or social connectedness while simultaneously feeling like a burden to others is another risk factor for suicidal ideation and, possibly, suicide attempts. There is also evidence suggesting that higher fearlessness about death combined with a higher pain threshold increases suicidal ideation, and perhaps suicidal behavior. Experiencing agitation also increases suicidal ideation, which describes a disinhibited or extremely excited and anxious state of being.

Mentally connecting one’s existence to death is an implicit association that can drive suicidal ideation, similar to having one’s attention becoming more and more preoccupied with (or attentionally biased toward) suicide. Not seeing a positive future and not having personal goals can drive suicidal behavior. This type of thinking is similar to having few reasons to live, which can also trigger suicidal behavior. Feeling like a burden to others (ie, perceived burdensomeness) increases suicidal ideation, especially when combined with perfectionism. Lastly, feeling defeated and trapped, and thus being unable to “escape from defeating or stressful circumstances,” increases suicidal thoughts and might also be associated with increased suicide attempts (p.7).⁷

From a larger social perspective, a family history of suicide increases suicide risk, as does being exposed to suicidal behavior exhibited by family and/or friends. Being socially isolated and not having an adequate amount of social support will increase suicide risk. There might even be a risk of suicide in vulnerable people exposed to depictions of suicide in the media, which has been associated with increased self-harming behavior.⁸

There is also a clear connection between negative life events and vulnerability toward suicide. In fact, there is a dose-response relationship between the amount of childhood adversities (eg, emotional, physical, or sexual abuse) and subsequent risk of suicide attempts. Experiencing tragic life events during adulthood (eg, sexual or physical abuse, death of a loved one, disasters, or accidents), even without any history of adverse childhood experiences, can also increase suicidal behavior; this too follows a dose-response relationship, in that more traumatic events result in increased suicidal risk. Finally, physical illness (eg, chronic pain) can be associated with suicidal behavior, although it is unclear whether this is caused by depression resulting from having a physical illness, or from the physical illness itself.

Explanatory Models of Suicide

Given the complexity (and uncertainties) about the underlying mechanisms that drive suicidal behavior, how do these factors tip the balance and result in a person attempting suicide or dying by it? Many theories that attempt to explain suicidal behavior rely on something known as the diathesis-stress model.⁷ Models that hold this perspective assert that some combination of vulnerabilities (ie, many of the factors described earlier) and stress or stressful life experience results in emotional overwhelm and possibly suicide attempts, or even completed suicides. Another theory – the integrated motivational-volitional model of suicidal behavior – describes the motivational phase encompassing specific factors “that govern the development of suicidal ideation and intent, whereas the volitional phase outlines the factors that determine whether an individual attempts suicide” (p.3).⁷

I have regrettably worked with 5 patients (that I am aware of) that died by suicide. One patient, that I shall identify as Veronica, possessed personality, cognitive, and physical vulnerabilities (ie, hopelessness, pessimism, severe anxiety, not seeing a positive future, feeling defeated and entrapped, and dealing with a chronic physical illness) that, when combined with the stress of never feeling physically or mentally well, resulted in significant enough emotional overwhelm to make suicide a viable option. Similarly, and from the motivational-volitional perspective, a patient, that I shall name Jordan, possessed numerous motivational factors that likely contributed to suicidal ideation (ie, hopelessness, anxiety, perfectionism, high neuroticism and low extraversion, cognitive rigidity, brooding ruminations, thought suppression, and feeling trapped and defeated) that, when combined with high levels of perceived burdensomeness, provided enough volitional energy to seriously attempt and die by a suicide.

Another explanatory model that has gained prominence in the suicidology literature is known as the “Interpersonal Theory of Suicide.”^9,10 This model describes how perceived burdensomeness, thwarted belongingness, and fearlessness (ie, those more capable of suicide) give rise to an increased probability of dying by suicide. This model has a lot of empirical support and speaks to the suicide vulnerability that happens when a person lacks social ties and connections (ie, a dysregulation of social forces) and feels like a burden to the important others in their life (ie, a self-hatred, self-loathing, or heightened distressful state, which develops when one feels like he/she is making life worse for close others). When these factors are then combined with being fearless (ie, losing some of the fear associated with suicide behaviors), the unfortunate possibility is a much greater likelihood of suicide.

Such vulnerable people will tend to present with a grossly diminished blink reflex, and often present with a deadpan-type stare or gaze.¹⁰ Most people blink once every 3 to 4 seconds (give or take), but should you notice a grossly diminished blink reflex in a vulnerable person, you ought to be concerned. When someone is getting ready to die by suicide, they need to biologically prepare for fear and to actually engage in a behavior that threatens their survivability. The lack of normal blinking is just an overt manifestation of the type of readiness and resolve needed to assuage fear. Thus, it might be worthwhile to simply ask suicidal patients if they feel like a burden to others, if they have lost or lack social ties in their life, and if they are fearless of their own death. Of course, take note of their blinking rate.

Conclusion

Most people that tragically die by suicide possess many of the aforementioned risk factors. It is also likely that many such people experienced adverse childhood events, or perhaps had experiences in adulthood that they would have deemed to be traumatic, and these too would increase their suicide risk. In addition, several theories have been described to explain why people engage in suicidal behavior. Notwithstanding these “speculative” truths, it still remains somewhat of a mystery as to why some people die by suicide while others do not.

References:

1. The Bridge 2006. [Video]. YouTube Web site. https://www.youtube.com/watch?v=pnsj7mwXnLY. Published August 20, 2017. Accessed October 14, 2017.
2. Fuchs T. Existential vulnerability: toward a psychopathology of limit solutions. Psychopathology. 2013;46(5):301-308.
3. Shneidman ES. Perspectives on suicidology. Further reflections on suicide and psychache. Suicide Life Threat Behav. 1998;28(3):245-250.
4. Shneidman ES. The psychological pain assessment scale. Suicide Life Threat Behav. 1999;29(4):287-294.
5. Yalom ID, Josselson R. Existential Psychotherapy. In: Wedding D, Corsini RJ, eds. Current Psychotherapies. 10th ed. Belmont, CA: Brooks/Cole, Cengage; 2014: 265-298.
6. Yalom ID. Existential Psychotherapy. New York, NY: Basic Books, Inc; 1980.
7. O’Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry. 2014;1(1):73-85.
8. Pirkis J, Nordentoft M. Media Influences on Suicide and Attempted Suicide. In: O’Connor RC, Platt S, Gordon J, eds. International Handbook of Suicide Prevention: Research, Policy and Practice. Chichester, England: John Wiley & Sons; 2011: 531-544.
9. Van Order KA, Witte TK, Cukrowicz KC, et al. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600.
10. Joiner TE. Why do people die by suicide? [Video]. YouTube Web site. https://www.youtube.com/watch?v=DESRIZtUIT4. Published February 4, 2016. Accessed October 19, 2017.

Photo by ANMOL on Unsplash

Jonathan E. Prousky, ND, MSc, MA, graduated from Bastyr University in 1998 with a Doctorate in Naturopathic Medicine. Dr Prousky then completed a Family Practice residency sponsored by NCNM. In 2008 he obtained an MSc degree in International Primary Health Care from the University of London, and in 2016 he obtained an MA degree in Counselling Psychology from Yorkville University. He is currently the Chief Naturopathic Medical Officer at CCNM. Dr Prousky was the first ND to receive the “Orthomolecular Doctor of the Year” award in 2010, and was also the first ND to be recognized in 2017 for his longstanding commitment to mental health by being inducted into the “Orthomolecular Hall of Fame.”