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Sondre

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Anxiety is a part of life, but some people are stuck in this state, unable to calm down. It is a state of physical symptoms, feelings of paralyzing fear and loss of control. How can drug and non-drug therapy help?

Anxiety is a part of life. It may even be beneficial in an evolutionary sense – the heightened awareness of surroundings and the anticipation of sudden reaction. The stalking lion and the Olympic sprinter both share a focused, whole body concentration and readiness. If the prey never materializes or the Starter’s pistol never fires, there is a short period of recovery while the mind and body relax back into a more normal state.

In contrast, consider the person who cannot turn the switch off, or for whom the switch is thrown inappropriately – there is no race to run, no prey to chase after. Now, what evolution has programmed into us becomes a disability. And the physical symptoms of anxiety disorder appear.

  • Rapid heart rate and palpitations – for some, the feeling that they are about to have a heart attack.
  • Sweating – as in the ‘sweaty palms’ of nervousness, only to an excessive degree.
  • Increased blood pressure, flushing, headaches, and trembling.

Along with the physical symptoms, feelings of paralyzing fear, anxiety and a loss of control predominate. The important difference between the common incidents we all feel and anxiety that requires treatment is the frequency and duration of the attacks and how much they interfere with daily life. Sometimes, even generalized anxiety in the form of chronic, diffuse worry is treated as an anxiety disorder, especially in older adults.

Conditions that fall under the umbrella of anxiety disorders include: panic attacks, obsessive-compulsive disorder, post traumatic stress disorder and others, including mixed types that overlap with depression. Depression often appears in patients with anxiety disorders (as high as 60%).

Non-pharmacological Treatments

The historical treatment of a shot of brandy and a slap on the face is the movie version of emergency care for those paralyzed by overwhelming stress. The idea is to induce a kind of ‘reset’, as one might do for a computer acting badly. Unfortunately, long-term, the results of such treatments are more likely to be alcoholism and a severely bruised face.

Patients do self-treat. For anxiety that causes insomnia (sometimes called ‘racing thoughts’) patients may try alcohol, over the counter sleep aids (usually antihistamines) or even illegal opioids. For anxiety that has a specific trigger, patients may adjust their lifestyle to avoid certain situations – for example, an agoraphobic who is careful to avoid elevators, bridges or exposure to heights.

Non-pharmacological medical treatments that have shown benefits include cognitive behavior therapy (CBT), hypnotherapy or interpersonal therapy. These methods attempt to train the patient in a stepwise fashion until previous stressors no longer induce anxiety (or at least not crippling anxiety). Of these, CBT has been shown to have excellent results for those patients for whom triggers can be determined. The method relies on exposure to the trigger situations in graduated degrees with relaxation training used to combat anxiety as it arises. The obvious benefit of CBT is the limiting aspect. Unlike medications, after a successful treatment regimen (which may be a dozen sessions) patients are free to fend for themselves and, in a real sense, are cured.

Pharmacological Agents

The benefits of anxiolytics alone, when contrasted with therapy alone, are that they are easier to administer (no special training is required and patients are expected to monitor their own usage) and often give quick results. They are less expensive initially (as opposed to psychiatric office visits) and the side-effect profile for many is quite good – this makes them an attractive choice for general practitioners who want to ‘try something out’ and insurance companies which are happy with the diagnosis + prescription model of reimbursement.

The rationale for chemical agents is also ‘more scientific’. It is more difficult to duplicate and measure what a talented therapist does and much easier to produce convincing statistical metrics with chemical entities (blood levels, pharmacokinetics, receptor sites). Once a patient is stabilized on a medication regimen that reduces symptoms, they can be largely ignored for months at a time, unless or until they need a dosage adjustment. These cost/benefit advantages allow for more care at a lower overall price.

The disadvantages are a lack of real ‘customization’ and the statistical filtering of the patient population. Statistical filtering means that a large patient population is prescribed a medication (perhaps overprescribed) and those that are not helped ‘fall through’. This smaller pool is then administered the next medication on the list and another portion is filtered out. The cycle can continue until only the most difficult cases remain, and those are then referred to psychiatric care.

At first, this system seems rational. But because many of the anti-anxiety drugs are prescribed by non-specialists (often based on the results of an in-the-office test) the filtering shunts many patients out of the system too soon. Without the expertise to evaluate often complex diagnoses, patients are treated in a ‘one size fits all manner’ by general practitioners who simply want to help.

Anxiolytics are classified by their mechanism of action:

  • SSRIs (Selective Serotonin Reuptake Inhibitors) interfere with serotonin removal from synapses in the brain. They are called ‘selective’ to contrast them with less specific drugs which also affect other neurotransmitters (norepinephrine and even dopamine). These represent first-line therapy for anxiety disorders and include fluoxetine, paroxetine and sertraline. These agents are also prescribed for depression.
  • Benzodiazepines, such as diazepam, clonazepam and alprazolam, are prescribed for short-term or ‘as needed’ relief of symptoms. They are habit forming and cause sedation. They can be prescribed for chronic use in patients who suffer from anxiety induced insomnia as a sleep aid. Some studies show that benzodiazepines may actually cause depression in some situations, either from higher doses or long-term use. (Example from Medscape.) Patients also commonly complain of cognitive impairment (memory loss) on benzodiazepines, which can restrict their use.
  • Azapirones – these include buspirone and tandospirone. These drugs act directly on serotonin receptors (5HT-1A) as partial agonists. They are not habit forming like the benzodiazepines, and in naïve patients, provide the same level of relief from symptoms. They also do not cause sedation and for this reason, patients who have used benzodiazepines may feel they are not working, because they do not get the drowsiness or mental impairment they have come to associate with their medication. This class is also not useful for as-needed relief – the effects can take several weeks to appear.
  • Barbituates have been used in the past to treat anxiety (acute), but are discouraged because of the high addiction potential and the danger of death in combination with alcohol. Currently, they only find use in sleep-onset insomnia.
  • Other drugs, such as beta blockers or hydroxyzine (anti-histamine) have been used effectively as anxiolytics because they address the physical symptoms, especially in performance anxiety situations. Inderal (propranolol) has seen amateur application by college students who suffer from test anxiety. The lower heart rate and blood pressure drop caused by the drug can stop what would otherwise be a downward spiral of nervousness during stressful exams. The effect is not spurious; students actually score higher with the correct dose.

Trends

Best practices will probably continue to be some combination of both drug and non-drug therapy. The gap between what psychiatry sees as physical (best treated with a physical agent) and mental (best treated with cognitive therapy) will continue to close as neuro-anatomy and neuro-physiology advance.

While the hope is that anxiolytics will become as specific as antibiotics are now, it is unlikely that skilled psychiatric care will be replaced by a short list of standard pharmaceuticals. Diagnosis remains an art. Patients are diverse enough that clear categorization into simplistic classes is unlikely. The overlap of conditions (i.e. depression paired with anxiety paired with failing health) makes single issue patients a rarity and agents that are helpful theoretically may interfere with other medications.

One caveat remains – the advent of each new drug leads to increased usage of drugs. The old saying is true: “When all you have is a hammer, the whole world starts to look like a nail.” In a sense, new drugs create new diseases. We must rely on psychiatrists to keep the process rational and realistic. They must resist pressure from other medical personnel to take over their profession with ‘quick fixes’.

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A sedative is meant to calm combative or over-active patients or reduce the impact of impending stress. A hypnotic is primarily meant to promote sleep. How do these medications actually work?

There is some overlap in both the terms and the drugs used in this category. Primarily, a sedative is meant to calm combative or over-active patients or reduce the impact of impending stress (such as in pre-operative sedation). A hypnotic is primarily meant to promote sleep.

The overlap occurs because some of the same drugs at different dosages can be used for either purpose.  One example of this is benzodiazepines.

Benzodiazepines

Benzodiazepines have been manufactured since the 1960s (chlordiazepoxide, diazepam) and more than 50 different types are available in the US. With so much competition, manufacturers have been hard pressed to distinguish the benefits of their product over others. Whether a particular benzodiazepine is used for sedation or as a hypnotic depends on the time to onset, the half-life of the parent drug (and its active metabolites) and the side effects profile.

The quicker a particular benzodiazepine acts and the shorter the half life, the more useful it is as a hypnotic. This is because patients can predict the onset of somnolence and their body can clear the medication by the next day. Unfortunately, these two factors increase addiction potential. While all benzodiazepines are both physically and psychologically addictive, those used as hypnotics have the most risk.

The mechanism of action for benzodiazepines is not completely understood. They are GABA agonists, which mean they potentiate the naturally occurring neurotransmitter GABA (gama aminobutyric acid) which has inhibitory properties in the brain. Just exactly how this reduces anxiety and promotes sedation remains under study. The peripheral effects make benzodiazepines useful as muscle relaxants and in the treatment of acute myoclonic or epileptic seizures.  They also find use mixed with anti-psychotics (haloperidol plus lorazepam) and given as an injection for psychiatric emergencies in patients that require restraints.

One of the most interesting applications is as an amnesia inducing agent. Benzodiazepines given before surgery can both relax the patient and cause them to forget the subsequent procedure. Diazepam given intra-venously is used in dental surgeries which require patients to be awake (to some extent) without suffering the anxiety of the procedure. They serve as ‘date rape’ drugs for the same reason. Flunitrazepam (Rohypnol) has an onset of about 45 minutes and causes anteretrograde amnesia. This produces a victim who is malleable and leaves them without a clear memory of the crime.

Classic Sedatives and Hypnotics

The most ancient sedative/hypnotic is probably ethanol, closely followed by opium. Potassium Bromide was given as a sedative in the 19th century as well as chloral hydrate. The barbiturates became available in the early 20thand replaced most of the earlier drugs. In modern times, barbiturates still find use as hypnotics, although benzodiazepines are considered a much safer alternative.

Agents such as antihistamines and melatonin are also available and many patients will self treat with these non-prescription alternatives before seeking help for insomnia.

Insomnia

It is estimated that about 10% of the US adult population suffers from chronic or severe insomnia, however, about half of this is attributable to medical conditions (i.e. sleep apnea secondary to obesity) and do not have a primary psychological cause. This makes a thorough medical examination necessary before considering the available medications. Attention must also be paid to current medications and temporary stressors, both of which may lead to insomnia.

The assumption that depression causes insomnia needs comment. Depression and insomnia are associated (a diagnosis of primary insomnia does increase the risk for a future diagnosis of depression or anxiety). However, they should be viewed as co-morbid conditions, rather than one causing the other.

Insomnia often results from some precipitating event, and about 70% of patients with primary insomnia can identify a reasonable cause. Prolonging or reinforcing comes when worries about sleep (and the consequences of insomnia) perpetuates the condition. Cognitive and behavior treatment (either with or without medication) is needed to improve ‘sleep hygiene’ and teach patients useful techniques. Often, for example, patients may take daytime naps in the hopes of ‘catching up’ which actually aggravates the problem.

Cognitive behavior therapy (CBT) has been shown to help many patients (50 -70% of patients show improvement) and is comparable to benzodiazepines in efficacy. More importantly, most patients will maintain improvement at 6 months after a course of CBT – while removal of a drug precipitates reoccurrence.

Patients who are not helped by therapy alone will require a sleep aid. Ideally, the choice of agent will depend on the results of a sleep study which measures not only the duration, but the quality of sleep prior to treatment. Sleep clinics monitor patients with an EKG to discover depth and duration of various stages of sleep. Information about a specific patient can determine if the problem is onset, duration or depth of sleep. Generally, patients will be asked to keep a sleep diary for several weeks as an aid in diagnosis.

All hypnotics help a patient get to sleep, but most will not keep them sleeping throughout the entire night. Hypnotics find the most use in temporary insomnia, where some life adjustment is occurring – the death of a loved one, for example.

It should be emphasized that hypnotics are not a long-term solution for sleep disturbances. Patients should be discouraged from using them every night and re-evaluation is needed on a regular basis. None of the drugs marketed as hypnotics (with the possible exception of zolpidem – a non-benzodiazepine) are meant for chronic use (more than 3-4 weeks). Therapists are often pressured by patients into extending the duration of drug treatment and will have to be forthright in asserting that hypnotics are not a solution. In fact, some studies suggest that longer term usage actually exacerbates primary insomnia.

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Depression affects many of us, and in some cases medication is needed. Antidepressant acts on the "balance" in the brains "neurochemistry", but how do they work? And what characterizes a depression? Anyway, depression remains an illness that needs better treatment options. The trend is for newer agents to either be more specific or have a better side effect profile.

To be considered a medically treatable disorder, depression must exceed the short-term ‘blues’ we all feel when our goals are not met or life takes a turn for the worse. The distinguishing features of clinical depression include:

  • Symptoms must rise to the level that they interfere with eating, sleeping or daily activities.
  • Symptoms must appear daily (or nearly so) for a period of two weeks or more.
  • To be primary depression, symptoms must not be due to substance abuse (or withdrawal) or directly attributable to the recent loss of a loved one. (Note, some clinicians will include other major life stressors, such as job loss or medical diagnosis.)
  • Primary depression cannot be the result of another medical condition – such as hypothyroidism. A medical history should rule out hormonal causes before treatment of depression begins (including medication history).The modern paradigm for the biology of depression revolves around three neurotransmitters and their actions in the brain. The phrase, ‘chemical imbalance’ is often used to describe the effects of various levels of these neurotransmitters, but it is misleading in that there is no agreed upon ‘balance’ to measure, other than a reduction of symptoms. This is important, because, unlike blood-sugar levels (a single measurable number), it takes a skilled practitioner to evaluate individual patients and drug effects.
  • Those suffering depression will report either a depressed mood (profound hopelessness) or an inability to act in the world. This latter isn’t merely unwillingness, it is felt as an uncontrollable physical and mental lassitude and ranges from deep ennui to obvious disengagement. Patients will report they can no longer enjoy those activities which used to bring pleasure.

Neurotransmitters

Serotonin, norepinephrine and dopamine are the three main neurotransmitters targeted by the commonly prescribed antidepressants. While it is known that depression is related to various levels of these neurotransmitters (hence the phrase, chemical imbalance) the relationship is not perfectly clear. As an example, one depressed patient may show lower than normal levels of norepinephrine and respond well to a drug which increases norepinephrine levels. Other patients with depression show a higher than normal level of norepinephrine.

The picture is far from simple and not clear. With 30 neurotransmitters to consider, the brain remains a very complex place to do business. Therapy is based on results – often, several medications must be tried until a ‘match’ is found. And even with the large number of drugs available, approximately 30% of patients will not get chronic relief with medications.

Agents

  • Tri-cyclic Antidepressants (TCAs) – The first class of medications used primarily to treat depression, these drugs were initially marketed in the late 1950s. The first, Imipramine, is still in use today. They find application in serious or intractable depression, but are limited because of a significant side effects profile, including tremor and cardiac arrhythmia.

TCAs act to increase serotonin and norepinephrine (strong) as well as dopamine (weak). They have an antihistamine effect peripherally and interact strongly with alcohol. In low doses, they are sometimes used as a sleep aid.

  • Mono-Amine Oxidase Inhibitors (MAOIs) – These drugs block the action of mono-amine oxidase, the primary enzyme which degrades serotonin, norepinephrine and dopamine (as well as other neurotransmitters). By blocking this enzyme, MAOIs keep naturally occurring neurotransmitters in the synaptic junction longer, leading to a greater effect for however much transmitter is produced.

