Breaking Through to a Suicidal Mind
When I first started my psychiatric practice many years ago I specialized in intervening with and treating suicidal patients. That’s largely because one of my first mentors, Dr. Edwin Shneidman, who was a pioneer in the study and treatment of suicidal individuals and their families, would do consultations to still-suicidal patients (but not acutely so) who couldn’t be discharged from the inpatient wards of UCLA unless an outside psychiatrist would agree to see them. For many of those patients that outside psychiatrist was me.
Because they were still suicidal, it enabled me to be innovative in dealing with them. After a while what became apparent to me regarding many of them was how their suicidal thinking was more often connected to des-pair than depression.
By that I mean they felt unpaired with hope, i.e. hopeless; with worth, i.e. worthless; help, i.e. helpless; meaningless, useless, pointless, etc. I think you get the point. And when they felt unpaired with all of these at the same time, they paired with death as a way to make the pain go away.
Upon discovering this I realized that if I could pair with them in their des-pair and cause them to feel felt by me and less alone, they might pair with me, instead of dead. And they might give up their suicidality, which most of them did.
To pair with them I found the following questions very helpful which often generated the subsequent answers:
- “At the worst that you can feel, how bad does that get?” Answer: “Horrible.”
- “When you’ve felt how bad it could get, how often did you feel alone?” Answer: “Always.”
- “And when you were feeling that horrible and alone with it, what did it make you think and want to do?” Answer: “I can’t take it anymore and I have to end the pain.”
- “And what did you do?” Answer: “I tried to kill myself” or “I just somehow stopped before I did something self-destructive.”
- “If that is the case, I don’t want you to be alone with those thoughts and feelings. So I’m asking you to call me when you are feeling that way and I will do my best to listen to, hear you and keep you company. I promise, I’m not going to give you advice or solutions unless you ask me for them. So would you be willing to call me when you’re feeling like that? And by the way, if you think you’re a burden, you’re not. You’re not a burden because inside you I can see and feel the good person that you are and also that you matter neither of which you can see or feel when you’re feeling so awful.” Answer: They often began to cry with relief and with that their suicidal thoughts and feelings often lessen.
Pain is pain; suffering is feeling alone in pain. When you eliminate the aloneness, suffering that people can’t live with becomes pain they can.
“Researchers say their findings may being us closer to a drug that can prevent suicidal behavior.”
In the journal Translational Psychiatry, researchers reveal how a certain variant of the enzyme ACMSD leads to abnormal levels of two acids in the brain, which may encourage suicidal behavior.
The research team – including senior author Dr. Lena Brundin of the Center for Neurodegenerative Science at Van Andel Research Institute in Grand Rapids, MI – say their findings could bring us closer to a blood test that can identify patients at high risk of suicide.
What is more, the study suggests ACMSD could be a promising drug target for suicide prevention.
However, the underlying mechanisms of this association have been unclear, which has hampered the discovery of clinical strategies to prevent suicide. The new study aimed to shed some light.
Past studies have shown patients with suicidal behavior experience persistent inflammation in their blood and cerebrospinal fluid (CSF).
With this in mind, the researchers assessed the blood and CSF samples of more than 300 individuals from Sweden, some of whom had attempted suicide.
ACMSD enzyme variant more prevalent in people with suicidal behavior
On comparing samples, the team found that individuals who had attempted suicide had abnormal levels of both picolinic acid and quinolinic acid. These irregular acid levels were identifiable in samples taken straight after a suicidal attempt and at various points over the subsequent 2 years.
Among subjects with suicidal behavior, levels of picolinic acid – known to have neuroprotective effects – were too low, while their levels of quinolinic acid – a known neurotoxin – were too high.
These abnormal levels were most prominent in CSF, the team reports, though they could still be identified in blood samples.
Since previous research had shown that both picolinic and quinolinic acid are regulated by the enzyme ACMSD – known to regulate brain inflammation – the researchers conducted a genetic analysis of individuals with suicidal behavior, as well as healthy controls.
From this, they found that individuals who had attempted suicide were more likely to possess a specific variant of ACMSD, and this variant was associated with increased levels of quinolinic acid.
