Accidental Overdose - or Suicide?

 

There has been a lot of news recently about the significant increase lately in the number of drug overdoses resulting in fatalities. Most of these overdoses are labeled “accidental,” and surely many of them are. Of course, if drugs have been secretly laced by dealers with something dangerous like fentanyl, and the addict is unaware of that, the overdose can indeed be accidental. Although not necessarily even in that case, because news about the fact that dealers are lacing other drugs with this one has been widely reported in the press, and many addicts know other addicts.

 

I suspect that a considerable portion of these “accidental” overdoses are actually suicides, either through specific intent at that particular moment, or through strong chronic suicidal intent leading to carelessness that will certainly cause death, but at some unpredictable time.

 

There is no way to know for certain, obviously, but I would like to discuss the deaths of two celebrities to illustrate my thesis here: actor Phillip Seymour Hoffman and Americana singer-songwriter Townes van Zant.

 

Van Zandt wrote numerous songs, such as "Pancho and Lefty", "For the Sake of the Song", "Tecumseh Valley", "Rex's Blues", and "To Live Is to Fly", that are widely considered masterpieces of American songwriting.  

 

Van Zandt died on New Year's Day 1997 from cardiac arrythmia caused by health problems stemming from years of substance abuse.  In 1994, he was admitted to the hospital to detox, when a doctor told Jeanene Van Zandt that trying to detox Townes again could potentially kill him. He grew increasingly frail during the mid-1990s, with friends noting that he seemed to have "withered.”

 

The evidence for my viewpoint comes in the shape of the lyrics of a song he wrote called “Waiting Around to Die.” I suspect that this is exactly what he was doing.

 

The lyrics:

Now I'm out of prison
I got me a friend at last
He don't drink or steal or cheat or lie
His name's Codine
He's the nicest thing I've seen
Together we're gonna wait around and die
Together we're gonna wait around and die

 

 Hoffman told friends he feared he would die of a heroin overdose weeks before his body was found on the floor of his Manhattan bathroom with a needle sticking out of his left arm. The star, who was found with 70 bags of heroin and 20 used needles in his home, returned to AA in December after relapsing into three-day binges. When asked how serious his addiction was, he replied: “If I don't stop now, I know I'm going to die.” And die he did. On 2/2/14, he was found dead in his New York apartment with a needle in his arm. The New York City Chief Medical Examiner said that he died of an accidental overdose of drugs, but one has to wonder how an “accident” can be predicted with such precision.

Book Review: The Shattered Oak by Sherry Genga

 

This involving book, based on a true story but with some facts altered, is written as a first person account (although it is not the author's story) from a woman involved in a severely physically and emotionally abusive marriage. The author takes the reader on a fascinating tour inside her mind and thought processes.

The book strongly implies that she made no effort to leave for many years, and says that her parents refused to help her do so, under the rationalization that they were too afraid of her husband. She finally does leave and files for divorce. The narrative does not discuss the husband’s behavior during the divorce, but it appears that it went fairly uneventfully and without any stalking by her ex. She received the house and custody of their three daughters in the settlement, and her ex seems to have made alimony payments regularly.

Three years later she has a “nervous breakdown,” and describes in vivid terms her overwhelming sense of doom due to her depression. She makes three serious suicide attempts, and describes her ambivalence over abandoning her children and leaving her eldest daughter to take care of the other two, while all the while also feeling tremendous guilt over her daughter having had to take care of her in a parent-child role reversal.

She finally gets committed to a horrible mental hospital and given ECT against her will. Although she does not say she was diagnosed with major depressive disorder, her disturbing descriptions of her thoughts and feelings while in the depressed state are impressive, and give the reader a sense of what it might be like to have been in her shoes. It later turns out that she did not have a typical major depressive disorder, but one caused by a medical disorder, Cushing’s disease, which leads to very high level of the stress hormone cortisol, a steroid. A major depressive syndrome is seen in 50%–70% of the cases of Cushing’s syndrome. 

She opines that the high levels of cortisol may have come from high levels of stress, which, she implies, seems to have increased rather than decreased after she got out of the marriage. As it turns out, however, that was not the case at all. Her disorder was caused by a tumor of the pituitary gland.