MAOIs, like TCAs, have a poor side effects profile, which limits their use. The blocking of mono-amine oxidase occurs throughout the body and, because the breakdown of amines is inhibited, a buildup occurs. Foods to be avoided contain tryptamine and tyramine. There are also a large number of other drugs which are metabolized by amine oxidation and patients on MAOIs must be screened for interactions.

  • Selective Serotonin Reuptake Inhibitors (SSRIs) – This newer class of compounds acts to keep available serotonin in the synaptic junction by slowing its reabsorbtion back into the neuron. This is the second of two removal mechanisms for serotonin. The first, degradation is blocked by MAOIs. Unlike MAOIs and TCAs, SSRIs tend to primarily affect serotonin levels (although specificity varies with different drugs).

In comparison to MAOIs and TCAs, this class has very few side effects that rise to the level of having to discontinue the medication. This makes them first line agents for depression and even non-specialists may feel comfortable prescribing them. An even newer class, serotonin-norepinephrine reuptake inhibitors (NSRIs) is also used in depression.

One cautionary note: Because agents in different classes have different modes of action with the same result (increased synaptic neurotransmitters) a washout period is required when switching medications. Consider what would happen if a patient were on an MAO along with an SSRI. The neurotransmitter, serotonin would be blocked from degradation (the MAOI) and reabsorbtion (SSRI). This can lead to supra-additive effects. Consequently, patients have to be weaned from one before starting the other. This can mean a period of essentially no benefit and patients are likely to relapse until the second agent begins to take effect.

Atypical and Treatment Resistant Depression

The agents mentioned above are all considered traditional antidepressants and most patients (in the US) receive them through their primary care physician (60+%). Atypical depression and resistant depression (two to four agents have failed) usually require the services of a psychiatrist or psychologist trained in these more intractable cases.

Often, medications will then be tried that are not classically thought of as antidepressants (benzodiazepines or antipsychotics). Atypical depression, for instance, may respond to lithium. Beyond this, treatment options extend from talk therapy sessions all the way through electroconvulsive therapy (shock therapy).

Depression remains an illness that needs better treatment options. Medications are still a good area of research as are transcranial magnetic stimulation and magnetic seizure therapy. Reducing adverse reactions is also an important consideration because patients will likely take medication for months or years. The trend is for newer agents to either be more specific or have a better side effect profile.

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Psychopharmaceuticals are used to treat psychiatric disorders. They are prescribed subsequent to a diagnosis by a physician qualified to treat mental illness, but how does it work? In today's psychiatry, the benefits and risks of drug therapy will be considered for each patient. There are difficult issues that require sufficient knowledge of psychotropic drugs.

To be classed as a psychiatric medication, a chemical entity has to have as its primary function an effect on mentation. More specifically, psychopharmaceuticals are used to treat psychiatric disorders. They are prescribed subsequent to a diagnosis by a physician qualified to treat mental illness.

Modern ideas about psychiatric medications depend on a model of diagnosis and selection rather than, for instance, a general trial and error procedure to see what medication may be helpful – while the latter seems odd, without a clear understanding of what drugs were doing biologically, this has been the practice in the past.

History

Although medications have been used since antiquity to influence human behavior, it was not until the late 1950s that psychiatry moved toward the paradigm of biological remedy instead of symptom based medications. Before this, psychiatric drugs fell into two general classes – those that induced sedation and those that elevated mood. Opiates (along with barbiturates) and amphetamines were the staples of outpatient care and ‘talk therapy’ was the mainstay of treatment. For inpatients, dramatic ‘challenge’ treatments would include insulin shock therapy and electro-shock therapy, but neither falls into the category of medications as primary agents. (An interesting exception is the use of thyroid supplements to treat schizophrenia, subsequently found to be ineffective.)

Psychiatry has quite a history of failed treatments and medications. In the mid-20th century, psychopharmacology could be best classified as ‘ham-handed’. The most useful property of sedatives, for example, was in the control of unruly patients. The advent of chlorpromazine and the elucidation of neurotransmitters began to change the way psychiatrists viewed medications. This trend has continued and the search for more biologically rational (and physiologically based) medications continues today.

The model is a familiar one in other areas of medicine: Researchers find some anomaly (perhaps even a cause) that is associated with a condition and this new knowledge results in a drug meant to affect the biology of those afflicted. Primarily these are based on receptor sites in the brain that are either stimulated or attenuated by a medication.

Classes of Agents

While not all-inclusive, most psychiatric drugs can be classified into one of four areas. These are generally based on the conditions being treated. (A different classification would be based on mechanism of action or chemical moiety.)

  • Anxiolytics, or anti-anxiety drugs, are prescribed to treat excessive anxiety or fear.
  • Sedatives, or hypnotics – used to induce or enhance sleep and used to treat insomnia. Note there is some overlap in the drugs used for these first two categories. For instance, when patients cannot sleep because they are overly anxious.
  • Antidepressants – These fall into two general classes, the tri-cyclic antidepressants (TCA) and the selective serotonin reuptake inhibitors (SSRI). Both are commonly prescribed, but the latter has fewer side effects and has become popular with doctors who are not psychiatric specialists to prescribe for mild/borderline depression.
  • Anti-psychotics – these are the mainstay of treatment for schizophrenia, bi-polar disorder and other, serious mental conditions. Again, there is an overlap with other conditions and these agents may be used in lower dosages to treat depression.

This classification leaves out many conditions that a psychiatrist may treat. For instance, amphetamines are commonly prescribed for attention deficit hyperactivity disorder (ADHD). Also, some medications marketed for a specific diagnosis can find uses outside of these categories. Imipramine, the first tri-cyclic anti-depressant discovered, has found use in treating childhood bedwetting (nocturnal enuresis).

Controversy

Like no other area of medical practice, psychiatry seems to beget criticism. Partially this is because treatments are often given without patient consent (and even against the wishes of a patient). Another criticism stems from the historical practice of a ‘chemical straitjacket’ – medications prescribed primarily to make a patient easier to handle. Psychiatry still suffers from a history that includes pre-frontal lobotomy and movement disorders induced by Thorazine.

Added to this is the fear most of us have about altering our own minds. The idea of reshaping ‘who we are’ in a fundamental way feels deeply invasive and unethical. For this reason, the diagnostic standard has become one of deciding if symptoms are severe enough to alter one’s normal lifestyle. In a real sense, this is how doctors decide if a condition rises to the level of necessitating intervention.

Some criticism is being leveled from within the psychiatric community itself. Doctor Joanna Moncrieff puts forth the idea that dependence on drug therapies has given psychiatrists an unsupported confidence and led to more and inappropriate treatments. Her paper, Drug Treatment in Modern Psychiatry: The History of a Delusion (2002) describes an overreliance on medications that do not help patients so much as they allow the practice of psychiatry to view itself as helpful.

Philosophical Considerations

To what extent are patients mentally diseased and to what extent are they merely ‘different’? The answer seems obvious with a patient who is clearly psychotic or dangerous. The case is less so when someone complains of depression or believes in other than ‘normal’ societal values. As late as 1970, homosexuality was considered by the American Psychiatric Association as a mental illness.

Psychiatrists often run up against the Hippocratic Oath’s dictum of primum non nocere (first, do no harm). They do not yet have the tools to look deeply into the neuropathology of a specific patient’s brain and correct aberrant conditions directly. There is always a risk of altering mentation in an unwanted direction or of a patient becoming addicted to a ‘remedy’.  The risks are made greater because most drug treatments do not directly cure mental illness, but rather, are given chronically to control symptoms.

Medications are developed and tested statistically. But they are prescribed individually. The US Food and Drug Administration first started warning about increased risk of suicide in patients prescribed anti-depressants (both TCA and SSRI) in 2004. Further studies (2006) showed a doubling of risk for patients in the 18-25 year old group. This is the conundrum. To what extent will this patient be helped and at what risk?

The philosophical question revolves around what are ‘norms’ and how they are determined. The public seems keenly aware that medications may be misused to enforce societal norms in an unethical fashion. Prozac, an SSRI, has been hugely overprescribed simply to ‘make life more pleasant’. There is current controversy surrounding the use of methylphenidate (an amphetamine) for ADHD – the worry is that the drug isn’t helping young students so much as making them less disruptive in a classroom; aiding the teacher more than the patient.

Modern Goals of Psychiatry

Let us not forget that psychiatrists are first medical doctors. They are highly trained scientists involved in a difficult area of medicine. The ideal is to understand the physiological mechanisms that cause disease and find treatments (both drug and other therapies) that have meaningful and reliable outcomes. These are laudable goals. The deserved criticisms of psychiatry shouldn’t overlook the fact that the discipline has progressed and will continue to do so.

The hope is that continued research in neuro-anatomy and physiology will bring more cause and effect relationships to light. Meanwhile, psychiatrists will continue to diagnose and treat patients with both the art and the science available.

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Depression can be cured by medication and psychotherapy, but meditation can also have a very healing effect.

Depression is commonly used term to describe a range of feelings pertaining to a sense of low well being. Beck and Alford have attempted to provide a comprehensive description of the term as typified by altered mood, negative self image and reduced activity levels. The feelings may vary from sadness to an extended period of despondency at varying levels. Specific events may lead to a feeling of ‘being low’. An event like a birthday that is forgotten by a close friend, a recent loss or separation without concurrent support from friends or family is a situation that may exacerbate depression. Some people are prone to depression regardless of the comfort and care they receive in their surroundings. Cases of depression are treated as mental disorders when the sense of reality is adversely affected. There are chronicles of highly intelligent people who berate their low mental capabilities and successful ones who feel bad about being failures. So, how do we care for our minds in this state?

The Way We Think

Take the case of Mrs. X who is hauled up by her supervisor for an error in her work. Mrs. X’s reaction is to feel hurt and withdraw. She starts telling herself she is useless because she makes too many mistakes. She remembers that this has been a problem since her childhood. She carries her anguish about the error and her inability to her home and finds it difficult to sleep. She sees a box of chocolates and binges. She tries to cry but finds it difficult to do so. She recalls all the past situations when she has been hauled up for mistakes and berates herself harshly. The next morning sees her wishing she did not have to go to work, in fact not wanting to get out of the bed. There is a downward spiral in her trend of thought.

Now, if Mrs. X were to view the situation objectively, she would probably realize that the error is because of flawed work planning or insufficient time to check her output. She would also realize that she has entered into a habit of accepting blame without ascertaining whether there are solutions to help her work better. Her current trend of thought impacts all aspects of her life and draws her deeper into a vortex of self-hate. She is unable to talk to her family about it because she knows they will be critical of her. She has no friends she can fall back on, she never could make friends.

An objective view would allow her to come up with better results. She would realize that her emotional reactions are probably based in childhood events where she was blamed for small mistakes and has adopted the attitude of being at fault. She has grown up to find that she is often at fault and fails to see that errors can be rectified or avoided. Of late, she has started developing severe headaches and often feels weepy without reason. Her food habits are erratic and she drives herself into binge eating situations. She is unable to recall a single event in her life that caused her to feel happy.

How Meditation Can Help

Meditation involves being in a comfortable position and focusing on breath as it enters and exits from the body. The body is guided into a state of restfulness and the person starts to go through a feeling of peacefulness. Some people may feel a headache coming on, but this goes away quickly. Some go through moments of catharsis while others feel itchy all over the body. Most of us prefer to keep ourselves occupied in activity that allows us to drown out past memories, chatter in our minds and a host of self negating beliefs. When we meditate, our feelings and thoughts come to the fore. In most cases, symptoms of discomfort disappear in a short while and the person starts looking forward to being engulfed in peace and quiet for a while. The person is guided to accept thoughts as they play out in the mind without becoming part of them. Repeated efforts yield the fruit of calmness, acceptance and widened perspective.

To understand the effect of meditation we must first understand the work of our nervous system in helping us to feel good. Our nervous system consists of tiny nerve cells that transfer impulses with the use of chemicals called neurotransmitters. The neurotransmitter, serotonin, is associated with a feeling of well being. Research on meditation has identified that this neurotransmitter is released during the practice of meditation and similar soothing activity.

In the case of Mrs. X, meditation will work on the physical discomfort that she faces and help alleviate the problem. She will be introduced to the idea that she is a valuable person and will find her mind slowly opening to a state of acceptance of herself. The utilization of psychotherapy in conjunction with meditation aids an opening up of the person’s mind to the mental games that one is being trapped in. As she continues in her practice with professional help, she will start to see her strengths and discover new sides of herself that she has not been aware of. She is likely to go through cathartic moments as she recognizes self-defeating thought patterns and sees others like herself.

Mrs. X should avoid trying to enter the phase of deep meditation until she has reached a stage of self awareness that allows her to stop dejection getting the better of her. The process of meditation works at the pace of a person’s acceptance of completeness. It increases the awareness of sameness between different individuals. She will slowly become aware that her concentration is under her control and can be improved with effort on her side.

Aspects to be Aware of

Meditation has a direct impact on the blood pressure of a person. It is proven to be beneficial for people with high blood pressure. Meditation should not be considered to be a ‘benign intervention’ explain Snyder and Lindquist in their book ‘Complementary/ alternate therapies in nursing’ (2006, p. 136-138). Patients who are on dosage for diabetes and hypertension must have their dosage reviewed after meditation. The authors are of the view that vital signs like blood pressure and heart rate should be monitored through the day in the initial phase for patients suffering from these diseases. They mention studies that have shown a connection between meditative practices and the reduction of HIV/AIDS killer cell activity. The practice is highly recommended for people undergoing chronic physical pain and stress or anxiety.

The authors recommend against the use of meditation for people who have hypotension since the blood pressure is likely to reduce further. In some cases, people go through hallucinations that require psychiatric treatment and medication to return them to a state of normalcy.

Postural hypotension is typified by giddiness due to a rapid shift to a vertical position after meditation. People who face this problem must get up from meditation in slow phases to avoid a sudden drop in blood pressure. People who are in a state of altered reality perception may find it difficult to follow the instructions to meditate at the start.

Until the person is able to concentrate and follow through with the instructions, it can be challenging to use guided meditation. In such cases, soothing music or continuous chants may be utilized in conjunction with prescribed medication. All in all, it is essential to practice meditation with the guidance an experienced practitioner who can gauge the pace at which you should practice and recommend a suitable method.

References

McNamara, Patrick, (2006). Where God and Science Meet. Greenwood Publishing Group.

Snyder, Mariah & Lindquist, Ruth (2006). Complementary/Alternative Therapies in Nursing. Springer Publishing Company.

 

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As our minds continuously focus on the externals, we might end up feeling empty. This emptiness deepens with time as relationships fail and there is emotional trauma. The mind is in a state of inertia.

Every object in a state of uniform motion tends to remain in that state unless an external force is applied to it; this is Newton’s first law of motion. This law explains the resistance to change that a body goes through with initial application of force before settling into a renewed state of inertia or acceptance of status quo. An application of this law to the working of our attitudes and behaviors directs our attention to the comfort zone that we allow ourselves to stay in.

We see evidence of this law in our day to day lives. A petty thief who finds it easy to escape without notice continues on the same path unless an external force (a law enforcement agency or a larger cartel) forces a change in ways. A depressed person meets an external force in the form of a therapist and weaves a way to a new form of thinking. An addict meets someone who helps to get life back on track. The external force may come in different forms; our own thoughts or an observation of the actions of another person can act as the route to a change.

