Guest entry: Suicide, psychiatry, and fiction

posted by Antigone Kostas, MD (psychiatry resident)

It's been insidious. Having been on vacation from psychiatry residency for a week with more time to peruse fiction selections, I have noticed a change.

At one point in a story I was reading the narrator noted that he and another guy "just ended up" peeing together behind a tree. He mentioned this detail in passing, as a segue to the conversation they had while peeing, but whoa! How does something like that happen? What happened to personal space and the fact that a whole field (without a mention of a paucity of trees) does not necessarily situate these urinals naturally next to each other? Suddenly, a major red flag appears. Details I would have normally glossed over, I now can't.

Way too much Freud.

In addition, since working in the psychiatric ER, I have learned not to dismiss things. I have learned to ask very specific questions and not to leave things to vague feelings. At first, I admit, I didn't see the point ("They're suicidal, they swallowed a bottle of pills, for god's sake hospitalize them!!"), but we can't hospitalize all the suicidal patients

¹, especially those with borderline personality disorder² when the events were just an acting out.

People with borderline personality disorder don't have a strong sense of 'wholeness.' Much of what they feel internally comes from what is going on externally, and as a result they cannot regulate their own emotions very well. They don't tolerate frustration well so they may jump from the extremes of being very angry to being okay. While they were in the throes of a very strong emotion when they tried to commit suicide, they just don't feel that way anymore. Borderlines often have multiple suicide attempts in their history and some actually do die, usually because they misjudged the lethality of their attempt, but more often the attempts are a cry for help or an acting out.

In the course of examining suicide attempts, innumerable questions arise. How serious was the attempt? How many pills did they take? What was it? For example, Benadryl is less serious. Did they take it in front of someone in a melodramatic gesture? Who found them? How were they found? Did they leave a note? A note is more serious and suggests they were not just acting in the heat of the moment. Have they attempted suicide before? What were their other suicide attempts like? Are they repetitive incidences of acting out or are they all serious attempts? Can they keep it together now in the psychiatric ER?

In the ER, as psychiatrists, we have to probe the patients' motivations at each step, study their current affect and decide whether we think they're serious about making another attempt. It can be tricky (and there's no guarantee that someone might not act unpredictably and try suicide again...), which is why we really have to make sure we probe every detail and make sure we don't miss something the patients are trying to hide.

This is the reason why now, reading fiction, if I read an odd description and the author does not explain the context or motivations of the characters, I feel like I am being duped. I cannot easily go on, gloss over for the sake of fiction, because the whole premise is false. It would never happen! There needs to be context... Instead of location location location, it's now context context context!

.....

1We can't hospitalize all the suicidal patients in part because there are too many of them.

2Borderline personality disorder is a complex syndrome and includes some of the following diagnostic criteria:

"– dramatic efforts to avoid being alone
– a pattern of intense unstable relationships
– disturbances of self-image
– self-damaging acts
– suicidal threats or gestures
– marked emotional instability
– persistent feelings of emptiness
– difficulties with controlling anger
– thoughts of persecution or episodes of dissociation”

(Robinson, David, J. Disordered personalities. Rapid Psychler Press, Michigan: 2005)