It does not mean that anyone is “blaming” her for the severe abuse she suffered, but it is extremely important in the mental health field's attempts to prevent others from following in her footsteps, to pose the question of why she stayed with her husband for so long, and why she felt more stressed out after the divorce than during the time she was with her husband. There is no way we can know the answers to this question for certain just from the descriptions in this book, but there are several tantalizing clues.

The usual excuses offered up to justify the behavior of women who repeatedly return to an abusive relationship often do not hold water, but especially so in this case. As per her own description, she was in far more danger of being killed by him over the long run if she stayed than if she left. While they were together, he constantly threatened to kill her and even fired gunshots at her, narrowly missing her head on purpose. There were literally bullet holes in the walls.

She also knew very well that he was violent before they were married, because there were episodes of it back then.

And why would she be more stressed out after she left if, as it seems, her ex was not stalking her? The narrator admits that she still loves her husband even after the divorce despite all the pain he put her through. She offers a very interesting hypothesis about why he abused her: he came from a highly abusive family himself, and was taking his anger out at them on her. The question she keeps asking herself is how she could have helped this man to become less bitter. Presumably, how else. What she had been doing clearly did not work. Her question is consistent with my hypothesis about  this case

Readers of this blog can probably guess what that hypothesis is: the odds are pretty good that she was sacrificing herself so that her husband, whom she loved, could continue to channel his destabilizing anger away from his own parents, and that her doing something like this might have also been her role in her own family of origin. You know, the family that refused to help her leave her husband. At the end of the book we find reasons that this hypothesis would certainly necessitate further exploration. 

She was treated like a servant by her own parents growing up, especially compared to her two siblings, who could seem to do no wrong in her parents' eyes. Her older brother finally tells her that she was the result of an affair that her mother had had with a neighbor, and she was not her father’s biological daughter. Might the father have taken his anger at her mother out on her, with her mother going along with the program in order to keep the family together? You be the judge.

I wonder what her parents' upbringing might have been like.

Debate over “No Suicide Contracts” presumes Patients are All Alike

An article entitled No Suicide Contracts: Can They Work by Caroline Roberts M.D. came out in the August 2020 issue of Clinical Psychiatric News. No suicide contracts (NSC’s) had been given for years by therapists and psychiatrists to potentially suicidal patients. The contract essentially gets the patient to sign off on a statement that they will not kill themselves. Alternatively, the patient commits to calling someone if they think they might make an attempt. Some NSC’s ask them to call a suicide hot line, while others say to call the therapist.

 

For quite some time now, however, use of NSC’s has been discouraged in the literature because they may give therapists a false sense of security. There is no clear-cut evidence that they are “effective.” In some populations, such as borderline personality disorder (BPD) where the patient may want to invalidate the therapist, they might even backfire. Or patients may not keep their word because they know the therapist might commit them to a mental hospital. They might not want to go there.

 

Dr. Roberts (“She helps you to understand and does everything she can” ~ say the Beatles) makes the obvious point in her article that the answer to the question of whether NSC’s can work “is conditional on the unique combination of patient, clinician, and therapeutic relationship.” And, I might add, the unique family dynamics and history of prior treatment that each patient brings to therapy. How could anyone think that the question of whether any intervention either will or will not work does not depend on everything that has happened before, during, and after the signing of the contract – both in the patients’ lives and in their relationship with the therapist?

 

This is yet another example of the ecological fallacy, in which an entire group of people is characterized just by its average member. It’s like the old joke about a drowning victim who couldn’t possibly have died in a certain lake because its average depth is only three feet!

 

Of course, no intervention is going to be effective 100% of the time in anyone. For one thing, new things can happen to a patient in between therapy sessions. Family fights can break out or people can be dumped by lovers. A loved one might even pass away.

 

Telling a patient to call a hot line will generally be less effective than if the patient can talk to the therapist personally. The patient may think (and I agree) that therapists should care enough to be available during emergencies, and to have someone who can substitute for them if they are not available. Therapists should also know how to empathically get patients off the phone in non-emergency situations.

