The phenomenon of suicidality: socio-demographic and clinical analysis by a Psychiatric Disability Unit

Brustenghi F.¹, Russo A.¹, Serra R.¹, Pierotti V.², Sabatini L.², Moretti P.¹ and Tortorella A.¹

1 Department of Psychiatry University of Perugia, Perugia, PG, Italy

2 School of Medicine University of Perugia, Perugia, PG, Italy

Introduction: suicidality is the set of self-injurious behaviors ranging from non-lethal ideas and behavior to committed suicide; according to Shneidman this is “the human act of intentionally self-inflicting the cessation of life”, “one of the human possibilities” says Hillmann. Non-lethal behaviors include suicidal ideation (SI, self-injurious behavior (SB) and suicide attempts, in which the subject survives suicidal action.

Freud, in Mourning and Melancholia (1915), describes the mental process that leads to suicide as a mechanism of punishment and revenge following the impossibility of turning its love impulses to the libidinal object that has been introjected. To better understand this concept it is useful to remember how melancholy develops. The latter derives a part of its characteristics from mourning and the other part from the regression that proceeds from the narcissistic type of object choice to narcissism.

When love for an object has taken refuge in narcissistic identification, it happens that hatred is put to work against this substitutive object by offending, denigrating it, causing it to suffer and deriving from this suffering a sadistic satisfaction. The self-absorption of the melancholic reflects the satisfaction of sadistic tendencies and hatred; these tendencies refer to a given object and have found a way to apply to the person of the subject.
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However, the patient is able to take a “revenge” on the original objects and, therefore, to torment their loved ones through the disease, in which they took refuge not to directly manifest their hostility. According to Freud, the person who has aroused the emotional disturbance of the patient is among those closest to him. In this way, the love investment of the melancholic for its object on the one hand regresses to identification, on the other it is brought back to the stage of sadism. And it is this sadism that explains the inclination to suicide of the melancholic. The ego can only kill itself when it manages to treat itself as an object, thus directing against itself the hostility concerning an object and representing the original reaction of the ego with respect to the objects of the external world. Thus, through the regression that starts from an object choice of a narcissistic type, a renunciation of the object occurred, which however proved to be stronger than the ego itself. In the two opposite situations of the most intense falling in love and suicide, concludes Freud, the ego is overwhelmed by the object, albeit with antithetical results¹.

On Beyond the pleasure principle (1920), Freud theorized the presence of a drive dualism, the coexistence of Eros (life instinct) and Thanatos (death drive). Eros and Thanatos, original fundamental and primitive drives, are in a consubstantial relationship. Eros gathers all forms of libidinal drives, but it is much more than a sexual drive as it exists in every cell and “pushes the different parts of the living substance into each other” and keeps them together. Thanatos is defined by its purpose, or the return to the inanimate and inorganic, achievable only by untying the relations and relationships established by Eros. The concept of death drive carries with it another fundamental consequence, that is, the concept of primary masochism and sadism. From 1920 onwards, Freud understood aggression as a manifestation of the death drive facing out, while primary masochism derives from that part of the death drive that is not moved outside but remains in the organism, still direct. towards the subject itself and linked to the libido.

Secondary masochism, on the other hand, is defined as a refolding of sadism against one’s own person and is added to primary masochism. The two drives are intermixed; thus the death instinct is expressed in the sadistic component of the sexual drive, whereas in the self-contained sadism (in the form of perversion) the model of the drive division is recognized².

