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Elements of Suicide

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David Foster Wallace, who killed himself by hanging in 2008, gave this phenomenological account of “depression” in his 1996 novel Infinite Jest:

And re Ennet House resident Kate Gompert and this depression issue:

Some psychiatric patients — plus a certain percentage of people who’ve gotten so dependent on chemicals for feelings of well-being that when the chemicals have to be abandoned they undergo a loss-trauma that reaches way down deep into the soul’s core system — these persons know firsthand that there’s more than one kind of so-called ‘depression.’ One kind is low-grade and sometimes gets called anhedonia or simple melancholy. It’s a kind of spiritual torpor in which one loses the ability to feel pleasure or attachment to things formerly important. The avid bowler drops out of his league and stays home at night staring dully at kick-boxing cartridges. The gourmand is off his feed. The sensualist finds his beloved Unit all of a sudden to be so much feelingless gristle, just hanging there. The devoted wife and mother finds the thought of her family about as moving, all of a sudden, as a theorem of Euclid. It’s a kind of emotional novocaine, this form of depression, and while it’s not overtly painful its deadness is disconcerting and . . . well, depressing. Kate Gompert’s always thought of this anhedonic state as a kind of radical abstracting of everything, a hollowing out of stuff that used to have affective content. Terms the undepressed toss around and take for granted as full and fleshy — happiness, joie de vivre, preference, love — are stripped to their skeletons and reduced to abstract ideas. They have, as it were, denotation but not connotation. The anhedonic can still speak about happiness and meaning et al., but she has become incapable of feeling anything in them, of understanding anything about them, of hoping anything about them, or of believing them to exist as anything more than concepts. Everything becomes an outline of the thing. Objects become schemata. The world becomes a map of the world. An anhedonic can navigate, but has no location. I.e. the anhedonic becomes, in the lingo of Boston AA, Unable To Identify. . . .

* * *

Hal isn’t old enough yet to know that . . . dead-eyed anhedonia is but a remora on the ventral flank of the true predator, the Great White Shark of pain. Authorities term this condition clinical depression or involutional depression or unipolar dysphoria. Instead of just an incapacity for feeling, a deadening of soul, the predator-grade depression Kate Gompert always feels as she Withdraws from secret marijuana is itself a feeling. It goes by many names — anguish, despair, torment, or q.v. Burton’s melancholia or Yevtuschenko’s more authoritative psychotic depression — but Kate Gompert, down in the trenches with the thing itself, knows it simply as It.

It is a level of psychic pain wholly incompatible with human life as we know it. It is a sense of radical and thoroughgoing evil not just as a feature but as the essence of conscious existence. It is a sense of poisoning that pervades the self at the self’s most elementary levels. It is a nausea of the cells and soul. It is an unnumb intuition in which the world is fully rich and animate and un-map-like and also throughly painful and malignant and antagonistic to the self, which depressed self It billows on and coagulates around and wraps in Its black folds and absorbs into Itself, so that an almost mystical unity is achieved with a world every constituent of which means painful harm to the self. Its emotional character, the feeling Gompert describes It as, is probably the most indescribable except as a sort of double bind in which any/all of the alternatives we associate with human agency — sitting or standing, doing or resting, speaking or keeping silent, living or dying — are not just unpleasant but literally horrible.

It is also lonely on a level that cannot be conveyed. There is no way Kate Gompert could ever even begin to make someone else understand what clinical depression feels like, not even another person who is herself clinically depressed, because a person in such a state is incapable of empathy with any other living thing. This anhedonic Inability To Identify is also an integral part of It. If a person in physical pain has a hard time attending to anything except that pain, a clinically depressed person cannot even perceive any other person or thing as independent of the universal pain that is digesting her cell by cell. Everything is part of the problem, and there is no solution. It is a hell for one.

The authoritative term psychotic depression makes Kate Gompert feel especially lonely. Specifically the psychotic part. Think of it this way. Two people are screaming in pain. One of them is being tortured with electric current. The other is not. The screamer who’s being tortured with electric current is not psychotic: her screams are circumstantially appropriate. The screaming person who’s not being tortured, however, is psychotic, since the outside parties making the diagnoses can see no electrodes or measurable amperage. One of the least pleasant things about being psychotically depressed on a ward full of psychotically depressed patients is coming to see that none of them is really psychotic, that their screams are entirely appropriate to certain circumstances part of whose special charm is that they are undetectable by any outside party. Thus the loneliness: it’s a closed circuit: the current is both applied and received from within.