With patients with BPD, therapists will most likely have better results with an NSC if they have validated their patients without having fed into their false selves.

The therapist can ask patients if they are afraid they might be committed, and let them know that commitment will only be used as a last resort to save the patient’s life, and that the therapist realizes that patients can feel even worse when thrown into a mental hospital.

 

Simple answers to complex questions are usually simple minded, as they are here, and are only employed by simpletons. 

Book Review: Saving Ourselves From Suicide: Before and After by Linda Pacha

 

This book describes ways to handle your emotions and responses if you lose someone close to you to suicide. The author herself lost her son that way a few years ago. He was away at college for the first time. He had been diagnosed by one of two therapists as having Asberger’s Disease, a mild variation of autism, and was also experiencing confusion about his sexuality. He was having trouble relating to his classmates and was the subject of a lot of gossip and innuendo. He told his mother he felt depressed but never at any point in time mentioned that he was thinking that he might want to kill himself. The story the author tells in the beginning of the book about what happened with her son during this period is both gripping and highly disturbing. The author is an excellent writer.

 

The advice she give to parents and other survivors throughout the book is spot on. She talks about all the second guessing survivors subject themselves to, all the what-ifs and if-onlys, and the difficulties in interactions with friends, family, and acquaintances. What if you are being judged?

 

She relates her experiences and gives advice on issues such as how to handle grief during the first and second years after the death.  How does one handle anniversary reactions or one’s shattered religious faith?

 

She then goes on to her views about how to spot warning signs that someone you love is heading down the path of suicide, and how people in general and parents in particular can advocate for mental health and decreasing all of the pressures on today’s adolescents.  And then she goes on to the general subject of helping others who have gone through what she did.

 

Since she is not a mental health professional herself, she wisely avoids discussing suicides that result from adverse childhood experiences like sexual or physical abuse by parents, domestic violence, chaotic parental relationships with substance abuse and/or frequent affairs, parental alienation in divorce cases, double messages in the family, and the like. The book is not at all meant for those types of parents, whose problems far exceed the loss of a loved one, as bad as that still can be for them.

 

Another point that I like to make is that people who come from an abusive or chaotic environments are way more likely to become bullies or to bully others themselves, which means that the idea that bullying is the main cause of suicide is somewhat of a red herring.  As is the idea about suicide being caused by watching TV shows like 13 Reasons Why. Watching that could conceivable affect the timing of an attempt, but is hardly the actual cause. People are not that fragile.

 

I was happy to see that she wrote about the problems created by helicopter parenting, although she doesn’t use that term. A lot of parents these days are being absurdly over-protective to the point where kids today often feel fragile and incompetent , as well as a big burden on their parents. In response, they may in some cases start to think the parents would be a whole lot better off without them. This has gotten out of hand on college campuses with all the nonsense about microaggressions and “safe spaces” and viewing other people’s opinions as traumatizing.

 

This is in general an excellent book and well worth reading.

When Anecdotal Evidence is Sufficient Proof

Printed by Publish Any Damn Thing or Perish Press. Research funded by the Keep Unimaginative Academics Employed Foundation.

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013, June 3, 2014, and February 24, 2015, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of Duh! My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

May 7, 2105. Study: Bisexual And Gay Children More Likely To Be Bullied As They Grow Up

The AP (5/7, Stobbe) reports that a research letter published May 7 in the New England Journal of Medicine suggests that bisexual and gay children “are more likely to be bullied as they’re growing up – even at an early age.” Researchers found that “many of the nearly 4,300 students surveyed said they were bullied, especially at younger ages,” but 13 percent of the 630 bisexual and gay youngsters reported being bullied “on a weekly basis,” compared to just eight percent of the other children.

        HealthDay (5/7, Haelle) reports that “consequences of bullying can include physical injury, anxiety, low self-esteem, depression, suicidal thoughts, post-traumatic stress and negative school performance...said” the study’s lead author. 

This is just more propaganda from people advancing the gay agenda.

6/15/15. Small Study: Lisdexamfetamine May Improve Memory, Concentration Problems Associated With Menopause.