We learn new attitudes, come across new events and thoughts that impact us in different ways. The good thing is that we have the option of choosing the forces that we will accept. We have only to be alert or mindful when taking a choice about the option. Unlike an object that has no option but to respond to the forces that work on it, the human mind has the capacity to step back from the situation and gauge what is really happening. This is theoretically feasible but the reality is that a large portion of the populace accepts thoughts as they enter the mind, react to events as they occur and undergoes troubling reactions. The mind remains in turmoil and the body reacts in accordance.

We are products of the cultures we come from. Focusing on the external persona is a universally accepted norm. Yet, the sign of a refined mind is one that is able to reach the realm of thought without giving credence to the physical appearance. We are continuously exposed to visuals of smart looking personalities whose lavish lives seem to be under control. Books guide us about the use of body language and power clothing. We see advertisements of brands that will enhance our looks and attract attention to the worldly, savvy image we wish to portray, though we are internally unsure of ourselves. As our minds continuously focus on the externals, our vision is distorted as is our sense of reality. This is akin to our view of a coin in a cup of water; we miss the actual trajectory of light and view the coin along an altered path.

In order to view the coin along the correct path, the viewer would have to enter the medium in which the coin lies. So it is with altered impressions. We read about lives and follow paths others have laid down without considering what we are all about. We form relationships with popular people, hope to be seen with the right types of people and reject those who do not ‘fit in’. The acceptance of others determines acceptance of the self. At some point the external view leaves us feeling empty. This emptiness deepens with time as relationships fail and there is emotional trauma. The mind at this point is in a state of inertia.

A slight external force can tip the mind into a state of disequilibrium. Rejection by a loved one, the loss of a friend, business losses, work place issues and a host of events that make us question our worth lead us into a confused mental frame. Since acceptance and popularity are commonly synonymous with success and power; the realization of dependence on others causes internal disturbance. Attachment to work is another example of such dependence. Most of us define ourselves and our worth by the work we do. An alteration of this perception is required. The acceptance that we are but the perfect energy behind the work and that the final outcomes are dependent on factors outside our control helps create a sense of controlled attachment. Doctors and scientists are found to possess this attitude. There is a

It is difficult to consider a paradigm shift to an internal focus. Instead, the mind prefers to remain in the present state by focusing on the search for a new set of relationships that foster the feeling of acceptance. The sensitivity of the individual and the extent of mental dependence on external acceptance are factors that determine the pace at which the mind accepts a shift to a different focus.

An application of the laws of physics to our mental state can open up a fund of information and understanding as we see that reality is continuously under pressure of different forces. The more we strengthen our opinions of ourselves, the less the external forces can affect our state of equilibrium.

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There are different types of critical minds, and the worst ones are those who use criticism to improve a feeling of self-worth by negating the worth of the person on the other side.

Language has a way of evolving a vocabulary that filter out attitudes in thought. There is one type of critical mind that objectively weighs the pros and cons and reaches a conclusion. There is another type of critical mind that works on the basis of emotional values and reaches a judgment. The former is called a critique while the latter is considered critical. The latter is often partnered with a stridency that leads to reactions of aggression or withdrawal.

A critique works to find ways to reach perfection by focusing on a task or output. The creation rather than the creator is the focus. Personal preferences with respect to the topic under discussion may come into play. The creator’s personal whimsicalities and irreverence do not affect the judgment of the person who provides a critique.

Contrast this with the mind of a critical person. Criticism stems from an internal sense of dissatisfaction and a continuous effort to counter the feeling. An individual who uses criticism is trying to improve a feeling of self-worth by negating the worth of the person on the other side. Criticism has its base in self-hate and is a primary relationship killer.

Imagine the players in a team who are unable to see positive traits in each other. The colleague’s sense the mutual lack of acceptance and display apathy or complete antagonism. This increases the mutual display of negative actions until the working relationship is fractured. Key issues are ignored as each individual tries to highlight the faults in the other team members while underplaying their own. The environment is fraught with negative thoughts and the team fails to function effectively.

Companies that claim to foster competition in the hope of maximizing profits fail to recognize that criticism is confused with competition. An environment that promotes an attitude of bettering the performance of a predecessor or competitor hopes to gain confidence that it progressively betters its past. However, this aim is lost when the members start to compare themselves and assume they are better than their competition merely because it makes them feel better about themselves. The overall purpose of organizational betterment takes second place to individual’s working to prove their own worth.

A relationship based on thoughts of the absence of certain qualities in the partner fails to celebrate the presence of alternate traits. So a person might berate a spouse for lacking drive or the capacity for cleanliness and fail to recognize the ability to connect with the children and be involved with their development.

Often, divorce becomes the way out of a relationship because the love has gone out of life. Love is selfish. The feeling of love thrives in an environment that involves appreciation and acceptance of the self. It grows unencumbered in the presence of mirth and continuous bouts of bonding either through shared interests or good conversation. Getting used to a spouse becomes the next step. One gets used to their habits, idiosyncrasies and specific individual traits. One accepts these until the relationship moves to a point of taking the person for granted. What is happening to the relationship? Taking a person for granted becomes the death knell and the main reason for ‘love to move out’. The couple ceases to see each other as special. The traits that were earlier lovable become the hothouse for distress.

Criticism takes the place of acceptance and reduces the scope for looking forward to enjoying each other’s company. The stresses of everyday life take precedence over the special preparedness of seeing each other at day’s end. The loss of togetherness and moments of bonding lead the way to a slow drifting apart to a point that the partners look upon each other as strangers. No wonder then, couples prefer to stay apart. Self-hate, the ground on which criticism bases itself, manifests and prevents the presence of love and acceptance.

What about criticism at the work place? An over critical boss can mean doom to a career, critical colleagues can make a person miserable and unable to function while critical subordinates can alter the course of the most well-planned projects. Back-biting, taking sides and losing track of the larger organizational purpose are common in organizations where a critical attitude is allowed to flourish. Each individual is sensitive to criticism. It is safer to wear a mask of professionalism and work within strictly defined limits rather than risk the reactions to working beyond limits and floundering.

Voicing Criticism

Ignoring criticism because of the manner of presentation can close out the possibility of accepting a potentially powerful critique that can bring positive change. If the statement is made in a tone that lays blame or makes a person appear vulnerable in front of compatriots, it will more likely be rejected without considering the merits. How should a criticism be worded to increase acceptance?

Firstly, there are no problems with people only with the processes followed in completing a task. An error in a task is not a sign of impoverished capability of the person carrying it out.

Secondly, the statements used need to be objectively worded. Avoid assumptions about the intent of the person who is being addressed, focus instead on correcting the issue.

Thirdly, be positive in tone. Let the listener know that you believe in the ability to perform and would like to add a perspective.

Fourthly, when a person complains about a colleague, insist on bringing the issues out into the open. This will prevent those who complain in order to distort your impressions about others and also helps to sort out process gaps that need to be addressed. It will also increase the security among team members that you are not biased against a few.

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Obedience and loyalty ensures that people reach their goals together, but by blind conformity we risk losing ourselves and our values. It can be dangerous!

Obedience is necessary; a team, family, army or for that matter any organisation runs smoothly on the tenets of obedience. All the organs must work towards a set direction in order to achieve set goals. The objective is set and the group knows that they must now unstintingly go ahead with the plan.

This seems straightforward enough; but what happens when the goal is at odds with those of the larger organisation. A person who believes in the futility of war who is forced into one or a person who believes in euthanasia being a part of a medical organisation that follows the policy of extending life. We may find ourselves in a situation where the policies of the agency that we work with are against our personal belief systems. In these cases, we may decide to compromise due to the career choices or circumstances of our personal lives. We settle for a compromise on account of the certainty that the organisation offers, the compensation we receive or the opportunities that appear in front of us. If this is not acceptable, there is a route of moving out of the situation by considering a change of workplace or career. In cases where moving out is not an option, like the soldier on the warfront there is only the option of quieting the voice of the soul and going along with the demand of the moment or entering a mental state akin to a breakdown.

So, what is the problem?

The problem lies in the mental state preceding an act of obedience. A child is obedient to the parent in a state of innocence. This form of obedience is essential for survival. As time passes by, the child enters a stage of identifying boundaries and making a personal definition of the world. Insufficient guidance, excessive judgemental responses, low display of mature behaviour and an environment riddled with bigotry affects the ability of an individual to form a strong sense of self.

We see examples of this in our daily lives and are all in some way a part of this behaviour cycle. The girl who decides she needs surgery to look better, the man who chooses to marry and keep homosexual preferences in check and the person who stays on in a seemingly happy relationship to avoid social censure. We see images of seeming perfection and rarely question who has decided that this is indeed perfect. How often do we stop to think whether there is an industry that thrives on individual insecurity about physical imperfection? Cosmetics, medicine, entertainment, fitness, foods, fashion and a host of others are direct or indirect beneficiaries of the need to obey the diktat of the knowledgeable few.

Multiply the external influences with a family of people who live to please or impress the outside world and rarely stop to think about what they are doing, the product is a highly obedient, unsure and emotionally uncertain human being. This person will be led into decisions that seem to advance them but will benefit others. Joining a religious group on the premise of proximity with a supreme power, being a part of an organisation that propagates obedience as a route to satisfy the will of an invisible power are but examples of this mindset.

An individual of the high obedience – low self thought mind is easily led by those who feed insecurity by providing sufficient doses of appreciation to keep the interest high. Such an individual can be expected to do what is told in order to keep the much needed dose of appreciation coming from the right quarters. The individual starts to feel a false sense of power without realising the manipulation involved.

A decision to be obedient that is preceded by emotional awareness, thought, involved discussion with an open attitude the resultant obedience will be a positive experience. The person will go through an enriching experience and will know when to move away from it when it shows signs of decay.

Mr. B is a senior management member of an organisation. He is asked to frame a policy that he is aware will not be acceptable to the employee base at large. However, his superior is of the view that the policy should be forced notwithstanding individual viewpoints. Mr. B comes from a standpoint of obedience to superiors and avoids arguing his case since he is afraid of being viewed negatively. He goes ahead with the instructions. During the next few days, business heads have reverted to the top management that Mr. B’s draconian policy is creating anguish among the employees. Clients heard about the policy and asked the business heads how they expected to continue in business if they adopted such questionable work practices. Mr. B’s superior changed his stance and roundly condemned Mr. B for introducing the rules. The business heads were critical of Mr. B’s role.

When Mr. B tried to remind his boss about his original stand, the superior informed him that he had not done a good job of convincing his superiors.

Mr. B is unable to understand the issue. He had voiced his opinion, it was ignored. When the business heads brought up the same view, the policy was revoked. He had tried to do his job but had wound up lampooned from all sides. What is the problem?

Now consider Mrs. X who has always been described as a highly obedient person. Give her a rule, she will make a process out of it and never let the rule bend unless permitted to. When she married, her husband seemed like a good person though he tended to bully her a little bit. Of late, he has started physically abusing her and insulting her at the slightest opportunity. She goes out of her way to keep him happy but nothing seems to work. She is now afraid to make a move without her husband’s tacit approval, but that does not make the abuse any less. Her husband seems repentant at the end of his bouts of violence but always makes it seem to be her fault. The coffee she served was too cold or she forgot to add salt or she was unresponsive when he called, whatever, she provoked a reaction. She continues to obey and tries to please her husband while he continues to find reason to let her hurt.

Excess Obedience

Obedience that necessitates sacrifice of personal power is excess obedience. You may trust a friend but withdraw from the friendship when the trust is broken. This means that the ability to use your mind and weigh the situation lies in your hands. However, if the trust is broken and you continue the friendship because you are afraid of being lonely, it is likely that you will find the trust being broken again. A cycle of continued trust reneging followed by repentance and a return to normalcy starts to wear away at the seams of the relationship. The friend is likely to perceive your need for dependence as a sign of your weakness. The ability to break trust and retain the friendship soon gets perceived as a sign of personal power by the friend.

This type of relationship tends to feed itself with the obedient one facing victimisation and hoping for correction and the perpetrator feeling a sense of enhanced power that must be maintained at all costs. The boundaries of trust will be explored while the obedient person flounders for ways to handle new transgressions and the bully finds new ways to hold on to power. The relationship has evolved into a bully-victim cycle.

Obedience that allows for a powerful and weak person combination is a sign of excess obedience.

Every relationship must work within boundaries of trust and personal space in order to flourish. A belief that obedience constitutes a good job done is questionable. Time has shown us that good teams require thinking and contributing members in order to be successful. Once the entire team’s intelligence has worked on a solution, it is time to go ahead. A team’s efforts may be impeded along the way or might find itself in a different situation from what was originally envisaged. It is necessary to find an immediate solution to the changed situation and again move on.

Similarly, in a personal relationship, the parties must understand each other and agree to certain behavioural norms if the relationship is to succeed. Once both parties are in agreement, it is time to forge ahead in a state of trust.

Right Forms of Obedience

Obedience to a cause involves identifying measures and means to reach the goal of the cause. A person may decide to work towards world peace or develop innovative designs or work to better internal business processes.

Obedience to legitimate demands, adjustment to global needs, legally upheld clauses are all forms of right obedience.

Obedience to medical advice is right obedience.

Obedience to a teacher or parent within legitimate limits is right obedience.

Obedience to an individual must however be treated with care. Every relationship must have limits within which it functions. A parent may obey a child’s request for a purchase, a spouse will obey a family rule to clear a mess, and a subordinate will obey a superior’s legitimate demand for information. In each case, the request is weighed before acceding to.

Obedience that leads to a sense of confusion, a reduced sense of self, acceptance of abuse, removal of power from your hands, reducing your personal rights or causing harm or injury to self or others is not right obedience.

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Some people carry misplaced guilt that causes anxiety and depression. Others may lie to save themselves or falsely place blame on others without any feeling of guilt. How can we understand the psychology of guilt?

Guilt seems to have become a bad word in today’s scenario. We are told to let go of the feeling, to avoid doing things that make us feel guilty and are assured that the feeling is misplaced. Yet, there are certain situations when the absence of guilt portends ill for the future of the individual and the relationships that are being fostered. The presence of guilt requires appropriate responses in order to be dealt with effectively.

Well-placed guilt

Take the case of a parent who reacts inappropriately to an incident and wrongly places the blame on a child. Later, the parent realises the error and feels bad for misunderstanding the situation and erroneously castigating the child. Guilt creeps in and gnaws the adult mind. In this situation the feeling of guilt is rightly placed and is in fact important for the development of trust between parent and child.

A person may falsely implicate an innocent without realising the truth. The guilt that follows this act is a necessary reaction and a sure sign that the conscience is alive and kicking.

Misplaced Guilt

Misplaced guilt is a reaction when a person accepts blame for an event that was out of their control. A wife might blame her husband for failing to get a doctor in time to save their child. The distraught father accepts the blame in the moment of grief and drives himself into a state of despair with the thought that the child’s life was in his hands. This acceptance of guilt may happen due to a habit of incorrectly assessing a situation and accepting responsibility beyond one’s scope or it may happen when blame is roundly placed in a traumatic moment. This is the form of guilt that is sought to be dispelled with a consideration of reality.

Families and organisations may foster the importance of placing blame for a problem and this gives rise to the search for a scapegoat. Some people tend to fall in this trap more often than others due to an attitudinal predisposition that prevents objectivity.