The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom Its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’, can understand the jump. Not really. You’d have to have personally been trapped and felt flames to really understand a terror way beyond falling.

But and so the idea of a person in the grip of It being bound by a ‘Suicide Contract’ some well-meaning Substance-abuse halfway house makes her sign is simply absurd. Because such a contract will constrain such a person only until the exact psychic circumstances that made the contract necessary in the first place assert themselves, invisibly and indescribably. That the well-meaning halfway-house Staff does not understand Its overriding terror will only make the depressed resident feel more alone.

One fellow psychotically depressed patient Kate Gompert came to know at Newton-Wellesley Hospital in Newton two years ago was a man in his fifties. He was a civil engineer whose hobby was model trains — like from Lionel Trains Inc., etc. — for which he erected incredibly intricate systems of switching and track that filled his basement recreation room. His wife brought photographs of the trains and networks of trellis and track into the locked ward, to help remind him. The man said he had been suffering from psychotic depression for seventeen straight years, and Kate Gompert had had no reason to disbelieve him. He was stocky and swart with thinning hair and hands that he held very still in his lap as he sat. Twenty years ago he had slipped on a patch of 3-In-1-brand oil from his model-train tracks and bonked his head on the cement floor of his basement rec room in Wellesley Hills, and when he woke up in the E.R. he was depressed beyond all human endurance, and stayed that way. He’d never once tried suicide, though he confessed that he yearned for unconsciousness without end. His wife was very devoted and loving. She went to Catholic Mass every day. She was very devout. The psychotically depressed man, too, went to daily mass when he was not institutionalized. He prayed for relief. He still had his job and his hobby. He went to work regularly, taking medical leaves only when the invisible torment got too bad for him to trust himself, or when there was some radical new treatment the psychiatrists wanted him to try. They’d tried Tricyclics, M.A.O.I.s, insulin-comas, Selective-Serotonin-Reuptake-Inhibitors, the newand side-effect-laden Quadracyclics. They’d scanned his lobes and affective matrices for lesions and scars. Nothing worked. Not even high-amperage E.C.T. relieved It. This happens sometimes. Some cases of depression are beyond human aid. The man’s case gave Kate Gompert the howling fantods. The idea of this man going to work and to Mass and building miniaturized railroad networks day after day after day while feeling anything like what Kate Gompert felt in that ward was simply beyond her ability to imagine. The rationo-spiritual part of her knew this man and his wife must be possessed of a courage way off any sort of known courage-chart. But in her toxified soul Kate Gompert felt only a paralyzing horror at the idea of the squat dead-eyed man laying toy track slowly and carefully in the silence of his wood-panelled rec room, the silence total except for the sounds of the track being oiled and snapped together and laid into place, the man’s head full of poison and worms and every cell in his body screaming for relief from flames no one else could help with or even feel.

The permanently psychotically depressed man was finally transferred to a place on Long Island to be evaluated for a radical new type of psychosurgery where they supposedly went in and yanked out your whole limbic system, which is the part of the brain that causes all sentiment and feeling. The man’s fondest dream was anhedonia, complete psychic numbing. I.e. death in life. The prospect of radical psychosurgery was the dangled carrot that Kate guessed still gave the man’s life enough meaning for him to hang onto the windowsill by his fingernails, which were probably black and gnarled from the flames. That and his wife: he seemed genuinely to love his wife, and she him. He went to bed every night at home holding her, weeping for it to be over, while she prayed or did that devout thing with beads.

The couple had gotten Kate Gompert’s mother’s address and had sent Kate an Xmas card the last two years, Mr. and Mrs. Ernest Feaster of Wellesley Hills MA, stating that she was in their prayers and wishing her all available joy. Kate Gompert doesn’t know whether Mr. Ernest Feaster’s limbic system got yanked out or not. Whether he achieved anhedonia. The Xmas cards had had excruciating little watercolor pictures of locomotives on them. She could barely stand to think about them, even at the best of times, which the present was not.