While the study is unable to demonstrate that ACMSD activity is directly linked to suicide risk, the researchers say their findings suggest the enzyme could be a potential drug target for suicide prevention.
“We now want to find out if these changes are only seen in individuals with suicidal thoughts or if patients with severe depression also exhibit this. We also want to develop drugs that might activate the enzyme ACMSD and thus restore balance between quinolinic and picolinic acid.”
Co-study leader Dr. Sophie Erhardt, Karolinska Institutet, Sweden
Additionally, since the results show that abnormal levels of picolinic and quinolinic acid can be identified in the blood, the team says they may bring us closer to a blood test that can identify patients at high risk of suicidal behavior.
Anxiety in Grief
Think of something that scares you. Perhaps it’s the thought of giving a speech in front of a crowd, taking a test, asking your crush out on a date, or jumping out of an airplane. Even if you’re mostly fearless, everyone’s got something.
Now think about the thoughts and sensations you typically experience right before doing this thing that scares you; this is your fear and anxiety at work. Maybe your stomach starts doing cartwheels, your heart begins to race, or your breathing becomes rapid. Perhaps your thoughts start running through all the worst potential outcomes and you think to yourself…
“There’s still time. I could still run from this situation.”
I know you know what I’m talking about. Even the bravest people feel fear and anxiety, they just know how to navigate the experience more exquisitely than most.
Are you still with me? Okay good, now take a second and think backwards to a time when you experienced the thoughts and sensations of fear and anxiety in your grief. Maybe this isn’t one particularly traumatic moment, but a prolonged period of time when you experienced ongoing apprehension and worry, upon worry, upon worry.
Using a personal example, I remember feeling panic-like anxiety when my father told me of my mother’s terminal cancer diagnosis, and then the slow hum of persistent anxiety in the weeks and months afterwards as my family frantically searched for treatments and clinical trials. For one year I held my breath and prepared for the worst, knowing that my mother’s death was not a possibility but a probability.
People experience anxiety after the death of a loved one for a number of reasons and, you guessed it, we’d like to discuss a few of them here today.
After the death of a loved one, you may experience anxiety because…
…you are trying to avoid unpleasant thoughts, memories, and emotions.
I want to start by discussing avoidance because the act of avoidance is involved in perpetuating all of the scenarios to follow. When we talk about avoidance in grief we are usually referring to experiential avoidance. As we noted in a previous article about avoidance…
“Experiential avoidance is an attempt to block out, reduce or change unpleasant thoughts, emotions or bodily sensations. These are internal experiences that are perceived to be painful or threatening and might include fears of losing control, being embarrassed, or physical harm and thoughts and feelings including shame, guilt, hopelessness, meaninglessness, separation, isolation, etc. Now please note I say “perceive to be painful or threatening,” these judgements are often subjective and what is perceived as threatening to one may seem totally irrational to another.”
Although grief is always unpleasant and uncomfortable, for some there are aspects that actually seem threatening and these perceptions can lead to attempts to control or avoid frightening feelings and reactions. Although avoidance can be useful in certain scenarios, for many it can become a harmful cycle that persists to the detriment of personal healing.
Many mistakenly think that if they make efforts to avoid their feelings for long enough these unpleasant emotions will be kept at bay or fade away, when in actuality deliberate attempts to suppress certain thoughts often make them more likely to surface. Avoidance is a large factor in the development and maintenance of anxiety.
…it’s a learned response.
There may be elements of your loved one’s death that, in the moment, you perceived as traumatic and terrifying. (We’ve written on traumatic grief before, you can find that article here) One of the quickest routes to acquiring fear and anxiety towards an object or situation is through a direct, negative experience.
When something traumatic happens the thoughts, emotions and sensations experienced in that moment can become paired with objects and situations associated with the event. Psychologists call this phenomena, Classical Conditioning.
Here’s an example, a parent’s phone rings at 5am and the person on the other end tells them that their son unexpectedly died in a car accident the night before (I’m sorry if this situation hits too close to home). Before this moment a phone ringing in the morning might not have given the parent a second thought, but now every time the phone rings before 8am the parent feels a temporary surge of panic.
Many people can pinpoint at least one thing that, since their loss, makes them feel anxious in ways it never did before.
…you fear grief emotion
The relationship you have with your emotions is complicated and nuanced. People begin learning about emotion from a very early age through learning and observation. Beliefs about emotion can be impacted by many factors, but some common influences include…
- Adult role models (what they told us and how they handled emotions themselves)
- Cultural and societal messages and norms
- Television, books, and movies
- Personal experience
The death of a loved can evoke such new and distressing emotions that test your existing understanding of emotion.
After a death mourners often feel as though they are going crazy. If a person interprets their symptoms as dangerous, threatening, or indicative of a larger mental or physical problem, they are more likely to fear their reactions. Those who fear grief responses and grief related emotions (i.e. fear of emotion and anxiety themselves), will likely experience increased feelings of anxiety in a world where emotion is unpredictable and easily triggered. Those who are fearful of their reactions may also engage in maladaptive and persistent avoidance of triggers or reminders of the death or of their loved one, which can prevent the mourner from learning to cope with their thoughts, emotions, and memories, and contribute to the development of ongoing anxiety.
…you aren’t confident in your ability to cope
A person may also experience anxiety if they have little confidence in their ability to cope with their emotions, either because they feel their coping skills aren’t sufficient enough or because they feel that they can’t control their emotions. As noted by Abramowitz, Deacon, and Whiteside (2012),
“Clinically anxious patients typically underestimate their capacity to control or cope with perceived threats, as well as their fear reaction to such threats.”
Although only some people will experience anxiety that would be considered “clinically anxious”, it’s normal to feel anxious about experiencing new emotions, grief triggers, and painful memories. For this reason, we caution people from resisting to temptation to chronically avoid, and encourage people to search for the coping tools that will help them deal with their grief little-by-little.
…you now know bad things can happen.
Prior to your loved one’s death you may have assumed that the world was a good and benevolent place where things happened for a reason. You may have also subconsciously believed that bad things wouldn’t happen to you. When something bad did happen your assumptions about the world became shattered and the world turned upside down. Depending on your understanding of what happened to you and your loved one, you may now hold new beliefs or engage in modes of thinking that contribute to feelings of anxiety such as probably overestimation, cost overestimation, and intolerance of uncertainty.
Probability overestimation: You may overestimate the likelihood of bad things happening. Perhaps you overestimate the likelihood of the event that led to your loved ones death, like cancer, accidents, or violence, happening to you or to other loved ones. Or perhaps your loved one’s death led to the belief that bad things can happen to anyone at any time and now you feel that disaster is likely to strike at any moment.
Cost overestimation: Cost overestimation occurs when someone believes that the consequences of something happening will be worse than they truly are. For example, you may worry that if you encounter a grief trigger in public you will become emotional and lose control in front of everyone and that this will be a mortifying experience. Because you believe that the pain of experiencing this event is so excruciating, you may feel anxiety over the possibility of it happening and engage in avoidance to prevent it. However, by never allowing yourself to experience the event, you are never able to learn that (1) the cost isn’t as high as you assumed and (2) you are capable of coping with the experience.
Intolerance of uncertainty: Some people have a very hard time dealing with even the remote possibility of something bad happening. Even if the odds of an event occurring are very low, the uncertainty of whether it will happen is enough to cause intense anxiety and distress.
Many of you have learned first hand that worst case, low probability, scenarios can happen, so it may be futile for anyone to tell you to take comfort in the likelihood that these things won’t happen. As someone who has experienced the unlikely, the task for you becomes learning to live in an unpredictable world that you can’t completely control.
…you don’t want to find yourself caught of guard.
There an interesting theory put forth by Michelle Newman and Sandra Llera (2011) to explain worry and avoidance in Generalized Anxiety Disorder (GAD) called the Contrast-Avoidance Model. Newman and Llera (2011) theorize that people with GAD, “…use worry as a coping strategy because they prefer to feel chronically distressed in order to prepare for the worst outcome, rather than to experience a shift from a positive or euthymic state to a negative emotion.”
