Saturday, April 11, 2015

Suicidality: from phenomenology to treatment

      Suicidality can be viewed as whole-organism apoptosis (self-poptosis). First, suicide might have evolved to occur adaptively due to life factors, to minimize detrimental impact and burden on the extended kin when the present is perceived as bleak and unsuccessful for the individual, and there is little hope for future improvement and successes, with the individual perceiving it is irreversibly damaged, not needed by family, extended kin, peer group, or society at large. Suicidality is a decision and choice leading to self-harming actions and behaviors driven by feelings and thoughts of pain or fear, hopelessness or anger, despondency or perceived uselessness. Conversely, a life that is perceived to be successful and meaningful is protective. Second, suicide often occurs maladaptively, due to mind abnormalities, with the individual who commits suicide being vulnerable due to a psychiatric illness, misperceiving circumstances and/or overreacting in an impulsive fashion. Related to that, suicide can be an attempt to assuage perceived guilt, or an attempt to harm (through social opprobrium or guilt) the individual(s) perceived to be the source of the lack of success of the suicidal person. Conversely, a well-balanced and functioning mind is protective. Third, body health abnormalities. Having severe health problems or pain may make an individual more prone to suicide. Conversely, a healthy, strong and resilient body is protective. Fourth, environmental factors. Environmental stressors, such as a hostile environment and loss of social connections and status can make individuals more prone to suicide. Conversely, a pleasant environment and good social standing are protective. Fifth, addictions. Addictions may destroy an individual’s life, mind and body, making them more prone to suicide. Conversely, being free from and immune to addictions is protective. Sixth, cultural factors. Cultural enablers (a personal or family history of suicidality, or being part of an environment or culture where suicide is an option) also come into play. Conversely, cultural and religious beliefs that make suicide not be an option are protective.

      Suicidality is a combination of increased risk factors/drivers (increased reasons why to do it) and decreased protective factors/brakes (decreased reasons not to do it). Younger people, older people, and males are more at risk for it. The evolutionary rationale in the young is primarily to avoid transmitting damaging combinations of genes. In the old, it is primarily to avoid being a burden. In males, it may be a price paid for increased testosterone-related drive and impulsivity.

      Discrepancies between where you are in your life vs. your standards and goals (where you would have liked to be in life) can lead to suicidality. Treatment and prevention need to involve reducing this perceived gap, in addition to improving hope for the future, and improving the mind (feelings and thoughts) that can color how life is perceived, improving body health, improving environment, improving any addictions, and improving cultural factors.

 Alexander B. Niculescu, III, MD, PhD