— David Foster Wallace, Infinite Jest, pp. 692-998 (Little, Brown, 1996). Footnotes omitted.

When I first read Infinite Jest, around 1999, I felt particularly comforted by this passage. I was comforted at seeing the thing It named and described, but on a more practical level, I was comforted by the reminder that I could always try ECT, and maybe even surgery. (I read about the practice of trepanation with longing.) Something about this thought seemed a little traitorous to me, believing as I did at that point that suicide was wrong. Is there, at the most essential level, any difference between suicide on the one hand, and attempting to erase one’s experience with electroconvulsive therapy or psychosurgery on the other? What is the difference, if there is one, between suicide and having one’s capacity to feel emotion removed?

I suspect that many people who would want to prevent Ernest Feaster from committing suicide would want to allow him to get his desired emotion-destroying psychosurgery. This, I think, is inconsistent.

The most essential thing another human being is to us is a co-experiencer. To experience ourselves and to have a truly human experience of the world, we need to see ourselves and our environments reflected through the eyes of another person. A body without an experiencer within is but an animate doll, of no use to the doll himself, and by that fact of no morally appropriate use to those who love him.

If we want to offer mercy to a man by ridding him of painful aspects of his experience, how different, then, to allow him to rid himself of all aspects of his experience, if all he experiences is pain? What reason, save religion or cruelty, to force a man to experience pain against his will?

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Written by Sister Y

April 14, 2011 at 3:14 am

If Suicide is Caused by Mental Illness, Why Improve Working Conditions at Suicide Hotspots?

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In response to a high number of worker suicides at miserable Chinese iPad factories, the bosses are, apparently, giving the workers a raise.

The most common argument for forcibly preventing suicides is that they are brought on by irrationality, by mental illness. So what good is a rational incentive going to do in the face of elevated suicide rates?

People need to admit that suicide is rational, already.

Written by Sister Y

May 29, 2010 at 11:47 pm

On Being Your Patients’ Keeper

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Sexy psych nurse Mr. Ian of MentalNurse wonders why “risk assessment” (for harm to others) is the exclusive province of mental health professionals, to the exclusion of other specialties. Medical patients other than mental patients often pose a risk to other people – but doctors and other health care workers are not expected to police them. Whose risk is it, anyway? He says:

Who says it’s my responsiblity to assess, manage and mitigate risk of harm to others?

I could flip the question – why is risk assessment and management only an obligation of the mental health sector?

Why aren’t parole boards required to meet the same standard when releasing a known violent person? They don’t even have an obligation to the offender. Their obligation is to the safety of the public.

Why can’t opticians remove someone’s license to drive when they’ve failed an eye test or GPs remove licenses from those with ‘at risk’ medical conditions? Why aren’t these people risk assessed and arrested if they fail the eye test but found driving a car?

I think the same questions can be asked for risk assessment focusing on “danger to self.”

Written by Sister Y

March 22, 2009 at 5:26 am

More Evidence for Rational Suicide

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A letter in the upcoming January 2009 issue of the journal Psychiatric Services (Psychiatr Serv 60:126, January 2009) reports on the relationship between suicide method and past health care contacts. The authors of the letter report that people who commit suicide by charcoal burning (a method of carbon monoxide poisoning gaining popularity in Hong Kong and Taiwan) are significantly less likely to have had mental health care (or hospital visits for any reason) than people who commit suicide by hanging or solid or liquid poisoning. That is, there is an identifiable population of people who commit suicide using relatively painless means that require preparation, and this population is less likely to be mentally or physically ill than people who commit suicide using other means. These results are in line with past studies, and “corroborate findings from Hong Kong that victims [sic] of charcoal-burning suicide were less likely to have pre-existing mental or physical illness,” say the authors [emphasis mine; citations omitted].

The letter displays problematic logic in the interpretation of its findings. In relevant part, the authors say:

Our results support the point previously raised by researchers from Hong Kong that this new method may have attracted individuals who would otherwise not have considered suicide. Acute stress, particularly economic difficulty, rather than mental disorders may be the major precipitating factor of suicide in this suicide subgroup. Population-based prevention strategies to prevent charcoal-burning suicide that might be considered include efforts to destigmatize mental illness to enhance appropriate help-seeking behaviors, restrictions on access to charcoal (for example, by removing charcoal from open shelves and making it necessary for the customer to request it from a shop assistant), and guidance for the media on how to report on suicide events. [Emphasis mine; citations omitted.]