Newman and Llera (2011) point out, that worry preceding a negative event provides protection from experiencing a drastic increase in negative emotions when the event happens. This makes sense if you think about it because our society promotes worry all the time. We say things like, “brace yourself,” and “don’t let your guard down,” which translates to, “don’t let something bad happen when you least expect it.
…you are experiencing an anxiety disorder or post-traumatic stress disorder
Anxiety disorders are one of the most common mental health disorders. Logically, many people who already struggle with anxiety will experience grief. For others, the death of a loved one may lead to new and unfamiliar struggles with anxiety.
While it’s normal to experience a sense of fear and apprehension during times of hardship and high stress, if you feel that you are experiencing excessive worry and panic in the absence of an actual threat and for a prolonged period of time then you might want to speak to a mental health professional. Your situation is unique and the best way to truly understand your anxiety related experiences is to speak to a trained mental health professional in a one-on-one capacity. That said, here are some articles that you may find helpful.
Google the phrase “mentally ill” and you’ll find the following: “Mentally Ill Man’s Shooting Fits Troubling Pattern.” “Solitary Confinement Out for Mentally Ill?” “Chicago Police to Receive New Training on How to Assist Mentally Ill.”
And so on. There’s a potentially troubling subtext to these headlines, in that it makes “the mentally ill” sound like a separate subset of the population. The fact is, however, that mental illness — which is itself a huge umbrella covering everything from depression to schizophrenia to bipolar disorder and more — affects one in five American adults (or more than 43 million people 18 and over), according to the National Alliance on Mental Illness. Now new research makes the case that simply using the phrase “the mentally ill” may be inadvertently promoting a dangerous level of intolerance.
Darcy Haag Granello and Todd A. Gibbs at the Ohio State University just released a paper in The Journal of Counseling & Development looking at this issue. They took more than 600 people — undergraduate students, adults, and counselors-in-training — and used the Community Attitudes Towards the Mentally Ill (CAMI) survey. The one twist: Half of the respondents got statements associated with “the mentally ill,” and the other half got the exact same statements with “people with mental illnesses” instead. When the phrase “the mentally ill” was used, different groups showed different levels of intolerance. College students are more likely to believe that people with mental illnesses should be controlled and isolated. Adults, on the other hand, are less empathetic or “benevolent” to those suffering from mental illness and are more likely to want to have them separated from the “normal” community.
What’s most surprising is the reaction that counselors have when the phrase “the mentally ill” is used: They’re more likely to believe that those suffering from mental illness should be controlled and isolated from the rest of the community. That’s pretty surprising, given that these counselors are perhaps the ones most likely to be aware of the special needs and varying differences in diagnoses of the group.
Counselors also showed the largest differences in how intolerant they were based on the language, which boosted the researchers’ belief that simply changing language is important in not only understanding people who suffer from mental illness but also helping them adjust and cope. “Even counselors who work every day with people who have mental illness can be affected by language,” Granello said in a press release. “They need to be aware of how language might influence their decision-making when they work with clients.”
The concept of changing the way we refer to people with mental illnesses dates back to the “person-first” (sometimes referred to as “people-first”) movement of the 1990s, when advocates argued that defining a person by their disability robbed them of their personhood and their identity. “When you say ‘people with mental illness,’ you are emphasizing that they aren’t defined solely by their disability,” Gibbs said. “But when you talk about ‘the mentally ill’ the disability is the entire definition of the person.” Despite the “person-first” movement of the 1990s, Granello and Gibbs’s study is the first one to look at how language affects how we perceive this population.
Granello is hesitant to say that a conclusion can be drawn from this, that it was too early to draw definitive conclusions about how different populations responded to the phrase “the mentally ill.” The study participants were mostly white Americans; race might have a huge factor to play. And the authors note that gender could also play a role in a person’s conception of another person with mental illness.
That said, a simple change in our language, while admittedly “cumbersome,” is something that is important to not only give people with mental illness recognition of the fact that they are more than their condition, but also a way to help them integrate into society. “The important point to take away is that no one, at least in our study, was immune,” Granello said in the news release, pointing to how counselors too showed levels of intolerance. “All showed some evidence of being affected by the language used to describe people with mental illness.”
By Tanya Basu
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