HealthDay (6/13, Haelle) reported that the stimulant medication lisdexamfetamine, which is “marketed for attention-deficit/hyperactivity disorder, might improve memory and concentration problems associated with menopause,” according to a study of 32 menopausal women published online June 11 in Psychopharmacology. The study, which received support from the NIH and Shire, the maker of lisdexamfetamine, revealed that “brain activities such as memory, reasoning, multitasking, planning and problem-solving,” improved while women were taking the medicine.

Hate to break this to the Pharma shills, but stimulants will do that for ANYBODY.

8/4/15. Pediatric brain injuries may be associated with attention issues

The Washington Post (8/4, Cha) “To Your Health” blog reports that youngsters who suffer a brain injury, even one considered minor, may be “more likely to experience attention issues,” according to a study published online Aug. 3 in Pediatrics. For the study, investigators included “113 children, ages six to 13, who suffered from traumatic brain injuries (TBIs) ranging from a concussion that gave them a headache or caused them to vomit, to losing consciousness for more than 30 minutes, and compared them with a group of 53 children who experienced a trauma that was not head-related.” HealthDay (8/4, Doheny) reports that the study found that “attention lapses” suffered by the kids with TBIs “led to lower behavior and intelligence ratings by their parents and teachers.” What’s more, the “loss of focus was apparent even when scans showed no obvious brain damage, the researchers said.”

Because injuries to the brain always improve its performance.

8/18/15. Family Problems Early In Life May Raise Boys’ Risk Of Depression, Anxiety.

HealthDay (8/18, Preidt) reports, “Family problems early in life might raise boys’ risk of depression and anxiety, which is also tied to altered brain structure in their late teens and” into early adulthood, according to a study published online Aug. 17 in JAMA Pediatrics. The study, which “included nearly 500 males, ages 18 to 21,” found that “those boys who faced family problems during” the years from birth to age six “were more likely to have depression and anxiety at ages seven, 10 and 13.” Such boys “were more likely to have lower volume of...’gray matter’ in the brain by the time they reached ages 18 to 21.”

What was Freud even THINKING?

8/31/15. Risky Behaviors May Be Signs Of High Suicide Risk In People With Depression.

 

HealthDay (8/30, Preidt) reported, “Risky behaviors such as reckless driving or sudden promiscuity, or nervous behaviors such as agitation, hand-wringing or pacing, can be signs that suicide risk may be high in depressed people,” research presented at the European College of Neuropsychopharmacology’s Congress suggests. The study, which involved some 2,800 people with depression, also revealed that “other warning signs may include doing things on impulse with little thought about the consequences.” People with depression “with any of these symptoms are at least 50 percent more likely to attempt suicide, the new study found.” 

This is just silly. We all know that people who are keen to die are risk averse.

10/7/15. Small Study: Older Adults Appear To Recover More Slowly From Concussion Than Younger Patients.

HealthDay (10/7, Preidt) reports that “older adults recover more slowly from concussion than younger patients,” according to a study published online Oct. 6 in the journal Radiology. Included in the study were “13 older adults, aged 51 to 68, and 13 young adults, aged 21 to 30.” All participants were evaluated at the four-week and 10-week mark following their concussions. While “a significant decline in concussion symptoms – such as problems with working memory – was seen among young patients between the first and second assessment,” researchers found “no such decrease in symptoms...in older patients.”

Aw come on. The body always improves with advanced age.

10/14/15.  Psychological Distress May Be Highly Prevalent In Caregivers Of Patients With Advanced Cancer.

Medscape (10/14, O'Rourke) reports that “psychological distress is highly prevalent in caregivers of patients with advanced cancer and is associated with both caregiver and patient factors, researchers said...at the Palliative Care in Oncology Symposium (PCOS) 2015.” Lead study author Ryan David Nipp, MD, said, “Caregiver characteristics that were significantly associated with caregiver depression were being female and having anxiety.” Dr. Nipp added, “Patient factors that were associated with caregiver depression included patients reporting depression, that the goal of their care was to cure their cancer, and using emotional support coping.”

The impending death of loved ones is always such a high!

10/21/15. Parental Involvement May Optimize Therapy For Kids With Disruptive Behavior Disorders.

Reuters (10/21, Rapaport) reports that having parents participate in therapy for youngsters with disruptive behavior disorders may help the children respond optimally to that treatment, according to a meta-analysis of 66 studies published online Oct. 19 in the journal Pediatrics.

Nonsense. We all know that being rude is genetic.

10/28/15. Cancer diagnosis may lead to loss of income, study indicates

The Washington Post (10/28, Blakemore) “To Your Health” blog reports that research indicates that cancer “can take a heavy toll on patients’ pocketbooks, even long after they recover.” The Los Angeles Times (10/28, Kaplan) reports in “Science Now” that researchers found that “in the second year after being diagnosed with cancer, survivors were earning up to 40% less than they had been before they became sick, on average.” The data indicated that “even in the fifth year after diagnosis, annual earnings still had not recovered to their precancer levels.”The findings were published in Cancer.

Because, thanks to the demise of unions, fewer and fewer folks get paid sick days from their job any more. (I'm not being funny).

11/10/15.  Study Supports Raising SSRI Doses in Patients Who Do Not Respond to Low-Dose Treatment

Using a higher dose of selective serotonin reuptake inhibitors (SSRIs) for major depressive disorder appears to be associated with an increased likelihood of response, according to a meta-analysis published today in AJP in Advance. This benefit, which is somewhat offset by decreased tolerability of SSRIs at high doses, appears to plateau at about 50 mg of fluoxetine (250 mg imipramine-equivalent dose). A team of researchers in the United States and London searched PubMed for randomized, placebo-controlled trials that examined the efficacy of SSRIs for treating adults with major depressive disorder and assessed improvement in depression severity at multiple time points.
       

Er- the first lesson in psychopharmacology 101, I believe.

11/20/15.  Opioid Addiction In Women May Often Start With Physician-Prescribed Medications.

Medscape (11/20, Brooks) reports that new research suggests that the upsurge in the number of women with opioid addiction may be attributed to prescription medicines. Researchers evaluated “sex differences in substance use, health, and social functioning among 266 men and 226 women receiving methadone treatment for opioid use disorder in Ontario.” The researchers found that over half of women (52%) and a third of men (38%) “reported physician-prescribed opioids as their first contact with the” medications. The findings were published online Nov. 9 in the journal of Biology of Sex Differences.

This can't be right. Addiction can only be caused by that evil weed gateway drug, marijuana. Or was that beer?

Researchers Aren't Wasting Time Looking for Cures for Alzheimer's Disease or Schizophrenia

As I did on my posts of November 30, 2011,  October 2, 2012, and September 17, 2013, it’s once again time to look over the highlights of the latest issue of one of my two favorite medical journals, Duh! and No Sh*t, Sherlock. Let’s take a look at the unsurprising findings published in the latest issue of Duh! My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

9/13/13. Effects of Child Abuse Can Carry Over, Study Finds.

Researchers with the National Academy of Sciences reported Thursday that the damaging consequences of abuse can not only reshape a child’s brain, but can last a lifetime. Untreated, the effects of child abuse and neglect, the researchers found, can profoundly influence a child’s physical and mental health, their ability to control emotions and impulses, their achievement in school, and the relationships they form as children and as adults.

Cognitive behavioral therapists are all up in arms in reaction to this, thoroughly annoyed that the psychoanalysts were right about some things.

9/16/13.  Teens Who Text About Fighting, Drug Use More Likely To Engage In Those Behaviors.

HealthDay (9/14, Preidt) reported that research published in the Journal of Abnormal Child Psychology suggests that “teens who text about bad behaviors such as drug use or fighting are more likely to actually engage in those behaviors.” Researchers examined the text messages of more than 170 ninth-graders. Their behaviors were rated by their teachers, parents, and fellow students. The investigators “found a strong link between antisocial text messages and higher ratings of antisocial and aggressive behavior at the end of the school year.”

If they were real sociopaths, they wouldn’t have to brag about it.

 

9/27/13. Common Pain Relievers May Reduce Depression In Individuals With Osteoarthritis.

Reuters (9/27, Doyle) reports that research published in the American Journal of Medicine suggests that common pain relievers may reduce both pain and depression among individuals with osteoarthritis. Investigators came to this conclusion after looking at data from five trials that included approximately 1,500 patients.

Pain causes people unhappiness??  I always thought pain was something that causes unremitting happiness and celebration.

10/21/13. Stalking May Cause Psychological Distress.

HealthDay (10/19, Dallas) reported that, according to a study published online in the journal Social Science Quarterly, “women who are the victims of stalkers are up to three times more likely than their peers to experience psychological distress.” Researchers arrived at this conclusion after examining data “compiled on over 8,100 women from three major surveys.”

And here I thought stalkers were spreading joy wherever they went.

2/27/14.  Suicide Attempts Early in Life Signal Long-Term Social, Health Problems, Study Finds

Young people who attempt suicide are not only more likely to have persistent psychiatric problems as they approach midlife than non-attempters, but they are also more likely to have physical health problems, engage in violence, and need more social supports as they age. These are key findings from a study by led by Sidra Goldman-Mellor, Ph.D., and colleagues at Duke University and several other institutions and reported in JAMA Psychiatry.

The best predictor of future behavior is past behavior?  Who knew?

2/27/14. Study: Stigma Associated With Mental Illness May Prevent Many People From Seeking Care.

HealthDay (2/27) reports that research published in Psychological Medicine suggests that “the stigma often associated with mental illness prevents many people from getting the care they need.” Investigators looked at data from 144 studies that included a total of approximately 90,000 people. The researchers found that “stigma ranked as the fourth highest of 10 barriers to care.” The investigators also found that, “aside from the stigma of using mental health services or being treated for mental illness, the participants also reported feelings of shame and embarrassment as reasons for not seeking care.”

Caring about what other people think?  Worrying about your reputation?  Who does THAT?

3/17/14. Stress May Impact Kid's Health, Well- Being  

HealthDay (3/15, Preidt) reported that according to research presented at the American Psychosomatic Society’s annual meeting, “stressful events can have an almost immediate impact on children’s health and well-being.” After analyzing data on some 96,000 US children, researchers also found that youngsters “who experienced three or more stressful events were six times more likely to have physical or mental health problems or a learning disorder than those who had no stressful experiences.”

Nonsense.  Learning how to react to constant threats to your well being builds character!

4/8/14. Study: Physician appointment availability greater with private insurance than Medicaid.

Reuters (4/8, Seaman) reports on a new study, published in the current edition of JAMA Internal Medicine, which shows the availability of physicians varies depending on a patient’s insurance coverage. Researchers, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, found they were able to book appointments 85% of the time when claiming private insurance, compared to just 58% when they claimed to be covered by Medicaid.

Oh come on. Doctors absolutely hate to make money.

4/14/14. Paternal Alcoholism Tied To Family Conflict.

Reuters (4/11, Bond) reported that according to a study published online March 15 in the journal Addictive Behaviors, families in which the father had a problem with alcohol appeared to experience increased levels of conflict. However, treating men for alcoholism may result in an improved home life for their children.

Gee, and I thought drug addiction was a symptom of family harmony.

4/22/14.  False-Positive Mammograms Linked To Increased, But Temporary, Anxiety.

The Los Angeles Times (4/22, Kaplan) “Science Now” blog reports that in a study published in JAMA Internal Medicine, investigators “examined data from a large clinical trial of digital mammography and concluded that false-positives produced a ‘significant increase in anxiety,’ though it was only temporary.”

       

People get nervous if they think they might die. Really?

5/1/14. Effects of Recurrent Violence on Post-traumatic Stress Disorder and Severe Distress in Conflict-affected Timor-Leste: a 6-year longitudinal study

Silove D, et al. – Recurrent violence resulted in a major increase in post–traumatic stress disorder and severe distress in a community previously exposed to mass conflict. Poverty, ongoing community tensions, and persisting feelings of injustice contributed to mental disorders. The findings underscore the importance of preventing recurrent violence, alleviating poverty, and addressing injustices in countries emerging from conflict.

So what does trauma have to do with PTSD anyway?