In The Ego and the Id (1922) Freud states that in melancholia the anguish of death admits a single explanation: the ego renounces itself because, instead of being loved, it feels hated and persecuted by a super-ego sadico³. Self-aggression, that is, the masochistic element constituting melancholy, reaches its maximum expression when it is not only maintained on the psychic ground, but when it translates into physical self-aggression, that is, into suicide. Suicide is a frequent conclusion of severe forms of melancholy, but can be had in all serious psychoses and psychoneuroses. In obsessional neuroses, however, even though there is an important sense of guilt (due to the aggressiveness of the Super-ego), it appears only in a few cases. In this type of neurosis, in fact, there are external objects on which aggressive impulses are addressed, so that these can not be completely poured on the subject. Therefore, in these pathologies, the partial orientation of aggression towards the outside preserves from suicide. Musatti believes that there are two mechanisms responsible for the psychogenesis of suicide. The first mechanism is determined by the loss of the loved one and the conflict that is generated between the impossibility of abandoning the libidinal investment related to that person and the attestation of reality, that is to say that the libidinal object is no longer recoverable. The conflict is solved, with a lot of recovery of the investment made, through identification with the beloved object: the subject collects with the object following its fate. Even the means by which suicide is committed is often modeled on the same kind of death as the beloved object.

The second mechanism, on the other hand, is more properly neurotic and consists in the conversion of external aggression into self-aggression. According to Freud, in any case of attempted suicide of a neurotic, there is always someone with respect to whom the subject would have lived, in a most unconscious way, a homicidal impulse. Suicide, therefore, can be experienced as an indirect means of achieving that self-aggression that has no way to fulfill itself directly, due to the weakness or inability of the subject. It represents an escape through which the subject has the impression of triumphing over reality. This mechanism would also explain the suicide carried out for fear of death: an extremely painful situation, imposed by the outside world against our will, appears more tolerable if we have the impression of intentionally promoting it. Suicide creates the illusion of an active triumph over destiny. As the child vents his bad mood towards adults threatening to harm himself, so the suicide feels to punish destiny and external reality, of cruelty towards himself, subtracting his own person. Moreover, through this punishment, the suicide has the impression of regaining the benevolence of the world, through the common social disaster for the dead. Through this paradoxical behavior, suicide brings with it its own annulment also its reality. The triumph over the hostile destiny that he would like to obtain is a triumph that he will not be able to live and the benevolence of the world he wants to conquer is a benevolence which he can not benefit from. However, this absurdity does not exist for suicide, because like all other men, it is incapable of representing one’s own death. To represent it, it has to split up and that is, imagining itself alive, must witness its own death: this mechanism is implemented on the basis of the illusion of surviving one’s own death, when the suicide stages his own death or worries about how the corpse will appear to others , etc. ⁴. Sullivan considers suicide to be a casual disgrace: “A certain person who had a destructive influence in the patient’s past is the true goal of self-destruction” ⁵.
According to Menninger (1933) there are three desires that can contribute to a suicidal act: the desire to kill, the desire to be killed and the desire to die⁶. In other cases aggression plays a less important role in the psychogenesis of suicide. According to Fenichel (1945), suicide may be the satisfaction of a desire for reunification, “a joyous and magical reunion with a lost loved object, or a narcissistic union with a beloved superegoic figure” ⁷
This would explain some statistical data, which see a correlation between suicide and the anniversary of the death of a loved one. According to Gabbard “when self-esteem and a person’s integrity depend on the attachment of a lost object, suicide may appear to be the only way to establish the cohesion of the self” ⁸.

Similar situations are found in the Parasuicide, a non-fatal act in which an individual deliberately performs a behavior that harms himself (eg rejection of therapies); or the ingestion in excess of a substance generally recognized as therapeutic that had been prescribed in therapeutic dosage, aiming to obtain, as a consequence of this, physical damage. This condition is a sort of “signal function” of a fragile ego overwhelmed by mental suffering, which tries to expel it in order not to succumb to it and which, potentially, denies death for what it is, that is a “disappear for always”. “Suicide is one of the human possibilities”, says James Hillman, a dramatic event, one of the most serious that can affect a family, friends and society itself⁹

Epidemiology: : Suicide is a public health problem of alarming dimensions: according to WHO estimates reported in the first global report on suicide prevention “Preventing Suicide. A global Imperative “, the number of suicide deaths in 2012 was 800,000, equal to a rate of 11.4 / 100,000 (15.0 for men and 8.0 for women). In Italy the deaths due to this phenomenon were 4,000, corresponding to a rate of 4.6 / 100,000 (7.6 for men and 1.9 for women). Suicide is considered a relatively rare event and its frequency increases with age. In general, suicide places itself at the tenth position as a cause of death considering all age groups. This corresponds to about 1% of all deaths for females and 2% for males. However, between the different countries there are noticeable differences between suicide rates in general, gender and age groups; for example, Hungary and Denmark have the highest rate compared to other European countries, the suicide mortality rate of males is on average four times higher than that of females. Analyzing the event by age groups, between 15 and 34 years, the percentage of suicide deaths is about 20 times higher than the 65-74 age group. In some northern European countries, such as Denmark, suicide is the leading cause of death in the 25-34 age group. In Italy, suicide is the second most common cause of death among men aged between 15 and 29, the same mortality caused by tumors (13% of the total). For women of the same age, suicide mortality is ranked third in the ranking of causes for death, with a position equal to that of vascular disease death (8%) and preceded only by deaths from cancer (26%) and road accidents (24%). On ISTAT data, the decrease in suicides in the twenty years 1995-2015 (-14.0%) was significant and transversal, by gender and age: in 1995 there were 8.1 suicides per 100 thousand inhabitants, which fell to 6, 5 in 2015 (3,935 deaths). This places Italy at the bottom of the European ranking (6.3) the standardized rate of mortality by age in 2014; 11.2 the EU average. [28] Suicide is a non-gender-neutral phenomenon: every 100 thousand inhabitants The deceased by suicide are 10.4 among men and 2.8 among women. Also the gradient for educational qualification is found among men but not among women: 14.8 suicides per 100 thousand men with no qualifications or low level of education, 9.2 suicides among men with a degree or higher education. Suicide is an age-related phenomenon: increasing quotients are observed with increasing age (1.4 suicides per 100,000 inhabitants up to 24 years, 10.4 over 65 years). It is also a marked phenomenon seasonality: growing trend in the first half of the year – May, June and July, the most critical months – and a downward trend in the second half. However, the international statistics on suicides can underestimate the phenomenon due, in the first place, to the difficulty in identifying suicide as a cause of death. According to the international literature, however, this difficulty does not act in a selective manner on the different population groups and, therefore, does not compromise the usability of these statistics, with the appropriate precautions, for comparisons in time and space. Secondly, it is extremely difficult to identify the reasons that induce the individual to take his own life, due to the multidimensional nature of the phenomenon. Among the factors contributing to the underestimation of the number of suicides are hidden cases for legal and insurance issues and cases disguised as a traffic accident. However, it seems that the underestimation of the number of suicides is constant in relation to the population for which this does not affect the statistical processing of data.

Socio – demographic variables such as gender, age, marital status and employment greatly affect suicidal behavior. Men commit suicide three times more often than women. There is a specularly reversed situation in women, as regards parasuicide.

The percentage of suicides in people over 75 is three times higher than that of young people. The parasuicides are more common in young people than in the elderly. It is estimated that the parasuicide / suicide ratio is around 3 in the elderly while it is 100 in the young. In America the suicide rate is 11 / 100.00 for the married couple, it is almost double for the unmarried, reaches the rate of 24 / 100,000 for the divorced and even 40 / 100,000 for widowers.
Suicide, as expected, is more common among the unemployed. There is a positive correlation between unemployment and suicides and, of course, the age group is the working age group.
It appears that increases in suicide rates are observed in spring and autumn in close correlation with mood swings.

Regarding the epidemiology of suicidal ideation, it is not known what percentage of people presenting episodes of suicidal ideation. However, suicidal ideation is a common phenomenon in adolescence with prevalence in the female sex. There is a direct proportionality of suicidal ideation with age, in both sexes, up to 17-18 years.