The absence of guilt

At times, a profession demands the curtailment of feelings of guilt. A soldier would be unable to function if assailed by feelings about the families of the enemy soldiers. A doctor must continue to work with patients though a few lose their lives despite the best efforts. A parent who does not want to hit a child may inadvertently do so when the child enters a high risk situation. Though there is hurt and pain, the actions are well intentioned.

A person who inflicts pain on others and does so without a thought of the impact of the actions is in a situation of reduced guilt and there is no limit as to how far such a person will go. A great deal of time spent on reflection is necessary to re-awaken a sense of right and wrong. The reality is that until the person is caught and incarcerated, there is little to be done to prevent the actions. Once caught, if the individual is placed with others who follow the same route of using violent means to survive, the behaviour thrives. This is the cycle found in abusive relationships, criminal activity, predatory actions and the like. Isolation is an effective tool that forces the person to think about the past and leads to the rise of guilt.

The management of guilt

When an individual is facing well placed guilt, it is beneficial to be honest with the wronged party to retain the openness of the relationship. For instance, the parent may apologise to the child and rectify the situation. This helps make the situation better. However, the context is important and may act as an impediment to an admission. This means that the individual takes a conscious decision to stay quiet though there is a silent admission of wrong.

Misplaced guilt, on the other hand, can be a source of anguish for a long time. The perspective of a friend or a professional therapist can help overcome the anguish. Over time, acceptance must set in.

The return of guilt after a long absence needs to be closely managed to enable a person’s return to normalcy.

Identifying types of guilt

You are feeling guilty and have not determined how to reduce the weight of the feeling. When you reflect on the event, you feel the pain of your actions. You may be living in the past or facing misplaced guilt. It is useful to take professional help in these cases to help you sort out your feelings and the reality and assess whether you are guilty of wilful wrong.

As children, we may cause immense pain to our loved ones and feel bad about it when we are older. In such a case, we must accept the context of the time and the feelings associated with the age. Inaction and wrong action may be caused by wrongly understanding a situation and it may be too late to do anything about it. When the event is long past and allows for no rectification, it is difficult to make the feeling of loss disappear. An acceptance of personal imperfection in a past moment is a route to release.

The importance of acceptance

Yes, human beings may, thereby being just the opposite of what they would like to be. We all have sins and omissions of the past that force us to review what we have done and correct assumptions of people and events. Guilt forces us to see that though we try to absolve ourselves and appear perfect in our own eyes, we are not what we want to be. It increases our understanding of people and reduces the bigotry that would otherwise blind us. It helps us see the diversity around us and realise the underlying similarity. These events are crucial points of learning and growth and must be treated as such. Acceptance of flaws and situational responses is an important step to acceptance and growth.

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Some suicides are impulsive, others are carefully planned and some suicides are due to depression or chronic stress. Here we discuss the circumstances and train of thought that can lead to suicide.

Circumstances leading up to a suicide vary widely.

The event may occur in a rash and impulsive manner. A distressing event occurs and circumstances to aid suicide appear at just the point when the person seriously considers it. A student who fails an examination after high anticipation may walk out of the street pondering a bleak future and sees the possibility of escape on a busy road.

Relationship issues that lead to repeated misunderstandings and the feeling that things are bound to fail can lead up to a flashpoint. An innocuous fight can lead to a rash step that has actually been played out in the mind for a long time and have vindictive intent. The act is neither deeply planned nor impulsive, though it may give an impression of impulsiveness.

Suicide may occur after the onset of depression when the person has been through months of moping through life and glides into suicide. The movement from depression to suicide occurs as a natural progression though if the attempt fails, the patient may consider the impact on others. This is not impulse-driven like the first case; rather it is a state of mind.

Then there is the planned suicide. The person may be undergoing depressive thoughts and sees little reason to continue with life. The person then proceeds to plan actions and takes care to ensure that family members are well cared for after the exit. Once the decision is taken and responsibilities completed, the person proceeds to implement the plan.

Phases of thinking

Walter and Schiff (2005, p. 44) point out that the ‘intense emotional strain’ that suicides feel makes them consider death as the way out of the continual stress.

Robinson (2001, p. 169) describes the phases of thought that go into planned suicide. The first and longest phase is that of agitation during which the person resolves the internal conflict about self-killing. At this phase they consider the impact on their loved ones. Once the initial restlessness has been justified and plans made to care for the family after the suicide, the person works out how to do it. This done, there is a state of relief and giving away of belongings and tidying up personal and financial issues. At this point, the person may appear calm and cheerful thereby making the incident of suicide more shocking.

Henden (2008, p. 52) mentions the main findings about the thinking of a suicide victim before the act. Hopelessness, the future appears negative, low self-belief, hyper-critical of the self and low self-evaluation are prime factors that drive the thought that death is preferable to life.

The current thinking when a patient appears to be suicidal is hospitalization and the administration of anti-depressants. A patient on the medication typically ceases to have feelings or motivations and faces the complete loss of happiness. Family members and therapists prefer this route because the possibility of suicide is daunting for them to face. The author considers alternate approaches to managing the breakdown situations that suicides face.

The problem solving capacity of suicide victims has been found to be compromised. They may be taught to adopt suitable behaviors that improve their response to problems. Jade was 17-years old when she committed suicide. Her relationship with her family was strained because of her excessive drinking and she had a stormy relationship with her boyfriend. One day, after another of their many fights, she crashed the car into a wall. Jade had not learned to verbalize her anger and channelize it to achieve a better outcome nor had she matured to less impulsivity.

Suicide victims may blame themselves overly or feel extremely uncertain about themselves in moments of conflict. They need to be taught to widen their perspectives and realistically see their role. The search for solutions rather than acceptance of blame and guilt is the way ahead. Sanli has been in an abusive relationship for a while now. She started to justify the beatings and continued victimization by telling herself that she was to blame, if she changed herself things would become better. The continued taunting and torment and increasing viciousness led her to jump out of the window. She had never seen the possibility of not being responsible for the trouble or that there was a way out of the situation. Her sisters and mother had gone through similar relationships, only Sanli chose to die.

The introduction of learning methods of thinking and focusing on pleasurable activity is found to help overcoming suicidal thought. The extreme emotional stand that victims tend to take has the capacity to convert an innocuous occurrence into a spiral that pushes up the mental note of self-destruction. Statements like, “If she says she won’t be with me, my life is of no value” or “If I lose my job, I’m finished, I’d better die” are examples of extreme thinking. The person requires behavioral interventions that temper the thoughts.

Signs of suicidal thought

Schleifer (p. 40) refers to teens feeling overwhelmed and consider suicide. The telling signs of this are: sudden withdrawal from social circles, staying away from the family, talking about suicide and uncharacteristic risk-taking behavior.

Blumenthal and Kupfer (1990, p. 247) refer to pre-existing psychological disturbances like unipolar depression or substance abuse as causative factors for suicide. An adult may direct hostility towards the self before the act. Physical inability related to age or condition can lead to decisions to end life.

Bibliography

Alters, Sandra & Schiff, Wendy (2005). Essential Concepts for Healthy Living. Jones & Bartlett.

Henden, John (2008). Preventing Suicide: The Solution Focused Approach. Wiley.

Robinson, Rita (2001). Survivors of Suicide. Career Press.

Schleifer, Jay (1999). Everything You Need to Know about Teen Suicide. Rosen.

Blumenthal and Kupfer (1990). Suicide over the Life Cycle. American Psychiatric Publishers

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Viruses and bacteria can make people sick, but it can often be treated. Virus affecting our mindset in a destructive fashion, might be more difficult to treat, and therefore more dangerous. Is it possible to understand it as a form of “mental virus”? Suicide as an epidemic has been noticed by early historians and has notably been countered with harsh civil and religious measures. What factors might lead to suicide epidemics? Is it possible to understand it as a form of “mental virus”?

Suicide as an epidemic has been noticed by early historians and has notably been countered with harsh civil and religious measures. Capuzzi and Golden (1988, p.89) refer to historical evidence of a suicide epidemic among young women in the Greek city of Miletus that was effectively curtailed by parading the bodies through the marketplace. The inherent humiliation brought the situation under control.

Religious fervour has a history of leading people to suicide for reasons that are not easily comprehensible. Stillion and McDowell (1996, p. 6) consider the suicide of Judas as one that may have resulted from remorse and that of Socrates and Jesus of Nazareth as cases of ‘altruistic suicide’. Socrates was given a choice of changing behavior but chose to opt for death as did Jesus of Nazareth. These acts are seen as cases of martyrdom as distinct from suicide. These people stood for their principles rather than choose death as a means of escape. These deaths were followed by a spate of suicides by people who glorified the acts of martyrdom.

Gibbon describes the Donatists, a sect that comprised of fanatics ‘possessed with the horror of life and the desire for martyrdom… sometimes they profaned the temples of paganism… forced their way into courts of justice and compelled the affrighted judge to give orders for their immediate execution.’ They were willing to go to any lengths to get killed in the hope of attaining eternal happiness. The destruction of idols was bound to lead to vindictive backlashes that would result in their murder. They would accost strangers with the threat of death if the stranger refused to kill them (2008, p. 70).

The religious attitude towards suicide as a route to martyrdom was later castigated as the trend caught on and an increasing number of people chose the route. This led to St. Augustine and later Aquinas roundly condemning the act as being against the will of God and excommunication of suicide victims. Open desecration of bodies was conducted to drive home the sinfulness of suicide.

More recently, the notion of suicide as an epidemic has caught the attention of authors. Literature chronicles cases of seemingly normal people who go on carnage before turning the gun on their heads. Youngsters are increasingly attracted to the promise of a faraway goal and fervently participate in suicide missions. Desjarlais and Eisenberg (1996, p. 72) note that there was a 160% increase in the rate of suicide among young people in the US. A survey highlighted the fact that 60% of the victims had known another person who had died by suicide. ‘Imitative suicides’ are high among teenagers when the information of a suicide is sensationalized by media reports. Cluster suicides have been reported in India in response to the natural death of political leaders.

Cultures in which disagreement with elders is discouraged and strained relationships place youngsters at a disadvantage to express their views see a higher incidence of suicide. These suicides are culturally viewed as a means to manage interpersonal conflict and conciliation. In South Pacific cultures, the notion that suicide is a result of psychological disorder is not prevalent. Rather is seen as an outcome of the changing social structure and the pressures it places on the family unit. (1996, p. 73)

The idea that suicide is a contagion was put forth by Paz Soldan who believed that information about a suicide should be condemnatory and concise. The vilification of suicide would help control the epidemic. Rather than the social conditions surrounding this type of epidemic, it is the nature of attention afforded that makes it worth trying. Religion sees suicide as an action by responsible individuals whereas medicine views the suicide as beyond the responsibility of the victim. The biologist Rios was of the view that suicide is nature’s way of ridding the earth of people who are designed for self-destruction for the sake of the larger good. A common thread that runs through the remedial action involves the bettering of institutions and increasing the value for work (Weaver & Wright, 2008, p. 186)

Terrorist activity sees an increase in suicide epidemics. Suicide attacks carried out by individuals willing to martyr themselves even as they wreak havoc on unsuspecting victims. The prospect of martyrdom is of particular interest to young individuals who face the prospect of continued poverty, social ignominy and insignificance in the absence of this chance at redemption. A single act that will wipe out a large number of deemed sinners from the face of the earth and catapult the person to instant recognition has the power to attract hordes towards death (Reuter, 2004, p. 4).

Suicide epidemics may be tackled by providing scant respect or even desecration and limited attention. History has shown the power of negative press as a deterrent. This deterrent does not work with suicide bombings. The glorification of suicide by martyrdom makes it difficult for countries to comprehend and tackle it effectively. The vilification of suicide terror is effectively shielded off by the perpetrating countries with celebrations about the glory attained by a life that has been lost. Individual cultures have found ways to control suicide epidemics, nations are struggling to grapple with the issue.

 

Bibliography

Capuzzi, Dave & Golden, Larry B. (1988). Preventing Adolescent Suicide. Taylor & Francis.

Desjarlais, Robert & Eisenberg, Leon (1996). World Mental Health. Oxford University Press.

Stillion & McDowell (1996). Suicide across the Life Span. Taylor & Francis.

Reuter, Christoph (2004) My Life is a Weapon. Princeton University Press.

Weaver, John & Wright, David (2008). Histories of Suicide. University of Toronto Press.

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In this article we take a look at risk factors and warning signs for suicide. How to help a person with suicidal thoughts and how assess suicide risk?

Has the behavior of someone you know been troubling you? Are you afraid to ask them what’s really going on? Suicide is on the rise and lack of social connection plays a large role in this phenomenon.

“It’s just a stage,” “She’s been depressed before,” “She’s just trying to get attention,” “Time will heal all” and “He was just joking, wasn’t he?” are examples of things we say to ourselves to soothe our troubled minds.

More troubling is that 50%-75% of suicides do make some effort to tip off a friend or loved one or show imminent warning signs.

Your concern might be the very thing that makes the difference between life and death.

Psychiatrist Jerome Motter was haunted by a note left by the “successful” suicide of a patient of his: “I’m going to walk to the bridge. If one person smiles at me on the way, I will not jump.” 1

 

Risk Factors for suicide

Risk Factors for suicide are mostly related to loss:2 & 3

  • Loss of health
  • Loss of a loved one or a break-up
  • Loss of a job, money, status, home
  • Loss of feelings of personal security or self-esteem
  • Loss of a social network: friends, family or acquaintances due to moves, job changes, illness or death

 

Other factors that increase the risk of suicide include:

  • Access to firearms
  • Alcohol and/or drug use
  • Aging
  • Emotional trauma
  • Excess or prolonged adversity
  • Exposure to family members or friends who have committed suicide or overt media exposure
  • History of aggressive and/or disruptive behavior
  • History of risky behavior
  • History of neglect or abuse
  • History of self-harm
  • Incarceration
  • Impulsivity
  • Mental illness
  • Social isolation
  • Unemployment

Depression is a strong risk factor for depression. That’s not to say that all depressed people are suicidal, but two-thirds of those who die from suicide were depressed and 30% of those hospitalized for depression attempt suicide. 3

No one gets used to depression. Even if someone you know suffers from it on and off, that doesn’t mean it isn’t cause for concern. Having a severe bout of depression makes people 70% more likely to suffer another severe episode. The good news is that cognitive behavioral therapy and medication can help people overcome depression. 4 It’s just that they might need your help to get the impetus to seek treatment.

Depression isn’t just feeling blue once in awhile or even reacting strongly to an adverse event or mourning a loss. Clinical depression is diagnosed if 5 or more of the following symptoms are present during a two-week period and 1 of them must include loss of interest or pleasure in usual activities or depressed mood.4

  • Change in appetite or weight
  • Change in sleeping patterns
  • Decreased sex drive
  • Depressed mood
  • Diminished ability to think or concentrate, indecisiveness
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Loss of interest in usually pleasurable activities
  • Speaking or moving with unusual speed or unusual slowness
  • Thoughts of death or suicide

 

Symptoms of depression and suicide can overlap. The following are some symptoms that, unchecked, can lead to suicide. 5

  • A sense of hopelessness
  • Alterations in eating and sleeping habits
  • Declining performance at work or school or increased and fervent activity
  • Fears of losing control, harming oneself or others
  • Feelings of worthlessness, unlovability, shame, guilt or self-hatred
  • Neglect of personal welfare and physical appearance
  • Personality changes: acting out, anger, anxiety, apathy, irritability, hyperactivity, loss of interest in normal activities, sadness, withdrawal
  • Powerlessness
  • Social isolation

 

Imminent Risk of Suicide Warning Signs 3 & 5

  • Ambiguous statements such as “You won’t be seeing me then” or “You won’t have to worry about me anymore.”
  • Depression suddenly disappears
  • Development of a suicide plan
  • Explicit statements of suicidal thoughts and feelings
  • Extreme agitation, anxiety or rage
  • Feelings of desperation
  • Increase in alcohol and drug use
  • Making inappropriate jokes about death or suicide, fascination with morbid stories
  • Making of a will or giving away possessions
  • Precipitating event that exacerbates psychic pain: holidays, job loss, break-up etc.
  • Reckless behavior
  • Saying good-byes inappropriately
  • Self-injury
  • Self-starvation, dietary mismanagement, mismanaging medication
  • Sudden isolation
  • Wondering aloud about death,suicide or heaven

 

What to Do 5, 6 & 7

So what do you do if someone tells you they’re thinking of suicide?

1)Take it seriously

There’s a few myths about suicide that don’t pan out. Among them:

“The people who talk about it don’t do it.”

Remember, 50%-75% of all suicides do attempt to give some warning of their intention.

“Anyone who tries to kill themselves is seriously nuts (and that’s not my friend.)”

Only 10% of suicides are psychotic or severely mentally ill. Most people still function in their daily lives.

“Those problems aren’t serious enough for him to kill himself over.”

It’s not what the events are, but what the person is feeling inside, and that’s not something readily evident.

“If someone really wanted to kill themselves, they wouldn’t say anything and nothing would stop them.”

The truth is, suicide is a cry for help. Suicidal people are ambivalent: they wrestle with an extreme desire for escape from their pain and yet may still have some hope lying buried in their hopelessness. When someone tips you off, with words or behaviors, that small part of them is reaching out.

 

2) Listen

Make the time to give the person your full attention and be willing to help immediately. The person may have waited to talk to someone until they are at a critical point.

  1. Don’t assume you know what they’re feeling until they’ve had a chance to tell you.

Be patient and accepting. Voice your care and concern. Share examples of things you’ve noticed.

Resist the temptation to argue with someone about their feelings. You can’t use logic to argue someone out of something they feel.

Many suicidal people are fearful about sharing their thoughts for fear of seeming foolish or manipulative. Do everything you can to make them feel as if they’ve done the right thing by confiding in you.

Just venting and sharing their load will bring the person relief.

3) Ask the question

If they haven’t offered up the information freely, don’t be afraid to ask them if they are contemplating suicide and whether or not they have a specific plan. You won’t make someone commit suicide that hasn’t already been considering it.

If they have been considering it, ask them if they have set a time and date and whether or not they have the means or method in place.

Do not argue with them! Avoid making them feel guilty for your incipient sadness or that of their family. Don’t try to convince them that they have so much to live for. Don’t belittle their feelings or try to solve their problems.

Do acknowledge their feelings. Do tell them that in many cases, suicidal feelings do pass. Do tell them that you care, that they are not alone and that depression can be treated.

4) Get Help

Find out if they are seeing a therapist or taking medication. If the person has ingested drugs, do your best to find out what and how much, how long ago and what they’ve eaten. Do they take other medications for other health conditions?

Call the Poison Control Center if you can. Call an ambulance if necessary or take them to the hospital. Call the therapist if there is one.

If the person is not with you, find out where they are and make sure they are not left alone.

A suicidal person may initially refuse medical care or refuse to cooperate with your efforts to help. Stay sympathetic and non-judgmental.

5) After the crisis

If the person hasn’t yet attempted suicide, it’s up to you to make sure they aren’t left alone and you do contact someone for help. Not just for them, but for you.

Get the Poison Control Center number and keep the number for a suicide hotline nearby.

Make sure that means of suicide aren’t available in their home.

Your friend or loved one will need to see a mental health professional. Suicide can’t wait. The hopelessness and other overwhelming feelings they are experiencing makes it hard for them to push themselves. Help them get help immediately, no matter how reluctant they are. Be patient and persistent.

Take them there. Make sure they continue getting treatment. Talk to someone to manage your own trauma over the situation.

A Helpful Link

♥ http://www.iasp.info/resources/Crisis_Centres/


Sources

1) Thomas E. (2005) Why People die by Suicide. The President and Fellow of Harvard University.

2) All About Depression Staff (2009).Suicide and Depression. All About Depression [online]. Retrieved from http://www.allaboutdepression.com/tre_10.html

3) American Foundation for Suicide Prevention Staff Writer (2009) Risk Factors for Suicide. American Foundation for Suicide Prevention [online]. Retrieved from http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=05147440-E24E-E376-BDF4BF8BA6444E76

4)American Foundation for Suicide Prevention Staff Writer (2009) Depression and Suicide Prevention. American Foundation for Suicide Prevention [online]. Retrieved from

http://www.afsp.org/index.cfm?fuseaction=home.viewpage&page_id=050CDCA2-C158-FBAC-16ACCE9DC8B7026C

5) Conroy, David L. (2009). Nine ways to help a suicidal person; and Suicide Warning Signs. Metanoia [online]. Retrieved from http://www.metanoia.org/suicide/whattodo.htm

6) Conroy, David L. (2009) Handling a call from a suicidal person. Metanoia [online]. Retrieved from http://www.metanoia.org/suicide/sphone.htm

7) American Foundation for Suicide Prevention Staff Writer (2009) When You Fear Someone May Take Their Life. American Foundation for Suicide Prevention [online]. Retrieved from http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=F2F25092-7E90-9BD4-C4658F1D2B5D19A0

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Suicide rates have increased around the world at alarming rates. So what causes suicide? Is it genetically or ethnically-based? Or is suicide a cultural and sociological disease? Religion, media influence, globalization, social and cultural feelings of support and membership are probably among the crucial factors.

Suicide rates have increased around the world at alarming rates. Statistics from the World Health Organization (WHO) and the Center for Disease and Control (CDC): 1 & 2

  • 1 million people die of suicide every year
  • Suicide rates have increased by 60%
  • By 2020, 1 person will die of suicide every 20 seconds
  • By 2020, 1 person will attempt suicide every 1-2 seconds
  • Most suicide attempts are by the elderly but more youths are successful
  • Youth suicide is increasing at the fastest rate and suicide now ranks among the three leading causes of death for those 15-44
  • Males are 4 times as likely to die from suicide than females, but females attempt suicide 3 times more than males
  • In Eastern Europe, the rates of suicide for men and women are the same
  • Most deaths from suicide occur in Eastern Europe
  • The second highest rates of suicide occur in the island countries of Cuba, Japan and Mauritus
  • China and India report the most deaths but this number is due to their large population size
  • The lowest rates of suicide are in the Eastern Mediterranean and Islamic countries
  • Some of WHO’s numbers are skewed by the fact that Africa has not reported suicide rates, Asia rarely does and the Eastern Mediterranean, Western Pacific and Latin American countries do so irregularly

So what causes suicide? Is it genetically or ethnically-based? Or is suicide a cultural and sociological disease? Does culture and a country’s social practices determine susceptibility to suicide?

Alcohol and drug use make up the biggest risk factor for all age groups of people. Alcohol and drug use are linked to depression, impaired judgment and skewed thinking.

After substance abuse and depression, what commonalities can be found in suicides around the world?

One study, done by researchers Marusic and Farmer, suggests that genetic vulnerability could be a factor. The researchers point out that residents of Hungary and Finland have very different cultural and political practices but share a common genetic origin and a high rate of suicide. 3

On the other hand, a number of studies have looked at the genetically similar countries: Denmark, Norway and Sweden. Although members of these countries share ethnic backgrounds, Norway has a remarkably lower rate of suicide than either Denmark or Sweden. 4

Pharmaceutical companies are eager to fund research that will result in physiological cures for suicide and genetic research is the first step along that route.

What is not considered however, is the fact that genes and behavior don’t make up a one-way street. Our diet, environment, well-being and actions affect both the expression and evolution of our genes. 5 

Social Solidarity Evidence

Emile Durkheim proposed that suicide rates increase during times of change and crisis because our social bonds, cohesion, and integration are disrupted. 4

A great deal of evidence exists to support the idea that our social environment and practices greatly affect suicide rates.

The World Health Organization recognizes that depression and other mood disorders are linked to suicide and that alcohol and drug use play a large role too, but WHO expounds that “suicide results from many complex factors and is more likely to occur during periods of socioeconomic, family and individual crisis (e.g. loss of a loved one, unemployment, sexual orientation, difficulties with developing one’s identity, disassociation from one’s community or other social/belief group, and honour.” 6

In terms of prevention, WHO says that factors that seem to lessen the incidence of suicide include “high self-esteem and social “connectedness,” especially with family and friends, having social support and being in a stable relationship, and religious or spiritual commitment.” 6

Professor Michael Kearl concurs. He points out that Norway’s low suicide rates may be related to its strong and supportive family environments, that suicide rates fall during war time (we bond as a country then), that one study found that U.S. suicides increased by 360 people for every 1% rise in unemployment and that 30% of youth suicides were of homosexuals struggling with their identity in homophobic communities. 6

Indeed, the words of one youth struggling with his sexual identity illustrate his alienation when looking at couples together in a park. “There’s no belonging. So you’re an outcast. These people looked like they knew where they belonged. There was no place for me to feel comfortable with anyone or anything.” 4

Thomas Joiner, author of Why People Die of Suicide, believes that a lack of “belongingness” is a huge factor in suicide. He points out that suicide is common in the elderly (who lose social ties,) adolescents (who are struggling with developing identity,) and retirees (who suddenly cannot define themselves by a life-long career.) 7

Joiner also believes that residents of the former Soviet Union (countries with the highest rates of suicide in the world) have been cast out of their national identity and social group. 7

The case for the link between suicide and lack of social solidarity can be illustrated by looking at studies of immigrants, religion, media effects and the country of Norway.

Immigrants

The World Health Organization (WHO) and the International Association for Suicide Prevention (IASP) have teamed up to study the causes of suicide and promote its prevention all over the globe.

IASP says that increasing globalization, ease of travel and civil wars have spawned a great number of immigrants worldwide. 8 Being separated from one’s country and ending up where you are considered an “alien” increases the risk of suicide.

IASP is working to implement interventions that address the “specific cultural and religious attitudes” and “family and social structures” of different migrant groups, as well as teaching them coping skills and encouraging them to socialize. 8

An interesting study was done in 2004 on the suicide rates of Russian immigrants in Estonia. 9

Before WWII, the country of Estonia stood apart from its neighbor Russia. After its incorporation into the Soviet Union, Russian immigrants made up 30% of the population in Estonia, where they enjoyed a privileged status.

The researchers studied the rates of suicide among the Russian immigrants, Estonians and Russians at home before and after the dissolution of the Soviet Union.

Originally, Russians that emigrated to Estonia did not have to acculturate. After Estonia became independent, the Russian population has to study Estonian as the official language, apply for citizenship and adapt themselves to a very different social stratum.

The study found that the Russian immigrants experienced suicide rates that were 13.3% higher than native Russians and 22.1% higher than native Estonians.

Another at-risk group is the indigenous or aboriginal youths in Australia, Canada, New Zealand and the U.S. As westernization destroys aboriginal culture and forces them to join the majority of society, suicide rates rise significantly.

Colonization changes their lives drastically, disrupting family and social ties, changing the way they work and live, and results in a lack of secure cultural identity. 8

The North Dakota Adolescent Suicide Prevention Project was able to reduce suicide rates in 10-19 year-old indigenous youth by 47% over 4 years. The project worked to promote community involvement, recognize at-risk youth, and provided mentoring programs to affect the acculturation, guidance and inclusion of the youths. 8

Religion

Religion plays a large role in susceptibility to suicide. It’s not only that some religions strictly forbid or condemn the act as an unpardonable sin (although this plays a part), but the very fact of being part of a group with common beliefs and practices strengthens one’s social ties and personal identity.

In a review of the WHO’s international statistics for suicide, researchers have taken note of the suicide rates by religion. 10

Muslim countries (which strictly forbid suicide) have rates as low as 0.1%; countries that are Hindu have 9.6% suicide rates. Christian countries rank about 11.2%, Buddhist countries 17.9% and Atheists’ top the charts at 25.6%.

In a study titled “Religious Affiliation, Atheism and Suicide,” researchers studied suicide rates to determine if religious involvement lowered the number of suicides. 11

  • The researchers found that participants who did not have a religious affiliation had significantly more suicide attempts over their lifetime.
  • They also found that those same people were less likely to be married, have children or have much regular contact with their families.
  • The subjects without ties to religion reported fewer reasons for living and had fewer objections to the idea of suicide.
  • The unaffiliated participants were also more likely to be impulsive, aggressive and have abused substances in the past (characteristics tied to increased suicide incidence.)

The researchers concluded that religious affiliation provided more social ties and integration, less suicidal behavior (even in the depressed,) greater moral objection to taking their own lives and lower aggression levels.

Media

The media has a huge impact on cultural beliefs and practices. The WHO, IAPS and a host of other agencies are working to combat this effect.

The American Foundation for Suicide Prevention (AFSP)has worked with many agencies to develop media recommendations for responsible reporting on the subject of suicide. 12

Research from these agencies has found that “graphic, sensationalized or romanticized descriptions of suicide deaths in the news media can contribute to suicide contagion, popularly referred to as “copycat” suicides.” 12

AFSP tracks media coverage of suicides and attempts to watchdog the industry. The agency points out that in many circumstances, the media misrepresents the suicide case: attributing it to a single event such as a divorce of job loss, instead of educating the public about underlying factors that contribute to suicide. 12

Instead, the agency believes that the media can use stories to truly educate people on the warning signs and realities of suicide and its successful prevention and treatment. 12

World Health Organization’s Dr. Sarceno agrees. “We would urge that the media show sensitivity in its reporting on these tragic and frequently avoidable deaths. The media can play a major role in reducing stigma and discrimination associated with suicidal behaviors and mental disorders.” 6

In 1986, a study reviewed nationally-televised stories of suicide and the co-occurring teen suicide rates from 1973 to 1979. Teen suicides increased by 7% in the week following 38 broadcast suicide stories. 4

In Hong Kong, suicide is most often accomplished with poison. Media reports of a new way to take one’s life, charcoal burning, caused a large increase in suicide attempts even in those who had no history of such actions. 8

Suicide prevention experts worked to persuade the media to report the suicides more responsibly, access to charcoal was reduced in supermarkets and lodging owners were trained to recognize at-risk people that might be renting a room for the purpose of charcoal burning. The efforts greatly slowed the rate of the suicide attempts. 8

Although Norway has low rates of suicide and strong social cohesion, the “Werther effect” is starting to affect its country’s youth.

Werther was a character in a novel written by Johann Wolfgang von Goethe over 200 years ago. In Die Leiden des jungen Werthers (The Sorrows of Young Werther,) the broken-hearted character dresses in a blue coat, yellow vest and boots, opens a book on his desk and shoots himself.

The image was so vivid for so many young boys that followed in his footsteps; the book was banned from many countries.

Norwegian youth has been affected in the same way. In 1990, researchers found that suicide rates were rising. Bjerke et al. proposed that the increased availability of drugs and guns weren’t the only reason youth suicides were rising but spoke of a “cultural availability”—a Werther effect and spread of suicidal ideation. 13

A more recent study released by the Norwegian Social Research Association (NOVA) studied youth suicides for a decade. The researchers concluded that psychological problems for Norway’s young are only growing worse. 13

Professor Lars WichstrÃm, of the Norwegian University of Science and Technology, believes that substance abuse subsequent family conflicts are part of the problem. 14

He also believes that weight and dissatisfaction with one’s appearance, common themes in western cultures and on TV, increase pressure on Norway’s youth. 14

Norway

Although Norway has enjoyed some of the lowest suicide rates compared to its European neighbors in the past, the rate at which suicides are climbing is alarming.

Any change, good or bad, will disrupt social cohesion. In the way that one can startle a band of butterflies, suicide is a symptom of change. Butterflies make choices, reorganize themselves and settle back down to business.

The advent of the Internet, urbanization, global communication and the Werther Effect are causing casualties as Norwegians go through the same motions of reorganization.

For a long time, Norway’s geography and industry helped preserve its cultural identity and protect it from the negative influence of the rest of the world. As Nils Retterstøl put it, Norway was more “an outpost of Europe.” 15

Today, Norway has the advantage of research to combat the rise of suicide that is plaguing its citizens.

More than 40 years of investigations have looked at Norway’s strengths when it comes to suicide and identified what the most protective characteristics are.

In Suicide: A European Perspective, Nils Retterstøl identifies how well Norway fits neatly into Durkheim’s social theory of suicide, by reviewing the many studies conducted from the 1960’s to 1993. 15

He tells us how Erik Allardt evaluated Norway versus four of its neighbors on social qualifiers such as contentment and satisfaction, and degree of cohesion within a group, family and national origin. Norway scored very high on all qualifiers.

Retterstøl talks about Raoul Norrol’s research for his book, The Moral Order, in which Norrol proposes that close family groups and smaller communities provide strong adherence to norms, protecting citizens from undesirable behavior.

Norrol looked at 12 countries and judged them on 12 parameters that he judged to affect those norms and behavior. He rated Norway number 1 on all 12 and named it the “model country” for others to follow.

Retterstøl believed that Norway’s relative isolation preserved its cultural traditions and strong social identity and cohesion. Norway has been noted for its strong family ties, positive child upbringing, rural traditions, ties to nature, strong religious affiliation and a commitment to community and working for the common good.

But unfortunately we must emphasize that this romanticism of Norway belongs to a bygone era. Norway are on an equal footing with all of its neighbors, and even if Norway lack the EU membership, they are deeply connected to the rest of the world in many ways. Religiosity declines, and Professor Richard Dawkins, a scientist and an atheist, often refers to Norway as an atheist country. Secularization and globalization has taken over and Norway is in the middle of the global culture. The costs of such a process of change within a few decades, maybe just a kind of existential agony and inner turmoil that becomes visible in suicide statistics.

Last comment

Conformity, stability, and a kind of conservatism seem to be preventive factors in relation to suicide, but at the same time these factors might prevent development and change. Great changes are taking humanity forward, giving us new ways to live and wider perspectives, and our pool of information is increasing at a tremendous speed. Much information creates unstable systems that have potential for growth and change, but the cost is thus a kind of existential anxiety that might be associated with suicide. People’s basic fear of change and conservative forces are always working to preserve a kind of status quo (Latin expression for unaltered state).

Sources

1)Befrienders Staff Writer (2009). Suicide statistics. Befrienders [online]. Retrieved from http://www.befrienders.org/info/index.asp?PageURL=statistics.php

2)Bertolote, Jose Manoel and Fleischmann, Alexandra (2002) A Global Perspective in the Epidemiology of Suicide. Suicidologi [online]. Retrieved from http://www.med.uio.no/iasp/files/papers/Bertolote.pdf

3)Savitz, JB, Cupido CL, Ramesar, RS (2006, May 9). Trends in Suicidology: Personality as an Endophenotype for Molecular Genetic Investigations. PLOS Medicine[online]. Retrieved from http://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.0030107

4) Kearl, Michael C. (2004) Kearl’s Guide to the Sociology of Death: Suicide. Trinity University [online]. Retrieved from http://www.trinity.edu/~MKearl/death-su.html

5)Bondy, B, Buettner, A and Zill, P. (2006, February 7) Genetics of Suicide. Molecular Psychiatry [online]. Retrieved from http://www.nature.com/mp/journal/v11/n4/full/4001803a.html

6)WHO Staff (2004) Suicide huge but preventable public health problem, says WHO. World Health Organization [online]. Retrieved fromhttp://www.who.int/mediacentre/news/releases/2004/pr61/en/index.html

7) Joiner, Thomas E. (2005) Why People die by Suicide. The President and Fellow of Harvard University.

8) Religious Tolerance Staff (2009)Suicide: Worldwide efforts to prevent suicide. Religious Tolerance [online]. Retrieved from http://www.religioustolerance.org/sui_world1.htm

9) Värnik, Airi, Kõlves,Kairi and Wasserman,Danuta (2004, September 14). Suicide among Russians in Estonia: database study before and after independence. BMJ [online]. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544990/

10) Bertolote, Jose Manoel and Fleischmann, Alexandra (2002) A Global Perspective in the Epidemiology of Suicide

11) Dervic, Kanita, Oquendo, Maria, Grunebaum, Michael, Ellis, Steve, Burke, Ainsely and Mann, J. (2004, December) Religious Affiliation, Aetheism and Suicide. American Journal of Psychiatry [online]. Retrieved from http://www.adherents.com/misc/religion_suicide.html

12) American Foundation for Suicide Prevention Staff Writer (2009) Reporting on Suicide. American Foundation for Suicide Prevention [online]. Retrieved from http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=0523D365-A314-431E-A925C03E13E762B1

13) Rossow, Ingeborg (1993, May) Trends and Variations in Suicide in Norway. SIFA Rapport [online]. Retrieved from http://www.sirus.no/files/news/346/5-93.PDF

14) African Press Staff (2007, February 6). Norway: Suicide attempt rising among youngsters. African Press [online]. Retrieved from http://africanpress.wordpress.com/2007/02/06/norway-suicide-attempt-rising-among-youngsters/

15)Retterstøl, Nils (1993) Suicide: A European Perspective. University Press, Cambridge [online]. Retrieved fromhttp://books.google.com/books?id=JCCHtVitcKwC&printsec=frontcover&dq=suicide+a+european+perspective&ei=pjQiS5mWMqawywS34rSoCw&cd=1#v=onepage&q=&f=false

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What are the conditions that lead to suicide? The loss of hope, guilt, the absence of a choice, and overpowering grief are just a few of the human conditions that may lead to suicide.

What are the conditions that lead to suicide? The loss of hope, guilt, the absence of a choice, and overpowering grief are just a few of the human conditions that may lead to suicide. At a macro-level, wars may render families asunder and leave members losing the hope and desire for survival while at a micro-level families may fail to provide necessary support to each other in times of difficulty and experience the disastrous effect of chosen death. Circumstances like debilitating diseases with no positive prognosis and the development of depression understandably lead patients to the active seeking of ways to end their lives.

Circumstance as a rationale

As World War 2 drew to an end, Hitler realized that the Allies were gaining power over his armies. Rather than being caught by the Allies and ‘paraded by Mussolini’, Hitler chose suicide as did some of his closest aides (Giblin, 2002, p. 214). The absence of a choice and the circumstances that prevented escape made the choice of suicide the better one. Given the history, Hitler would have been treated with ignominy and would have met a horrible death.

A patient undergoing treatment for depression or a disorder that has led to depression may choose to end the ongoing suffering by committing suicide. In this case, the rationale for suicide arises from the absence of possible medical support or the extenuating circumstances of the ailment. A 70-year old who has lost the ability to do the activities of choice and must live in abject pain and dependence on caretakers may rationally choose to end the dependence. A patient of recurrent cancer episodes may choose death over the disturbances caused by medical treatment and operations. Werth (p. 6, 1999) considers the varying descriptions of rational suicide and concludes that a person who chooses this route must be in a ‘hopeless’ condition, makes a learned decision after appropriate consultation with specialists and family members and takes a rational decision that is based on facts. This is a possible justification for the argument in favour of euthanasia.

There are possible circumstantial justifications for suicide and mature consideration allows one to appreciate the appropriateness of the choice. In the first case, the escalation of events had a devastating effect on Hitler’s sense of insecurity but the final decision and action were taken in an unemotional and planned manner. In the second case, family prevarications and spurious intent can dilute the relevance of the legal right to end a life and lead to a universal negation of the choice. This does not take away from the rationale of choosing to end life when life has lost all meaning.

Mental health care and suicide

As a psychologist and clinician in mental health care, I most often experience that it is my duty to assist patients as far as possible to prevent suicide. In mental health, suicide is often associated with mental illness, and in many cases we see people whose mental imbalance has created a form of “blinders” that prevent a wider perspective. Depression is described by many as a dark tunnel with no end. Frequently life supporting perspectives is overshadowed by depression.

In some respects, you could say that mental health is the ability to take on ever more perspectives on life’s dilemmas, and maintain this ability under stressful circumstances. Conversely, mental illness may be a restriction in the number of perspectives that people can keep in mind regarding themselves and their opportunities. As a therapist you will strive to intervene in a way that makes room for new attitudes and ideas in the depressed mind. You will avoid imposing your own preferences or “worldviews” on the client, but still try to create space for multiple perspectives in the other. The idea is that life lived on narrow or single-minded ideas easily become destructive and harmful. Multiple perspectives create nuances and more spacious attitudes, which might act as suicide prevention. But this applies to people who suffer from mental illness that clouds their judgment, and may be not so much in cases where people see death as the best option based on “logical reasons”. But to distinguish the two groups, is no easy task.

Attitude as a reason

Some people seem to carry an inherent lack of desire for life. Are they born with this or does it develop at some point? A young girl from a loving family attempts suicide because she feels unloved though, paradoxically, she knows she is loved. A man decides against the continuation of life because his girlfriend has walked out on him. Do these circumstances indicate the absence of hope? Yet, the protagonist experiences feelings and personal verbiage that consist of hopelessness and futility. Victims of brutality, war and similar circumstances come out alive, though scarred, and wish to return to the business of living with yearn for the return of happiness. What makes the difference between the jilted lover and the scarred victim in the desire to continue living?

In his book, Frankl (1946) describes the harsh conditions of life in the concentration camps and the unifying desire to see their loved ones that drove prisoners to fight to survive. Yet, every once in a while, the will to continue to live broke and the author observed that death soon followed. In such cases, despite harsh treatment, an inmate would lose hope and died soon afterwards. ‘The prisoner who had lost faith in the future – his future – was doomed… he lost his spiritual hold… let himself decline and become subject to mental and physical decay.’(1946, p. 71)

The compromised surroundings provided a strong context for suicide, yet some continued to live on in the hope of better.

The search for meaning

When I read Frankl the first time, I was both shocked and uplifted. What amazed me most in relation to his observations in the concentration camp, was his theory about who died and who survived. One might expect that man under marginal conditions would fall back on a kind of “survival of the fittest” and that those who grabbed the most food and most benefits would survive. But Frankl paints a slightly different picture. It was not the greedy that survived, but those who in some way managed to keep their “humanity.” Those who continued to believe in the goodness of man, something bigger than themselves, an opinion or an idea of ​​the good, tended to survive according to Frankl. Humanity, kindness, care and the search for meaning was thus more life-maintaining than selfishness when faced with scarce resources. A similar story is found in Sartres chronicle about Brunet. In this book, it is only when the protagonist loses his “ideology” that he seriously suffers from depression and hopelessness to the degree of self destruction.

The ability to create hope, the ability to create meaning and faith in something better is probably decisive factors in how we manage to live and sustain life.

While Nietzsche claimed that man is characterized by the will to power and Freud talked about our drive for reproduction (sex), Frankl talks about man`s search for meaning as the strongest force. No matter how terrible the circumstances are, the belief in something greater might be the key for survival. Such a theory points to the possibility that those who take their lives because of persuasive argumentation (the rational suicide), still find themselves in a situation where they have lost something they can get back, that is the ability to invest meaning in life. The question is thus whether the pain, disability and recurrent tumor are factors that can be overcome by something as abstract as the “will to meaning”. Such an argument might shed a different light on our attitude towards euthanasia or our tacit acceptance of suicide under certain circumstances.

The attitude of self-pity justification

Self-pity arises for the dreariest or most valid of reasons. The absence of a welcoming smile, disregard from surrounding people, stray statements made out of turn, social rejection as a validation for one’s feeling of lack, continued victimization can cause an individual to implode. The notion of continuing injustice by factors beyond one’s control can make the individual enter into a morass of despondency and loss of hope. The search for alternatives shuts down and possibility of positive action is ignored. Loudon Wainwright (1965) discusses the rush of feelings that came up as he contemplated suicide at a brutal boot camp. The regimen was torturous; the climate hot and the surroundings were extremely uncomfortable. He writes that a rush of ‘full-bodied hate and self-pity’ in conjunction with the sharp sting of homesickness brought up an insane and uncontrollable desire to jump under a running truck. This was followed by ‘a feeling of relief and reprieve’ when the truck moved on without him under it.

It is this feeling that makes the difference between survivors of the worst circumstances and the ones who adopt the attitude of suicide as an option. Unlike the rational approach to suicide, the only rationale here is the presence of negative feeling and the rejection or the absence of perspectives or events that may assuage those feelings.

Bibliography

Frankl, Viktor (1946). Man’s Search for Meaning.

Gibbon, Edward (Digitized, 2008). The History of the Decline and Fall of the Roman Empire. Harvard University.

Giblin, James (2002). The Life and Death of Adolf Hitler. Harcourt.

Wainwright, Loudon (1965). The Suicide that Lives in All of Us. Life Magazine.

Werth, James L. (1999). Contemporary Perspectives on Rational Suicide. Psychology Press.

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Suicide is a crisis that will not blow over. The feeling of loss is inevitable; the void of death is permanent. How can we cope in the face of such a crisis?

20-year old Emily chose death. The reasons were hazy to her family. Her 12-year old brother had lost a sister who he had considered his best friend. Her mother was too devastated to search for a reason while her father locked himself in his study for many days. Jilted and homesick, Emily had been alone when she acted.

Suicide devastates the circle of people that have lived, worked or in any way known the victim. Families break down, children and friends undergo depression as they tackle with the loss and the search for reasons why such a step was chosen. Individuals cope differently with some wanting to be vocal and others preferring to stay behind closed doors in the effort to cope. Some people struggle with the pain while others seem to overcome it and return to life as a means of coping. This can lead to conflict within families with different coping mechanisms in evidence. Nothing can help the intensity of feelings that overcome family members and loved ones. Time is believed to heal the pain. The reality is different, secrecy about the reasons for the suicide, the inherent guilt and the absence of open communication between the affected individuals can lead to a lasting sense of loss with a depressed ability to return to life.

Monroe and Kraus (2005, p. 203) consider the existence of communication and support within families as determinants for the capacity to cope with the crisis. This is brought out by a family that avoids references to a ‘dead’ member to save each other from the pain of the memory.

Emily may not have been fully cognizant of her action and the impact at the time, a possibility that dawned on her family over many sessions of therapy. Her parents would recreate the events of the days before she fell, had it been a suicide at all? They would question a variety of possibilities and explore the death from different angles. The absence of answers and the continuous wrangling increased the sense of loss and hurt each member differently. If only I had been with her or if she had chosen to stay with us or if the boy had not or why didn’t her friends … were never-ending cycles of thought that engaged the minds of the family and worsened their feelings and ability to cope.

It was painful and Emily’s brother suddenly found himself mature beyond his years as he tried to cope with his mother’s depression and his father’s morose silence. Isolated and confused at first, he avoided conversation until friends and relatives. Well-meaning friends and relatives got together to be with the family in those stressful moments. Therapy, continuing support from friends and relatives and the young boy’s efforts helped the parents to see that there was responsibility and life to be managed.

Let us consider the impact of communication and shared grief. The initial loss may lead to a variety of reactions but once the initial phase is past, that is once any one of the members of the family wants to talk, it is helpful to sit together and talk. Rather than save each other from the memory of loss, it is better to share the pain of feelings held within. If the process is too painful, seek professional help for the family as a whole. The discussions may be never-ending, they bring no answers but it helps each individual in the family in many ways. The family may cry together as they discuss the loss, they open up about their feelings and helped strengthen the bond between them. When Emily’s friends and parents come to visit them, they may talk about old times and share little snippets that bring up memories of the girl. Yes, there would be tears all around but the family was together and knew they could count on external support.

A time arises when the family is able to make a reference to the dead person and though there are latent feelings of sadness, life has gone on. It is better to communicate and share the feelings of sadness instead of avoiding it. Over time, the ability to discuss the life that has ended and even enjoy positive memories about times spent together increases the ability to bond. Anecdotes that bring a smile to the face or references to lessons learnt from the person during the lifetime make it possible to recall that the life had seen positive moments and happiness.

The absence of this support and vocalization can have a devastating effect on the family. The mother’s depression could have turned her suicidal and created a spiral of suicidal thought in the minds of the others. The father’s silence could have led to strained relations within the family. If the boy had chosen isolation, important family processes and bonding would never have occurred and the family would have come under strain of survival.

Hewett (1980, p. 96) believes that religion can be soothing with explanations about the movement of the soul after death and reassuring the family that their child is in good hands. Further, the acceptance of a higher force in the storm of emotions after a suicide helps the family to return to living positively. The involvement of the community and professionals to help the bereaved family allows for better coping and mutual support.

Suicide is a crisis that will not blow over. The feeling of loss is inevitable; the void of death is permanent. The importance lies in the ability of the affected family to move on while being together after the crisis.

Bibliography

Hewett, John (1980). After Suicide.WJK Press.

Monroe, Barbara & Kraus, Frances (2005). Brief Interventions with Bereaved Children. Oxford University Press.

Editor Sondre Risholm Liverød
Clinical psychologist
for WebPsychologist.net

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The development of an obsessive view with respect to body image to the exclusion of all else can lead to the development of eating disorders and in worst case - death.

Myra was a cheerful outgoing mother of two. At forty two, she had been warned about her excess weight and advised to reduce. She smiled at the doctor and promised to start healthier habits. Of late, she has started hating her body more than ever. Her trim and fit husband avoided having her along for his business parties and the children were embarrassed with her appearance at the parent-teacher interactions. Being 35 kilograms overweight had led to joint pain, difficulty in sleeping and a continuous difficulty in breathing. She tried to start walking but her knees gave way and her back groaned. Her half-hearted efforts to lose weight had come to naught.

Her favorite comfort food – fries. She has been unhappy with her weight for long but it was difficult to see her loved ones viewing her with the disgust she viewed herself with. Her cheerful countenance and advice to others at the centre belied her feelings of inadequacy and loneliness.

She spoke to her husband as he responded with little involvement about her plan to lose weight. This time, she was serious. She made lifestyle changes necessary to reach her goal – her family was going to be proud of her. Snack items were banished from the kitchen (as a magazine had advised) and food portions curtailed to a quarter of the original. Fats were completely banned. Her family did not take her seriously and continued to bandy her favorite snack items and offering them to her. She was soon sneaking small snacks into the house. She gained weight and obsessed about it even more. She could never say when it happened that she started to binge and silently throw it up later. It was the perfect remedy. She was having her cake and eating it too.

After continuous disappointment on the scale, Myra started losing weight, rapidly. She was overwhelmed, she had hit upon the right method. Within less than a year, she had reduced 30 kilograms. She maintained a happy exterior but an unexplained sadness had overtaken her senses. She was increasingly confused and disoriented. She cried a lot over nothing. She started losing interest in the children’s activities, though she maintained she loved them. She had expected to lose weight and feel cheerful, but this was just the opposite. With time, smiling became a chore. Her 10-year old daughter who loved her mother to bits often reported that ‘Mummy was crying in the bathroom,’ to her father. Earlier, Myra used to look forward to the moment her children returned from school. She would make them snacks and listen to all the stories about their day at school. Of late, she has opened the door for them and lay down after they entered the house. She would lie in bed listlessly while her kids trooped into her room and regaled her with stories. Her son had been selected for the soccer team, her daughter was in a play, she has tried to smile, but given up.

Myra’s husband, indifferent at first, started observing his wife. The weight loss wasn’t doing her beauty much good. Her facial skin was sagging and wrinkled. At least she seemed to be reaching a healthy weight. She seemed to need a lot of sleep and her desire for neatness seemed to have reduced drastically. He had heard her retching in the bathroom a few times but she always passed it off as a minor stomach upset. She seemed to miss meals and was often quiet, trying to get her chores done for the day. Everything was okay, he returned to a state of mild indifference. Physical relations between Myra and her husband were at an all time low. Communication has completely stopped, even the short ‘how was your day’ lies ignored. He has been stressed because of work while she…

Due to insomnia, he had opted to use sleeping pills. They led to difficulty in waking; he stopped using them and left them in the drawer.

One morning, Myra did not wake up. Her husband checked her forehead, no fever. Her daughter ran in and hugged her goodbye before leaving for school; Myra did not open her eyes. Her 12-year old son came and kissed her forehead, she did not respond. He asked his father, ‘Is Mummy taking some sleep medicine?’

Startled, her husband rushed to the drawer where his pills had been kept. The bottle was empty.

Myra had overdosed on sleeping pills. She was rushed to the hospital and saved in the nick of time. Surely it had been a mistake, her husband justified. It had been dark, she tipped the pills into her mouth and by mistake, more than one had been consumed, she explained. The medical practitioners were not convinced.

She was visibly distressed by the injections being administered. ‘Please you have stop all these medicines; I don’t want to put on weight again,’ she explained. She fretted about the calorific value of the medicines that were being forced into her body.

When her daughter and son visited, the girl snuggled up to her and asked, ‘Mummy, you won’t die and go, right?’ Her son watched her from a little distance. Myra looked at her, vaguely comprehending but not responding. The girl’s chin trembled as she looked to her mother for succor. Myra was weeping again. She did not understand her feelings or lack of them. She cared but felt strangely empty. She understood her daughter’s distress but did not feel moved to reduce it. Her son’s confused silence would normally have pained her, now she felt nothing. She wished she could feel…

What is the problem?

Understand the brain

Schmidt (2006, p. 15) describes the brain as being largely made up of fats, ‘especially fatty acids which we get directly from our food.’ The author describes the brain as a network of ‘nerve fibers that hard-wire one area to another, branches that connect diverse regions and junctions that allow for communication.’ The nerve cells possess a membrane that consists of fat. Complex bodily functions require speedy transmission of nerve impulses. This is made possible by myelin, a mix of fats, fatty acids, cholesterol, phospholipids and protein. All these components must come from the diet since the body cannot produce on its own.

Bulimia

When a family member embarks on a weight loss program, family support includes being aware of mood disturbances or behavioral changes. The development of an obsessive view with respect to body image to the exclusion of all else can lead to the development of poor habits that seem to serve the purpose. The loss of nutrition due to voluntary expulsion after consumption is an eating disorder and has long been recognized as putting people at an increased risk of suicide. Tatarelli, Pompili and Girardi (2007, p. 155) quote the observation of Orbach that ‘dissatisfaction with the body can increase suffering and intensify self-destructive tendencies.’ Bulimia is explained by Watson (2007, p. 6) as a ‘type of eating disorder in which a person binges and purges.’ This disorder has numerous physical and mental health implications.

Depression

Depression is a disorder of the mood that may pass on or stay to convert into a severely disabling condition. Ainsworth describes the condition as being like a thief that sneaks into a ‘life gradually, robbing it of meaning, one loss at a time.’ Myra requires psychiatric help and a study of the various factors that are causing her spiral into depression and possible suicide. The connection between food, the state of mind and suicide must be clearly understood when undertaking a body shape correction. Myra’s extreme food deprivation has led to cognitive difficulties and makes the likelihood of grievous mistakes recurring in the future.

Schmidt (2006, p. 145) opines that there is a connection between fat consumption and depression. ‘Elevated blood cholesterol and triglycerides’ cause the blood to thicken and slow oxygen supply to the brain and create conditions like depression and other disorders. The author refers to an old book that recommends a diet prescription for depression ‘low-fat diet, borage oil and consumption of fish. For severe cases… cow brains.’ Myra has been on an all-food binge and purge diet and this has led to physical and mental disarray. The attitude of the husband towards his wife and underlying depressive factors requires immediate attention.

Bibliography

Schmidt, Michael A. (2006). Brain-Building Nutrition. Frog Books.

Tatarelli, Roberto, Pompili, Maurizio & Girardi, Paolo (2007). Suicide in Psychiatric Disorders.Nova Publishers.

Watson, Stephanie (2007). Bulimia. The Rosen Publishing Group.

 

Editor Sondre Risholm Liverød
Clinical psychologist
for WebPsychologist.net

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Are there situations in which suicide represents a good choice? Are we allowed to take our own lives? Suicide is not just about personal crises and psychology but also about philosophy and sociology.

The Social Theory of Suicide

Suicide has a very strong social component. The field of sociology grew upon the realization that suicide rates vary with sociological components, that suicide is not simply a psychological occurrence (Kearl, Michael C., 2004).

We come to perceive ourselves by the rules and norms that we learn in society, by the morality and roles that the different social groups we belong to mirror for us (Kearl, Michael C., 2005).

Once we have developed a sense of self, we are able to join in the construction of social reality with other people and give meaning to our life and actions (Kearl, Michael C., 2005).

The types of social groups we belong to, the strength of those bonds and the amount of deviance from those norms result in how much social cohesion or solidarity we have with others and how closely or distantly we view ourselves as members of any given group (Kearl, Michael C., 2005).

French sociologist Emile Durkheim was at the root of the sociological perspective of suicide.

Durkheim found that crisis and change (positive or negative) can disrupt social solidarity and increase the rate of suicide. He also purported that these bonds evolve over a long period of time so changes can leave both individuals and groups suffering from the sudden break and period of weak or nonexistent social bonds (Kearl, Michael C., 2005).

An economic boom can disrupt the social order and increase the rate of suicide and war can actually cause people to bond more closely together. Durkheim found that suicide rates were increased in certain social groups: single people, Protestants, and city-dwellers(Kearl, Michael C., 2004).

The lack of strong bonds with other people or groups and sudden changes in groups leave people wrestling with their identity, life-meaning and sense of belonging. Durkeheim said, “No individual is sufficient unto himself, it is from society that he receives all that is needful.” (Kearl, Michael C., 2005).

 

Four types of suicide

This discovery led Durkheim to argue that levels of social integration and regulation impact suicide rates. He believed that there were four types of suicide:

Egoistic: a result of too little social integration, when social bonds are weak or broken

(For example, the suicides of the isolated elderly)

Altruistic: a result of too much integration, when the self is subsumed by the group norms

(For example, the suicides of terrorist suicide bombers)

Anomic: a result of too little integration, when a social group is unable to fully integrate an individual and they suffer from a loss of meaning

(For example, the suicides of those whose ties have been broken with societal groups like retirees and the newly divorced)

Fatalistic: a result of excessive regulation and a need for control, when pressures to fall in with social rules are extreme and the individuating self wrestles with this pressure

(For example, high academic achievers who commit suicide after failing an exam)

Many studies have found evidence to support Durkheim’s social theory of suicide. (Kearl, Michael C., 2004 & 2005)

  • Norway has only 1/3rd the suicide rate that Denmark and Sweden have although residents of the three countries have similarities in genetics, culture and geography. It is argued that tight-knit and supportive family practices in Norway create the disparity.
  • Homosexuals account for 30% of youth suicides.
  • In the 1980’s, the number of suicides in the U.S. increased by 360 cases for every 1% rise in unemployment.
  • Immigrants experience a higher risk of suicide (Värnik, Kõlves,Kairi and Wasserman, 2004).
  • A study of Canadian youths found that those who experience ambiguity about their identity and future life-roles have a higher rate of suicide as compared to those who are entrenched in traditional culture with group involvement and planning (Development and Suicide: A Study of Native and Non-Native North American Adolescents).

 

Philosophical Timeline: Suicide

The right of individuals to commit suicide has long been argued, pro and con, throughout history.

Plato felt that suicide was an act of weakness or cowardice, a sign of an individual’s inability to weather the ups and downs of life. Aristotle felt that suicide was a kind of crime against society. These philosophers defined individuals in terms of their social roles and obligations (Cholbi, 2008).

Stoics such as Cicero believed that our nature depends upon having certain “natural advantages,” and that a wise man can recognize when “natural advantages” such as health and livelihood are lacking. Ending one’s life does not make one immoral, simply wise. The stoic Seneca believed that quality of life was superior to quantity. He said that “mere living is not a good, but living well.” (Cholbi, 2008).

Christianity has condemned suicide as a mortal sin. Thomas Aquinas held that suicide is an enemy of innate self-love, is injurious to the community and violates our duty to God to cherish the life he’s given us (as well as His authority to choose when and whether we live or die.) In Christianity, our bodies and lives are not our own—they’re on loan from God.

The Protestant religion was influenced by ideas of personal liberty during The Enlightenment. This religion lessened the severity of the sin of suicide, choosing to believe in the mercy and possibility of forgiveness from God for such a transgression (Cholbi, 2008)

In 1607, John Donne questioned the nature of suicide as a sin. He held that by Christian reasoning, any type of self-denial could be considered a sin against God and pointed out that Christians have regularly sanctioned the breaking of the “Thou Shalt Not Kill” commandment in terms of martyrdom, capital punishment and war.

David Hume believed strongly in the doctrine of personal liberty and self-determination. He argued that suicide “may be free of imputation of guilt and blame.” (Cholbi, 2008)

A variety of trends in the 19th and early 20th centuries changed the perspective of the arguments about suicide. Rather than arguing about a person’s will versus God’s, suicide came to be viewed as a result of the suffering society placed upon an individual. People that took their own lives were not viewed as weak but as victims who were almost justified in their actions.

Romantic novels in which “suicide was the inevitable response of a misunderstood and anguished soul jilted by love or shunned by society” emerged. Psychiatry emerged as a field and mental illnesses were thought to cause suicide. Sociology put forth that alienation in the modern world gave rise to suicide. (Cholbi, 2008)

Existentialists in the 20th century saw suicide as a response to the “absurdity or meaningless of the world and of human endeavor.”   Camus thought that suicide was still an escape from confronting absurdity in life while Sartre viewed it as an assertion of human will. To these philosophers, the individual is the source of all meaning (Cholbi, 2008)

The morality of the act of suicide has arisen again today. With the advent of suicide bombers and euthanasia, some believe that in some cases suicide may be obligatory or honorable—that it just makes the most sense in some cases. A soldier who sacrifices his life for others, a doctor who supports a terminally ill patient’s wish to end their suffering—questions like these have an assumption of rational choice behind them (Cholbi, 2008).

But how rational is a person who is in pain and depressed? How rational is the person who is so consumed with hopelessness that they cannot consider the possibility of happiness in their future or recognize that perhaps “This too shall pass?”

Suicidal people are often anxious and impulsive. They may consider death an entrance to a new life rather than the end of the old one. Suicidal impulses often dissipate on their own when they’re not acted upon. Depression is often a factor in suicide and depression affects cognition (Cholbi, 2008)

Philip Devine argues that suicide is irrational because without knowledge and experience of death, an individual cannot make comparisons or judge life with the alternative (Cholbi, 2008).

Suicide is too complex a topic to argue for or against based upon singular perspectives. We are all systemic, and a number of factors influence the role and meaning of suicide in our lives. Suicide is a loss, and it is a symptom.   It causes ripples in society and is affected by cultural developments.

In the end, we do not know enough to condemn or support suicide, though it is always something to mourn. Social solidarity does impact the incidence of suicide, and so perhaps the act is a wake-up call for society when it occurs. And who is to say what is one’s own will and what may be God’s as well?

 

Sources

Cholbi, Michael (2008) Suicide. Stanford Encyclopedia of Philosophy [online]. Retrieved from http://plato.stanford.edu/entries/suicide/

Development and Suicide: A Study of Native and Non-Native North American Adolescents. Wiley [online] 68:2. Retrieved from http://www.wiley.com/WileyCDA/WileyTitle/productCd-1405118792.html

Kearl, Michael C. (2004) Kearl’s Guide to the Sociology of Death: Suicide. Trinity University [online]. Retrieved from http://www.trinity.edu/~MKearl/death-su.html

Keller, Michael C., A Survey of Nanot (2005) Technology: Possibilities and Possible Ramifications. Kellered [online]. Retrieved from http://kellered.blogspot.com/2005/12/social-solidarity.html

Värnik, Airi, Kõlves,Kairi and Wasserman,Danuta (2004, September 14). Suicide among Russians in Estonia: database study before and after independence. BMJ [online]. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC544990/

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The question is whether some people are more prone to suicide than others? If so, the challenge is to recognize these people and provide help as early as possible. But what kind of help is needed?

Are some people more susceptible to suicide than others? Suicide is very complex, of course, and involves many factors.

Mental health disorders, especially depression and substance abuse, are most closely linked to suicide. Depression doesn’t necessarily lead to suicide, only about 25%-30% of people suffering from depression attempt suicide, but 90% of those who do attempt suicide experience depression beforehand. 1

Males die are four times more likely to die from a suicide attempt than females, but women attempt suicide three times as much as men. 1

A 2005 review of published studies on suicide found that much of the research found hopelessness, neuroticism and introversion related to the incidence of suicide. 2

A 2008 Zurich study found that most depressed people don’t attempt suicide. The 25% that do had a combination of externalizing traits and internalizing traits. 3

Externalizing traits were defined as aggression, conduct problems and impulsivity. Internalizing traits were defined as depressive personality, high neuroticism, poor coping skills and low self-esteem.

What does this mean?

Impulsivity

A number of studies tie impulsivity to suicide. In people that think things through, the suicidal impulse will usually pass.

One long term study followed impulsive toddlers for decades. Impulsive three year olds had an increased risk for attempted suicide by the time they were 21. 4

Another study found that impulsivity was a key factor in both attempted and completed suicide. 5

Psychotherapy for regulating emotions

In psychotherapy patients engage in a conscious effort to reflect on their own feelings and thoughts. People often experience powerful emotions that put all rational thought out of the game. They run the risk of acting impulsively in a situation they really should have thought twice about. The technique of psychotherapy is to train self-awareness, or the ability to reflect on our “inner lives” and emotional responses, so they lose some of their impulsive force.

Trauma and various types of neglect may cause poor skills regarding the ability to understand, tolerate and examine our impulses and impressions in difficult situations. Thus, there is a risk of acting too quickly on the emotional turbulence instigated by negative ideas, and the risk of doing something rash is of course present.

Aggression

Suicide is an aggressive act. Research has found that those who were often involved in physical fights often had violent (and so more successful) suicide attempts. They were more likely to have been arrested or have a criminal record and a study in South Africa found that conduct disorder was the most common diagnosis in suicidal adolescents. 5

Conduct disorder is defined as chronic behavioral problems such as antisocial behavior, criminal activity, defiance and impulsivity.

Aggressive feelings and actions in children treated at a child guidance clinic turned out to be a good predictor of those who later committed suicide. 5

Alcoholism increases aggression in those who have committed suicide and adult men who have committed suicide were found to have high spontaneous and reactive aggression scores. 5

Aggression isn’t always physical or overt. Defensiveness, being reactive, manipulative or driven for certain outcomes are examples of aggression too.

In many cases, a distinction is made between reactive and proactive aggression, whereupon both categories are associated with increased suicide risk. Reactive aggression is often a stable tendency to get angry in the face of frustrations, obstacles or provocations. In such situations one allow anger and outlet in negative actions. (Dodge, 1991)12 This form is overlapping with other terms such as “hostile aggression” and “emotional aggression”. (Berkovitz, 1993)13.

Reactive aggression is characterized by

• “warm-blooded” – Easy emotionally activated.
• Often captured by the moment – “boiling over” emotionally – the feelings can’t be regulated properly so the overwhelming emotions translates into an attack – with intent to harm.
• Not thinking clearly, but psychologically caught in the violent impulse.
• High risk of rejection (rejected). Interprets signals from the other with a negative trend (misinterpret).
• Narrow or compromised ability to interpret the situation. Strong tendencies for suspicion and distrust, which creates distance to others. They often provide a kind of hostile atmosphere.
• Concerned with aggressive images, symbols, language and so on.
• Have low status and lack popularity among peers.
• The prognosis appears to be relatively low and constant.

Proactive aggression is characterized by

• “Cool – calculating aggression”.
• Can lead to high social status in peer groups.
• Egocentric goals. Open aggression when necessary for obtaining their goals.
• Often respected in peer groups. Leadership skills.
The point is that many studies suggest that successful suicide attempt is associated with an aggressive style, which of course also about impulsivity and inability to manage emotions and impulses through reflection and rational consideration.

Introversion

Introversion involves having little preference for the company of other people. Introverts like to focus on one thing at a time and don’t enjoy crowds. Their lesser amount of social bonds may increase feelings of alienation when depressed.

Not all suicidal people are introverted but many suicidal patients have been found to be shyer, less optimistic and have less social supports. 5

Neuroticism

Neuroticism describes people who tend to quickly and easily experience anger, anxiety, depression, guilt and other negative emotions. 5

Neuroticism has been consistently linked to thoughts of suicide, attempted suicide and completed suicides. 5

The long term study that followed children for 21 years also found that high degrees of neuroticism were linked to later suicide attempts. 5

Social Integration

Suicidal people often have poor social integration and social bonds. One study found that depressed people make little eye contact when they’re speaking with others and don’t engage in much nonverbal communication, which accounts for 90% of our interactions with others. Head-nodding, or affirming what someone else is saying is a common way to strengthen communication and social bonding. 6

Suicidal people are also more likely to have experienced destructive environmental influences on social integration such as: 7

  • Crisis situations or adverse life events
  • Divorce or separation
  • Exposure to the suicides of others in the community, home or in the media
  • Family history of suicide
  • Family evidence of mental disorder
  • Incarceration
  • Firearms in the home
  • Neglect
  • Physical or sexual abuse
  • Substance abuse

Heredity

Considering that exposure to familial suicides and mental disorder influence the risk of suicide, many have wondered whether suicidal tendencies are genetic.

Genetic research has found that some personality traits are partly inherited. Certain genes have been found to be associated with aggression, impulsiveness and negative affectivity, traits that characterize suicidal people.

The 5-HTTLPR gene seems to influence how people handle stress. One study has found that 5-HTTLPR plays a role in mood disorders and violence and aggression in alcoholics and heroin addicts, but the link to increased risk of suicide is not clear.

MAO-A and COMT genes are associated with violence and aggression as well, but don’t show a relation to suicidal behavior.

The SERT gene is associated with anxiety-related personality traits.

All humans have the potential for aggression so creating a strong link to genes and suicide is difficult. Environmental factors seem to be a much stronger predictor of suicidal personality traits and environmental factors affect the expression and evolution of our genes. 5 & 8

Bipolar Disorder and Schizophrenia

Two disorders that do have genetic components are bipolar disorder and schizophrenia.

3% of patients with bipolar disorder die by suicide. 25%-90% make at least one suicide attempt. Hopelessness is the major risk factor associated with suicide by those with bipolar disorder.

20%-40% of schizophrenics make suicide attempts and 10% are succeed. Depression is the major risk factor in schizophrenic suicide. 1

Creative Personalities and Suicide

The suicides of famous artists have dominated the media for hundreds of years. Research does show that creative people, famous or not, does predispose people to depression and suicide.

Artists tend to be more introverted than most and follow their creative impulses.

Bipolar disorder is the most common affliction of creative people. Characterized by manic episodes of high energy, creativity, impulsivity and explosions of thought, these highs are what artists live for.

It’s the lows that follow—severe depressive episodes that deaden the feelings, inspiration and ability of the creative person—that make life unbearable.

Bipolar patients often go off medication that stabilizes their mood because they miss the highs and inspiration that comes with it. Lithium makes many feel deadened compared to the depth of feeling that they’re used to and their work suffers for it. Their creativity seems to be intricately linked to the disorders they endure.

This population of people tends to use alcohol and drugs to self-medicate, exacerbating depressive symptoms in the long run.

Examples

Poets and writers are four times more likely to suffer from affective disorders. Sylvia Plath, Anne Sexton, Ernest Hemingway and Virginia Woolf committed suicide due to their illnesses.

Visual artists Michelangelo, Georgia O’Keefe and Jackson Pollock suffered from depression. Van Gogh and Mark Rothko died of suicide.

Kurt Cobain, Tchaikovsky and Cole Porter are among the many musicians that suffered from affective disorders.

Effective Treatment of Suicide

The World Health Organization has worked with agencies all over the globe to help identify, treat and prevent suicide.

Their research suggests: 9

  • Reducing availability of suicide methods—guns, drugs and pesticides—seems to help reduce suicide rates
  • Education, prevention and treatment of alcohol and drugs reduces suicide rates
  • Education, prevention and treatment of depression reduces suicide rates
  • Crisis management, self-esteem enhancement, teaching coping skills and decision-making helps reduce youth suicides
  • Media management can reduce the number of copy-cat suicides
  • Immigrant support can reduce suicide numbers

“Mental disorders are not always the greatest risk factors for suicide,” says authors of Reducing Suicide: A National Imperative. 10

In India (and in Indian immigrants), humiliation, shame, economic hardship, failing exams and family disputes are the greatest risk factors for suicide.

In Norway, family strife influences rates of suicide and in Eastern Europe, political and national identity loss has created the highest rate of suicides in the world.

Antidepressants are commonly prescribed to treat depression and suicide. Their effectiveness is ambiguous however. Some pharmaceutical companies have not reported the effectiveness of placebos in relation to the drugs. In some cases, placebos have worked just as effectively as an antidepressant almost half the time.

That’s not to say that antidepressants don’t help many. They can be life-savers for some. People react in unpredictable ways to antidepressants: what works for one person wont’ work for the next. Side effects are another drawback of antidepressants.

Finding the proper medication involves several attempts and lots of patience: it takes up to 6 weeks for antidepressant medications to begin to have effect.

Certain types of psychotherapy have proven effective in treating depression. 11 Both Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) have proven especially useful.

80% of the elderly have found relief from depression with medication, psychotherapy or a combination of the two. 12

Recent research has discovered that a combination approach is most effective in older adults and that those who received IPT and the antidepressant nortriptyline were much less likely to experience a recurrence of depressive episodes than those who received medication only or therapy only.

In the end, social support that includes education and self-management skills about depression, substance abuse, child-rearing practices, impulse-control, social involvement, stress management, decision-making, treatment options, positive thinking and lifestyle choices can greatly reduce the incidence of suicide no matter the risk factors involved.

Sources

1)American Foundation for Suicide Prevention Staff Writer (2009) Risk Factors for Suicide. American Foundation for Suicide Prevention [online]. Retrieved from http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=05147440-E24E-E376-BDF4BF8BA6444E76

2) Brezo, J, Paris, J and Turecki, G (2005, October 5). Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review. Interscience [online]. Retrieved from http://www3.interscience.wiley.com/journal/118626217/abstract?CRETRY=1&SRETRY=0

3) Angst, J; Gamma, A; Ajdacic-Gross, V; Rössler, W (2008). Personality traits of subjects attempting suicide: results of the Zurich study.Zurich Open Repository and Archive [online] 3(1):315-321. Retrieved from https://www.zora.uzh.ch/6794/

4) Savitz, JB, Cupido CL, Ramesar, RS (2006, May 9). Trends in Suicidology: Personality as an Endophenotype for Molecular Genetic Investigations. PLOS Medicine [online]. Retrieved from http://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.0030107

5)Savitz, JB, Cupido CL, Ramesar, RS (2006, May 9). Trends in Suicidology: Personality as an Endophenotype for Molecular Genetic Investigations

6) Joiner, Thomas E. (2005) Why People die by Suicide. The President and Fellow of Harvard University. Retrieved from

http://books.google.com/books?id=C7uiA5EB5GAC&pg=PA70&lpg=PA70&dq=suicide++identity+Joiner&source=bl&ots=L3BeYpmZG7&sig=rGmjDKw-dIVPZwl1UZzmomoyTWA&hl=en&ei=Tl4hS9qjIYjIlAei1LiFCg&sa=X&oi=book_result&ct=result&resnum=7&ved=0CCMQ6AEwBg#v=onepage&q=&f=false

7) New York Times Staff (2009, December) Suicide and Suicidal Behavior. New York Times [online]. Retrieved from http://health.nytimes.com/health/guides/disease/suicide-and-suicidal-behavior/overview.html

8) Bondy, B, Buettner, A and Zill, P. (2006, February 7) Genetics of Suicide. Molecular Psychiatry [online]. Retrieved from http://www.nature.com/mp/journal/v11/n4/full/4001803a.html

9) WHO Staff (2004) Suicide huge but preventable public health problem, says WHO. World Health Organization [online]. Retrieved from http://www.who.int/mediacentre/news/releases/2004/pr61/en/index.html

10)Goldsmith, SK, Pellmar, TC, Kleinman, AM and Bunner, WE (2002) Reducing Suicide: A National Imperative- Chapter 3: Psychiatric and Psychological Factors. The National Academies Press, Washington D.C. [online]. Retrieved from http://www.nap.edu/openbook.php?record_id=10398&page=69

11) Wrong Diagnosis Staff (2009) Discussion of treatments for Suicide. Wrong Diagnosis [online]. Retrieved from http://www.wrongdiagnosis.com/s/suicide/treatments.htm

 

The WebPsychologist.net Writer Staff