Night Falls Fast

by Kay Redfield Jamison

  People with depression or manic-depression are particularly likely to kill themselves, or make serious suicide attempts, early in the course of their illness, often after their first attack of severe depression or following their release from a psychiatric hospital. It is not obvious why this should be so, although unfamiliarity with the experience of depression, uncertainty about personal and professional repercussions, and concerns about whether or when it will come back again all certainly play a role. Getting the correct treatment is a gamble and, even with the best of doctors, it often takes a long time to take effect. People often wait until they are most ill before seeking care and may be unable to stay the treatment course long enough to make them feel sufficiently well to continue living.

  Disconcertingly, one of the highest-risk periods for suicide is when patients are actually recovering from depression. The transition from hopelessness, lethargy, and despair, on the one hand, to normal mood and existence, on the other, is one freighted with hazard: mixed states are common during this time and bring with them rapid mood swings, perturbations of energy, and disrupted sleep. There may also be sharp disappointments when the jagged pattern of recovery leads to feeling first well and then ill again. A resurgence of will and vitality—ordinarily a sign of returning health—makes possible the acting out of previously frozen suicidal thoughts and desires.

  It can be difficult to distinguish between those genuinely getting well from those who may on an impulse, or during a especially hopeless moment, kill themselves. One study, for instance, compared written clinical observations made on patients shortly before they committed suicide with clinical observations made on patients of comparable ages and diagnoses who did not commit suicide. Counterintuitively, those who killed themselves had been assessed by their doctors as calmer and “in better spirits” than those who did not. In fact, nearly one-third of hospitalized psychiatric patients “look normal” to their doctors, family members, or friends in the minutes or hours just before suicide.

  This apparent calm before the storm may reflect different things: The suicidal patients may be experiencing a genuine calm in the midst of recovery but then switch precipitously into a severe depression or a mixed state. They may, on the other hand, be calmer because, having decided to kill themselves, they are relieved of the anxiety and pain entailed in having to continue to live. They may also be deliberately deceiving their doctors and families in order to secure the circumstances that will allow them to commit suicide. This latter tendency to deceive in order to die has been recognized for centuries. Among those to make note of this was the great eighteenth-century Philadelphia physician, educator, and patriot Benjamin Rush, surgeon general of the Continental Army and signer of the Declaration of Independence:

  We should be careful to distinguish between a return of reason and a certain cunning, which enables mad people to talk and behave correctly for a short time, and thereby to deceive their attendants, so as to obtain a premature discharge from their place of confinement. To prevent the evils that might arise from a mistake of this kind, they should be narrowly watched during their convalescence, nor should they be discharged, until their recovery had been confirmed by weeks of correct conversation and conduct. Three instances of suicide have occurred in patients soon after they left the Pennsylvania Hospital, and while they were receiving the congratulations of their friends upon their recovery.

  Mood disorders, although more linked to suicide than other mental illnesses, are not the only ones to cause early self-inflicted death. Schizophrenia, a terrible psychotic illness, often does as well.

  “This is a good-bye letter,” wrote poet and composer Ivor Gurney to a friend in June 1918. “I am afraid of slipping down and becoming a mere wreck—and I know you would rather know me dead than mad.… May God reward you and forgive me.” In a war hospital at the time, diagnosed with a “nervous breakdown from deferred shell-shock,” Gurney was acutely suicidal and at the beginning of a long, terrifying descent into paranoid schizophrenia. He threatened suicide on several occasions and at least twice attempted it, once by taking an overdose of sedatives given to him by his doctor, another time by gassing himself. Gurney’s agony was scarcely bearable. Imaginary voices told him to kill himself, and he was certain that electrical waves from the radio were bombarding him. The delusions were persistent, as were the voices that threatened and tormented him. His doctor described Gurney’s mental condition:

  The electricity manifests itself chiefly in thought. Words are conveyed to him. They are often threatening, [and] they have been obscene and sexual. He has heard many kinds of voices. He sees things when he is awake, faces etc. that he can recognize. He has also had a twisting of the inside. He cannot keep his mind on his work.… With regard to suicide he has had such pains in the head that he felt he would be better dead.

  There was little change for the better in Gurney’s psychiatric condition, and he remained almost continuously in an asylum from 1922 until the time of his death in 1937. He took his pain into his poetry. “There is a dreadful hell within me,” he wrote in one of his asylum poems, “And nothing helps.… I am praying for death, death, death.” In another, he proclaimed, “There is one who all day wishes to die … has prayed for mercy of Death.”

  Schizophrenia is the most severe and frightening of the psychiatric illnesses. Like manic-depression, it is an illness that first hits when an individual is young (in the late teens or early twenties); is genetic, although not as strikingly so as bipolar disorder; is relatively common (approximately one person in a hundred will get it); and is devastating to relationships, educational plans, and aspirations. Left untreated, it usually gets worse over time. Alienation from friends and family is the rule rather than the exception. Suicide, although less common than in the mood disorders, is still common enough to make it a very lethal disease—lethal and painful, for schizophrenia plays havoc with the senses, reason, emotion, and the wherewithal to act. It is malevolent, and it will kill 10 percent of its victims through suicide.