Methods:: in this retrospective study some clinical variables were analyzed, such as the diagnosis and therapy in progress, socio-demographic and environmental, such as age, sex, nationality and marital status of 154 patients admitted between January 2015 and December 2016 for SI and SB at the Psychiatric-SPDC Hospitalization Unit of the “Santa Maria della Misericordia” Hospital of Perugia. The criterion of inclusion in the study was represented solely by the reason for admission (IS and CA), patients of both sexes, of every nationality and of each age group were recruited. The eventual seasonal trend of the aforementioned hospitalization type has also been investigated. Descriptive statistical analyzes were performed in order to examine the characteristics of the sample under consideration, using the SPSS 20 software.

Results: within the sample of the 154 patients recruited, the average age was 41.5 years, the youngest patient was 15 years old, the oldest was 87. In general, the most represented age group (28%) it was between 25 and 35 years old and the male sex constituted 53.9% of the sample; only 38.8% of patients were conjugated. Regarding the reason for admission, in 77.9% of cases (122 patients) self-injurious behavior and in 22.1% (34 subjects) suicidal ideation; not substantial differences emerged in this respect between the sexes. Almost all the cases (144 patients) were admitted to a voluntary scheme, while for 10 patients it was necessary to resort to compulsory medical treatment. The most frequently encountered inpatient diagnoses were personality disorders (DP) in 36.3% of cases, of which 60.7% borderline disorder (DBP) and mood disorders (DU) in 21.4% of cases, among which in the first place the depressive disorder without psychotic symptoms constituted 12.3% of the sample; followed by NAS mood disorders and bipolar disorders; another important aspect examined was the seasonality: it should be noted that, analyzing individually the admissions for suicidal ideation, these were observed in 44% of cases during the autumn season; not substantial differences emerged instead in the seasonality of patients admitted for self-injurious behavior. Regarding the treatment, about two thirds (64.9%) of the patients underwent psychopharmacological treatment at the time of admission. Specifically, 69% of patients took benzodiazepine therapy, 55% with neuroleptics,
while 38% were treated with antidepressants and only 36% with mood stabilizers

Discussion:: suicide is a complex phenomenon, difficult to accept and to understand as an expression of man who destroys and eliminates himself. In the family and friends of those who commit suicide, the event causes feelings of pain, inadequacy, fear, frustration, feelings of guilt like probably no other cause of death. This has an even more unsustainable weight when the gesture is performed by young subjects; it is evident that the suicidal phenomenon has human and often economic costs of considerable importance for those who remain alive and can generate further psychopathology. It is essential to try to understand what may be the risk factors for suicide and, more generally, the conditions that can be associated more frequently to the event. Object of this study were some non-lethal behaviors in the field of suicidality such as self-injurious gestures and suicidal ideation, in order to describe from a clinical, socio-demographic and environmental point of view the type of patient who is admitted for such behaviors . Major depression is the most common psychiatric pathology associated with suicidal risk; approximately 50-70% of suicides occur during an episode of major depression, not so much in the most intense phase of the picture, when in the period of initial improvement of the symptoms in which the subject reacquires enough energy to act his own impulsivity and aggression. In general it is estimated that a patient suffering from mood disorders has a lifetime risk of committing suicide of 15%, or about 20 times higher than that of the general population for unipolar depression and 15 times higher in bipolar disorder. The conjugality is generally a protective factor towards suicidal risk, this “preservation coefficient” is maximum between 25 and 40 years, and then decreases with increasing age; widowhood is a condition of greater risk but not as much as celibacy. Also from seasonality emerges a trend known in the literature; in fact, suicidal behaviors would have two prevalence peaks, one in spring and one second in autumn.

Conclusions: patients with SI and SB are more frequently young, male, unmarried and already being treated at the time of admission. The diagnoses most often associated with IS and CA are DP, in particular DBP, and DU. The hospitalization for suicidal ideation occurred more frequently in the autumn season. Given that more studies and more numerous samples are needed to deepen the variables, the wide range of clinical and socio-demographic conditions that can be associated with suicidality, does justice to what, after all, remains a phenomenon that is difficult to theorize and scarcely foreseeable.

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