The authors’ perspective is that the availability of the method is what is causing the suicide. But isn’t it the individual’s choosing to commit suicide that is the proximate cause of the suicide? Is the “cause” of suicide the man or the gun?

The authors assume that suicide should not be allowed and that it is right to prevent it. Why should this be? No reason for or defense of this position is given. People committing suicide using the charcoal burning method are not likely to be mentally ill! Why shouldn’t they be allowed to choose to commit suicide in a relatively painless manner? Even forced life advocate Ezekiel Emanuel purportedly favors a “negative right” to suicide for rational people.

In addition, the authors’ proposed solution to the problem of non-mentally ill people committing suicide is: destigmatize mental illness. Huh? My interpretation of the data is that charcoal burning suicides are likely to be rational suicides – not the product of mental illness. How will destigmatizing mental illness help anything here? The authors also, predictably, recommend coercive suicide prevention methods (using the laughable tactic of restricting the sale of charcoal – no picnic barbecue for you if you look sad!) and media censorship.

There is little evidence that “destigmatizing mental illness” will prevent suicides in these cases. And even if coercive suicide prevention does prevent some suicides, they will be the wrong suicides. Take away the right to charcoal burning (not to mention the right to barbiturates), and you force people to choose between committing suicide by violent or ineffective means, or remaining alive in misery. And that is wrong.

Written by Sister Y

December 30, 2008 at 5:26 am

Study: Having a Good Reason to Kill Yourself Increases Suicide Risk

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A study out of Oxford University has found that prisoners with a lot to lose upon entering prison – ones who are married and employed prior to being imprisoned – are more likely to commit suicide than unmarried prisoners who were unemployed upon entering prison.

This is the expected result if suicide is a rational decision. But, for some reason, the researchers recommend increased investment in mental health services (coercive suicide prevention) for at-risk (married, employed) prisoners. Huh? Because if someone has a good reason to commit suicide, and therefore is at higher risk for committing suicide, he must be . . . crazy.

Other results of the study include the fact that serving a life sentence also increases the risk of death by suicide, as does living in a single cell (the latter, presumably, not just because of loneliness, but because it makes committing suicide easier in practical terms).

Mental health services – generally a euphemism for coercive suicide prevention tactics and other ineffective, humiliating practices – are the wrong solution to the “problem” of rational suicide. The idea that “mental health services” are the right thing to do to reduce suicides is ubiquitous, but it’s important to point out failures of rationality like this.

Update: apparently chronic pain – especially head pain and pain in multiple areas of the body – also increases the risk of suicide.

Written by Sister Y

November 6, 2008 at 5:41 pm

An Interview With Me

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Chip Smith of The Hoover Hog recently conducted an interview with me. The resulting document is an excellent synthesis of, and introduction to, my strange ideas.

What the DSM-II Got Right

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The DSM-II, or Diagnostic and Statistical Manual of Mental Disorders, Second Revision, was the diagnostic guide specifying the criteria for psychiatric disorders between 1968 and 1980.

In general, the DSM-II is very suspect. Until 1974, the DSM-II famously listed homosexuality as a mental disorder – specifically, it was listed under Personality Disorders and Certain Other Non-Psychotic Mental Disorders, Sexual Deviations, as DSM-II 302.0, Homosexuality. (Certain wacky Christian fringe groups and many Catholics still think the removal of homosexuality from the DSM was a real shame.) The DSM-II uses quaint terms like “neurosis” and includes controversial diagnoses like “Psychosis with childbirth,” “Involutional melancholia,” and “Depersonalization syndrome.”

More recent revisions of the DSM (DSM-III, DSM-IV, and DSM-IV-TR) are generally considered to contain diagnoses that map more scientifically onto observable real-world phenomena.

Partially due to a realization of ignorance of the etiology of many diseases, revisions beginning with the DSM-III tended to erase etiology from the names and diagnostic criteria of many conditions (except conditions where the etiology is obviously central, such as 292.1, “Psychosis with other syphilis of central nervous system” (psychosis caused by syphilis).