  Hallucinations, the perception of something where nothing exists, and delusions, false beliefs that persist in spite of incontrovertible evidence to the contrary, are only part of the terror of schizophrenia. Often the entire visual and emotional world is transformed into a dark, mapless horror. Auditory hallucinations, especially hearing voices, are common. The voices threaten, condemn, and demand. They may be located anywhere: near or far away; in the heart or head, in the nose or abdomen; in the external world: in birds, telephones, televisions, or the Internet. Usually the voices’ content is disturbing; occasionally it is incomprehensible. Sometimes the voice is a solitary one; often there is a conversation or argument between two voices; occasionally there is a cacophonous chorus of sounds and words.

  Visual hallucinations are not as common as auditory ones, but they are similarly chameleonic. Emil Kraepelin, an astute observer of psychosis in both mania and schizophrenia, gave examples of some of the many visual distortions and hallucinations experienced by his schizophrenic patients: they saw, he said, death’s heads, saints from all eternity, a tumbling clown, black birds of prey hovering overhead, the emperor of China, snakes in their food, Martin Luther, flames, red and white mice in a heart, two tortoises on the shoulder. They saw and heard varied and dreadful things.

  Physician and scientist Carol North, now on the medical school faculty at Washington University in St. Louis, described the frightening hallucinations, bizarre delusions, and contorted perceptions in her schizophrenic universe. Here she recalls her experiences in the Quiet Room of the hospital ward:

  I lay motionless on the plastic floor mat for hours, till my limbs grew stiff from not moving. The drain in the center of the concrete floor belched up rough voices that laughed at me and called me foul names that reverberated back and forth between the puke-green tile walls several times before dying away. Intermittently, ghoulish faces appeared on the other side of the door’s window to observe me as they might observe a reptile behind glass at the z
oo. At first I thought those faces belonged to the aides coming back to check on me; then I thought maybe they were really the faces of the voices, finally showing up to meet with me. Later, I wondered if maybe the faces weren’t there at all, but just another product of my troubled mind.

  I was caught in a limbo or maybe a purgatory, awaiting my place in the Other World. Oh, how I wished something would happen to break up the events and end my discomfort.

  Magically, the three-inch-thick door swung open.

  “Carol.” Dr. Falmouth’s voice. “I’d like to talk to you.”

  “Talk … walk, balk, chalk, gawk, squawk,” the voices echoed, rhyming Dr. Falmouth. That coded message meant we were now traveling toward the sun with supervelocity. We had emerged from special relativity into special-special-relativity. My body was electric, buzzing: a sixty-cycle hum, serving as conductive material in a communications network that allowed forty billion messages to zoom back and forth between parallel universes and Other Worlds. Without me to transfer their messages and hold them together, all of these systems would fall into chaos. Dr. Falmouth would never be able to hold strong against the awesome powers before us.

  Dr. Falmouth raised my arm into the air.

  My finger bolted themselves into a new mold, ready for firing off ray beams into multidimensional space.

  Grossly disorganized behavior and language also characterize schizophrenia; speech may become incoherent and meaningless. The gradual disintegration of a mind is almost incomprehensible. To observe its unwinding from within is surely intolerable. To be frightened of the world; to be walled off from it and harangued by voices; to see life as distorted faces and shapes and colors; to lose constancy and trust in one’s brain: for most the pain is beyond conveying. Robert Bayley, a patient with schizophrenia, put into words some of the awfulness of his day-to-day struggles:

  The reality for myself is almost constant pain and torment. The voices and visions, which are so commonly experienced, intrude and so disturb my everyday life. The voices are predominantly destructive, either rambling in alien tongues or screaming orders to carry out violent acts. They also persecute me by way of unwavering commentary and ridicule to deceive, derange, and force me into a world of crippling paranoia. Their commands are abrasive and all-encompassing and have resulted in periods of suicidal behavior and self-mutilation. I have run in front of speeding cars and severed arteries while feeling this compulsion to destroy my own life. As their tenacity gains momentum, there is often no element of choice, which leaves me feeling both tortured and drained. I also hear distorted sounds that modulate and contort from the very core of my brain. There are times when these sounds can erupt from nowhere as the voices continue to propel me into a crazed inner world.

  The visions are extremely vivid, provoking fear and consternation. For example, during periods of acute bombardment, paving stones transform into demonic faces, shattering in front of my petrified eyes. When I am in contact with people, they can become grotesquely deformed, their skin peeling away to reveal decomposing inner muscles and organs.

  Contortions of reality are not the only sources of pain. A malignant apathy is pervasive; emotions that are intense or pleasurable for others are often flat or blunted for those with schizophrenia; intellect, memory, and the ability to concentrate and think logically are eroded. (Not surprisingly, brain-imaging studies reveal pronounced differences in structure and functioning between individuals who have schizophrenia and those who do not.) These symptoms, although they overlap with those of depression, tend to be more permanent, less likely to remit over time. For many, mood is also affected: at least one in four schizophrenic patients suffers from serious depression, which in turn makes them far more likely to kill themselves.