Pro-Death Florida Legislators Run Amok

A physician determines that a patient, while not an imminent suicide risk, is a longer-term risk.  The patient has a history of impulsiveness, and under an acute stress might make a sudden and thoughtless decision to take his life.  The doctor inquires if the patient owns a firearm, and the patient answers in the affirmative.  The doctor advises the patient to get rid of the guns in the house so as to prevent any quick, irreversible decisions that might be made by the patient in an agitated state.

Someone in law enforcement finds about this and reports the doctor.  The physician is then arrested and convicted of violating Florida Bill 432.  He is then sentenced to five years in prison, and fined five million dollars.

I bet you think I am making this up, but believe it or not, this bill was actually proposed by members of the Florida state legislator, and similar proposals are planned by the NRA in several other states:
http://jacksonville.com/news/metro/2011-01-31/story/florida-physicians-take-nra-gun-privacy-issue.

The bill would make it a felony for a physician or any medical worker to ask a patient or the patient's family whether they own a gun.  This might include prohibiting pediatricians from advising parents on gun safety issues when there are children in the house.

After a large protest from physicians, the bill was finally amended to offer an exception to the legislation that would shield doctors from prosecution in cases that involve mental health issues, such as the patient who is suicidal.  It then passed both Florida houses and is expected to be signed by the governor.

Now contrary to what you might think, I tend to be rather right wing on the subject of guns and gun control.  I want firearms to remain legal and available.  I worry far more about collective violence than random crime, since many more people have been killed by groups and by governments over the years than by criminals. 

The governments of Syria and Iran would have a lot more trouble convincing their troops to mow down political demonstrators if their troops were afraid that they might be fired upon by snipers on rooftops all over the city.  Think something like that could not happen here?  Probably not, but then again, there was this little incident at Kent State in the sixties that came pretty close.  And then there were all those lynchings in the South.

On the matter of doctors advising patients, however, I think the proposed legislation is completely insane.  Besides being a gross violation of free speech, accepted community standards of practice, and professional ethics, it has absolutely nothing to do with the Second Amendment. 

A therapist cannot force a patient to get rid of their guns, although I personally would refuse to treat any potentially suicidal patient who did not agree to do this. 

Even if patients agree, they could lie to the doctor, or go out some time later and purchase another gun.  One patient I know who killed herself checked "yes" on the application to purchase a handgun on the question that asked if she suffered from a mental illness.  They sold her the gun anyway.

Well, you might protest, you do not need a gun to kill yourself.  You could go to a bridge and jump off, or obtain some pills and overdose, or hang yourself in the closet.  What is so important about getting rid of guns?

The answer is that using a gun is quicker and easier than any other method, and usually more deadly.  Other methods take some minimal advance planning, so are unlikely to be employed impulsively.

I'll bet these legislators call themselves pro-life, too.

How to Disarm a Borderline, Part VII: Suicide Threats

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), and Part VI (March 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In this post, I will discuss the most dangerous and difficult problem of all, suicide and parasuicidal behavior. Parasuicidality includes suicide attempts, gestures, threats and non-suicidal self-injurious behavior (SIB) such as cutting or burning oneself.  In my opinion, self-induced vomiting and drug or alcohol binging are also SIB.  In some cases, also in my opinion, excessive body piercing and tatooing may also be.

***Important caveat:  In cases in which a family member engages in suicidal or parasuicidal behavior, strong efforts should be made to get that person to a mental health professional who has experience with, or even specializes in, borderline personality disorder.  No one should attempt to deal with such a person all by themselves.  However, getting an oppositional individual to seek help is often in itself no simple feat.

Having said that, I can still discuss some things that are helpful for anyone dealing with such a person to know.

First of all, it is important to be aware that just because a person has make a lot of idle suicide threats in the past, this does not mean that they will not kill themselves in the future.  Follow-up studies have shown that individuals with BPD have a 10% rate of completed suicides over the long term.  That is nothing to sneeze at.  Of course, that means that the good news is that about 90% of persons with BPD will not kill themselves.

So one does have to take suicide threats seriously.  On the other hand, if a relative goes into hypercontrol mode every time a person talks about suicide, and tries over and over again to get the person committed to a mental hospital, this may actually make things worse rather than better. Remember, making others feel helpless is part of what persons with BPD try hard to do, while secretly hoping that they fail at it.

There is no evidence that psychiatric hospitalizations reduce the long term risk of suicide in patients with BPD.  Hospitalization should only be used occasionally to buy time during an unusual acute crisis so that the unusual circumstances pass.  This may reduce an imminent risk. 

Furthermore, individuals with BPD can use parasuicidal behavior to make others look foolish.

I learned this the hard way.  When I first started practicing in the late 1970's, a time when BPD was far less prevalent than it is today - it wasn't even in the DSM until 1980 - I was providing back up coverage for another psychiatrist.  I got a call from one of his patients. 

The woman immediately started making wild suicide threats.  I found out where she was at and called the police to go out to her house.  By the time they got there, she was calmly knitting away like Madame DeFarge and sweetly telling the police, "I don't know what Dr. Allen is so excited about; I never said anything about killing myself."

 

So what else should a lay person know that might be helpful in negotiating this minefield?
 
First of all, if an individual with BPD says that they are thinking about suicide, this is usually not a suicide threat.  People with BPD frequently think about suicide.  Doing so is actually one of the criteria for the condition.  If, on the other hand, the patient says, "I am going to kill myself," then the threat should be taken more seriously.
 
Second, if a person is dead set on killing himself, pardon the pun, then there is literally nothing you can do about it. You are helpless.  As mentioned, hospitalizations can only buy time.  We cannot lock such people in a hospital room and throw away the key.  They will be out eventually.  Fortunately, most individuals with BPD are highly ambivalent about dying.
 
Third, most SIB is not meant to lead to death.  People hurt themselves because it makes them feel better when they are overwhelmed and highly anxious, not because they wish to die.  "Pulling your hair out" is a common expression concerning this feeling, so the urge is not exactly unknown to non-BPD individuals.  Otherwise normal people often slap themselves in the head or pound their fist into a wall when frustrated.  So, while witnessing or hearing about a loved one engaging in SIB is very distressing, one usually does not have to worry about actual suicide.
 
Suicide gestures are usually impulsive, non-lethal reactions to an episode of an interpersonal conflict that are meant to manipulate the other person, and likewise do not often lead to death.  People in this situation will cut their wrists or take a handful of pills that they know will not kill them.  Obviously, if a person takes a handful of pills one should probably call 911 anyway.  Sometimes suicide gestures accidentally lead to death.  One can choke to death on the pills, for example.  Several rock stars apparently met their demise in this fashion.
 
Another important clue as to the seriousness of a suicide threat is the tone of voice and the choice of words made by the threatener.  If someone says that they may kill themselves at some point and are being coy about exactly when and where, that usually means that they are not imminently suicidal but are trying to make you feel helpless.  Another clue is when their tone sounds something like, "Nyah, Nyah, Nyah - Nyah, Nyah, I'm going to kill myself and there's nothing you can do about it." The threat may not be a serious one.
 
For example, the very first patient with BPD I saw as a resident, which coincidentally was the first patient I ever had in psychotherapy, started making such threats.  We were in an outpatient office late on a Friday afternoon.  I picked up the phone to call security.  She calmly reacted with, "You know if you call security, I'll run out of the room and I'll be gone before they get here."  Zing, she had me.  I was in a total panic as she indeed quickly left the office.

In the cell phone age, things are even worse.  Threateners can phone in a suicide threat, knowing that there is no way they can even be located. 
 
I spoke to a faculty member about the patient I just mentioned.  He suggested I could have said, "You really want me to worry about you, don't you?" 

Had she then replied, "Oh, bull! You don't care about me," I could have replied, "Well, I am going to be worried about you all weekend."  Good advice.

I could have also said, in a sincere tone, "I sure hope you don't do that."

By the way, that patient showed up on time for our next regularly scheduled visit as if nothing had happened.

I do have one other intervention I frequently use called the paradoxical offer to hospitalize.  It's paradoxical because it is meant to keep people out of the hospital.  It is not really appropriate for a lay person to use, so I won't describe it here (Therapists can find it in my book, Psychotherapy with Borderline Patients: An Integrated Approach).  Besides, I don't want potential patients to know all of my secrets.