Unfortunately, the refusal to link mental diseases with etiology resulted in a step backwards in the diagnosis and treatment of depression, according to Professor Gordon Parker (“Is depression overdiagnosed? Yes,” British Medical Journal 2007:328).

“Fifty years ago [under DSM-II criteria],” says Professor Parker, “clinical depression was either endogenous (melancholic) or reactive (neurotic). Endogenous depression was a categorical biological condition with a low lifetime prevalence (1-2%). By contrast, reactive depression was exogenous – induced by stressful events affecting a vulnerable personality.” In other words, the DSM-II recognized a type of biologically-determined depression, with a population frequency similar to other major, debilitating psychiatric disorders such as schizophrenia. (In fact, for various reasons including the severity and similar lifetime prevalence as schizophrenia, my reading of this is that endogenous “melancholic” depression, if studied in more detail, would be found to be specifically genetically linked, just like schizophrenia.) Another type of depression, much less severe and much more common, resulted from people “becoming depressed” secondary to negative life events.

Then, in 1980, the DSM-III revisions changed all that. They created a new taxonomy of depression, and rather than exogenous and endogenous, began to classify depression as “major” or “minor,” with no reference to etiology. Only the diagnostic modifier “melancholic features,” which I’ve previously discussed in my essay “Depression, Cognition, and Value,” was left of the endogenous depression distinction.

Unfortunately, the major/minor classification has never been borne out by scientific studies (though the “melancholic features” modifier is scientifically robust). As Professor Parker points out,

Meta-analyses show striking gradients favouring antidepressant drugs over placebo for melancholic depression. Yet trials in major depression show minimal differences between antidepressant drugs, evidence based psychotherapies, and placebo. . . . Extrapolating management of the more severe biological conditions to minor symptom states reflects marketing prowess rather than evidence. Depression will remain a non-specific “catch-all” diagnosis until common sense prevails. [Emphasis mine; citations omitted.]

Scientific studies do not back up diagnoses of “major” and “minor” depressive disorders as true disorders. The DSM-III criteria for major depression has “failed to demonstrate any coherent pattern of neurobiological changes or any specific pattern of treatment response outside in-patient treatment settings,” says Professor Parker. In other words, while the quaint diagnosis of “melancholic depression” under the DSM-II retains some scientific validity, the diagnosis of Major Depressive Disorder under the DSM-IV is not scientifically valid in any of the normal senses.

The implications for suicide rights are several. First, to the extent that everyone who is suicidal is assumed to be suffering from “Major Depressive Disorder,” we are being diagnosed with a disease whose scientific validity is extremely questionable. The laughable overdiagnosis of “Major Depressive Disorder,” coupled with the diagnosis’ failure to “demonstrate any coherent pattern of neurobiological changes or any specific pattern of treatment response,” must shake our confidence in the fashionable hypothesis that all suicide is secondary to a genuine mental disorder. Second, to the extent that our psychiatric establishment chooses to use these diagnostic criteria (Major Depressive Disorder), and since meta-studies generally show little significant difference between antidepressant medications, “evidence-based psychotherapies,” and placebo, if we have depression, we must be said to have an incurable disease. Both citizens in general the those in medical professions should be much more circumspect about their willingness to force people with “Major Depressive Disorder” to remain alive against their will, and especially to forcibly medicate or “treat” this “disease.”

While I think endogenous depression is a “real” disease, unlike DSM-IV Major Depressive Disorder, I do not think that all suicides have endogenous depression – not even close – nor do I think that endogenous depression is always treatable. At best, it is marginally more treatable than DSM-IV Major Depressive Disorder – that is to say, not very. The famous study that found that SSRIs work no better than a placebo found a slightly significant difference between drug and placebo for the most severely depressed people, which could be tracking endogenous depression, but this was primarily due to that group’s much lower response to placebo. From the study:

Drug–placebo differences increased as a function of initial severity, rising from virtually no difference at moderate levels of initial depression to a relatively small difference for patients with very severe depression, reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category. . . . Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.

Written by Sister Y

August 1, 2008 at 10:31 pm