  Schizophrenic patients who commit suicide, like those with mood disorders, are very likely to be depressed, intensely irritable, and restless. They are also more likely to have attempted suicide at some point (30 to 40 percent of schizophrenic patients attempt suicide at least once; as with depressed patients, a history of a serious suicide attempt is the single best predictor of subsequent suicide). They also tend to be in the early stages of their illness or recently released from a psychiatric hospital. Although hallucinations and delusions are clearly a source of distress to psychotic patients, the actual role they play in precipitating suicide is unclear.

  Several other psychiatric conditions, most significantly the anxiety disorders and the borderline and antisocial personality disorders, also carry with them a higher-than-expected risk of suicide. (Although the eating disorders anorexia nervosa and bulimia nervosa result in many medical complications and even death, the actual suicide rate is unclear. A review of more than thirty studies found that approximately 1 percent of those with eating disorders die by suicide.)

  Anxiety disorders, on the other hand, especially when accompanied by panic attacks or severe depression, definitely increase the chances of suicide. The defining symptoms of these disorders—excessive anxiety and worry, disturbed sleep, muscle tension, irritability, fatigue, and restlessness—tend to be long-standing features of an affected individual’s life. Symptoms of depression are common. Panic attacks are also associated with an increased rate of suicide and suicide attempts, although there has been a spirited debate about the extent of the increase. These attacks are discrete periods of intense fear or discomfort, accompanied by an abrupt onset of a number of unpleasant physical and mental symptoms such as palpitations or a pounding heart, sweating, shaking, a sense of being smothered or shortness of breath, chest pain, and an acute fear of dying or losing one’s mind. These symptoms often lead to emergency room visits because the people experiencing them are frightened they are having a heart attack. If panic attacks occur too often, they may lead to a sense of despair and hopelessness, as well as to self-imposed social isolation in an attempt to avoid situations that might trigger subsequent attacks. Severe anxiety, like severe agitation, is a potent predictor of suicide.

  Surprisingly, and uniquely among the major mental illnesses, obsessive-compulsive disorder seems not to put those who suffer from it at an increased risk for suicide. Although the persistent and intrusive thoughts and impulses and the highly repetitive behaviors—such as hand washing until the hands are raw, counting, repeatedly checking the door to ensure that it is locked—that are the hallmarks of this illness are not only deeply distressing to those who have them but also time-consuming (often taking up hours of every day) and highly disruptive to virtually all aspects of life, most studies find that suicide is rare in obsessive-compulsive disorder unless it is extremely severe or complicated by depression.

  A final broad category of psychiatric conditions, the so-called personality disorders, include two that result in a disproportionate number of suicides. Borderline personality disorder is broadly defined as a pervasive life pattern of stormy relationships and impulsive, self-destructive behaviors; symptoms can include unstable job history, chronic feelings of emptiness and fears of abandonment, intense periods of anger, rapid mood swings, wrist slashing, skin carving or burning, head banging, self-cutting, and suicidal behavior. Antisocial personality disorder, which often starts as a conduct disorder in childhood, is characterized by a pervasive pattern of disregard for the rights of others, a lack of empathy, excessive aggression, pathological lying, little or no capacity for remorse, and physical cruelty.

  Although these disorders are dissimilar in many significant respects (for example, antisocial personality disorder is three times as common in males; the reverse is true for borderline personality disorder), there are several features they share: both are familial disorders, that is, first-degree relatives (parents, siblings, and children) are far more likely to have borderline or antisocial personality disorders than would be expected by chance; both are relatively prevalent; and both have a tendency to diminish in severity over time. Other features shared by antisocial and borderline personality disorders probably also contribute to their increased risk of suicide: markedl
y impulsive behavior; uncontrollable fits of rage; frequent physical fights or unprovoked assaults; reckless behaviors, such as high-risk sexual promiscuity or substance abuse; highly unstable moods, and extreme irritability. The virulent instability of mood and behavior, coupled with the diagnostic hallmarks of manipulativeness and a disregard for the feelings and rights of other people, essentially guarantees combative relationships, an impoverished and solitary personal life, and occupational chaos, unemployment, or imprisonment.

  Reckless and violent behaviors, which we will look at more closely in the next several chapters, have been associated time and again with suicide and serious suicide attempts in those with psychiatric illnesses. When the unstable elements that define borderline and antisocial personality disorders mix with depression, alcoholism, or substance abuse, the combination can be explosive, dangerous, and not uncommonly lethal. Nearly three-quarters of those with borderline personality disorder attempt suicide at least once, and 5 to 10 percent do kill themselves. With these patients, suicidal behavior is more bound to their conflicts in relationships with other people than it is with patients who have major depression, schizophrenia, or manic-depression. Borderline patients are exquisitely sensitive to actual or perceived rejection, and their depressed moods, although short in duration, are far more responsive to setbacks in relationships. (Suicide itself often takes place in the physical presence of another person. In one study, more than 40 percent of suicides committed by borderline patients were witnessed by other people; in individuals with other diagnoses, only about 15 percent of suicides were witnessed.)

  A clinician who has worked a great deal with borderline personality disorder, Howard Wishnie, described a thirty-two-year-old mother of three children who had been hospitalized for depression and brief psychotic episodes: