Why do people attempt suicide?

Recently, while watching the Netflix miniseries, “Inventing Anna” I was struck by how one of the characters, journalist Vivian, interpreted the “suicide attempt” by Anna Delvey. Vivian took it to mean that Anna was a person with real feelings, including hurt and pain, and possibly emotionally damaged as a child. Was Vivian right?

Many years ago, as Chief Resident in Psychiatry at Montreal’s Jewish General Hospital, I gave lectures on “Psychiatry in the Emergency Room” to the Family Medicine residents. One of the topics we covered was suicidal patients. After researching the subject, I felt confident in saying that two important reasons why people made suicide attempts were, first, out of anger and a desire to hurt those that the suicidal person blamed for injuring them; and second, a delusional belief, for example that the world would be a better place if they were not in it, or that others would be better off.

The anger is easy to pick up when you hear a teenager say, “They’ll be sorry when I’m gone!” but it may also be apparent when the person chooses a particularly messy or violent way of doing themselves in, leaving the survivors to deal with the mess. Suicide attempts motivated by anger are often impulsive acts and frequently occur when judgment has been impaired by substances such as alcohol or benzodiazepines. And it may be that the person never really intended to die: in “Inventing Anna”, before overdosing on wine and sleeping pills in the Chateau Marmont hotel in Los Angeles, Anna calls Room Service to bring more wine and just to come in to the suite, pretty well guaranteeing that she will be found while still alive.

But even if the intent to be dead was not there, the outcome can still be fatal. The boyfriend who was supposed to be there at 11 pm gets into a car accident on the way over, or the individual took an overdose of something they mistakenly believed was nonlethal such as acetaminophen.

What about the second reason, a delusional belief? Severely depressed people can certainly become psychotic. A particularly striking example is the young mother with postpartum psychosis who begins to believe that she is a burden to the people around her; she may also kill her child so that it won’t suffer because of losing its mother.

A delusional intent to kill oneself is particularly problematic for clinicians and others. The suicidal individual won’t tell anyone about their intent, knowing full well that the other person will interfere with their plan. If they’re being followed or treated for depression, the clinician may notice a sudden improvement, a lightening of their mood, once they’ve made up their minds. Important not to misinterpret this!

Throughout history, famous people with bipolar disorder have taken their own lives. Virginia Woolf wrote a long, tender suicide note to her husband, which read in part, “Everything has gone from me but the certainty of your goodness. I can’t go on spoiling your life any longer.”

To help answer the question of why people attempt suicide, it’s instructive to consider why people do not. An important part of a standard psychiatric examination is evaluation of suicidal risk. One might ask directly “Do you feel so bad that you would want to end it all” or “kill yourself” or other words. In individuals in whom suicidal risk is low, however, asking “Have you ever felt so bad that you considered killing yourself” it turns out that most people have considered that option at some point in their lives. The followup question might be, “what stopped you?” to which a frequent response is that the individual did not want to do that to their loved ones. In other words, an empathic and caring response.

So a normally empathic and caring person might attempt suicide when anger and a desire for revenge overwhelm their empathy (the first reason, above) or when the empathy is misdirected by a delusional belief, as in the second reason).

And this consideration of why most people do not kill themselves gives rise to a third reason why some do: a lack of empathy. If you lack empathy, then killing yourself is ultimately a selfish act, to spare yourself pain or humiliation without needing to consider the pain you might be causing others. People who lack empathy may be labeled as psychopaths or sociopaths, and such people do take their own lives: think Adolf Hitler or Jeffrey Epstein. The fact that psychopathy has typically been studied in criminal populations may help to explain why suicide is the leading cause of death in jails and makes up more than one-third of all deaths in jails, according to the Psychiatric Times (Suicide Risk Following Criminal Arrest, December 30, 2020, Jennifer Piel, MD, JD),

However, dark triad types also have low empathy, and many politicians fit this mold. While corruption may be frequent, politicians rarely get caught; when they do, suicide attempts make headlines. Here are some examples.

“Former Romanian prime minister Adrian Nastase attempted suicide just hours after the southeast European nation’s highest court threw out his appeal of a two-year jail sentence on a corruption conviction” (LearnGerman news, accessed 2022-3-30)

Brazil: “In 1954, the former dictator-turned-democratically-elected president, Getúlio Vargas, committed suicide in the wake of the Mar de Lama (“Sea of Mud”) corruption scandal” (North American Congress on Latin America, accessed 2022-4-4)

Maryland, USA: “The Watergate hearings disclosed that Congressman Mills had accepted $25,000 from the Committee to Re-elect the President (CREEP) and had not reported it as required by Maryland law. Disgraced by the revelations, Mills committed suicide in 1973 before he was convicted.” (Centre for the Study of Democracy, St. Mary’s College of Maryland, accessed 2022-4-4)

Peru: “Prosecutors say Garcia led a ring of corrupt officials during his second government, from 2006 to 2011, collecting bribes and helping Odebrecht win contracts that included a billion-dollar light-rail line. One former official confessed to receiving $1.3 million from the builder and delivering cash to Garcia, sometimes at the presidential palace. A court ordered Garcia’s arrest April 17 along with eight others. Police arrived at his home early that morning, but before they could arrest him, he shot himself.” (Bloomberg news, accessed 2022-4-4)

Pennsylvania, USA: “In 1986, (State Treasurer) Dwyer was convicted for accepting a bribe from the California firm that won the contract. He was found guilty on 11 counts of conspiracy, mail fraud, perjury, and interstate transportation in aid of racketeering, and was scheduled to be sentenced on January 23, 1987.4 On January 22, Dwyer called a news conference in the Pennsylvania state capital of Harrisburg, during which he fatally shot himself with a .357 Magnum revolver in front of reporters.” (Wikipedia, accessed 2022-4-4)

Tennessee, USA: “Tennessee Secretary of State Gentry Crowell, a political kingpin known as “The Godfather” whose office has been one target of a corruption investigation, shot and critically wounded himself Tuesday in a suicide attempt, authorities said. Crowell is the second Tennessee politician to shoot himself this year as a federal-state investigation of corruption has unfolded. Crowell, 57, put a .38 caliber handgun into his mouth and pulled the trigger in the back yard of his home in nearby Lebanon, Tenn., at around 7 a.m., authorities said.” (Deseret News, accessed 2022-4-4)

So, back to Anna Delvey. According to the TV series, Anna staged her suicide attempt so as to get admitted to rehab to avoid being deported when her US visa expired. The real Anna Sorokin denies this, but it’s difficult to know if she is telling the truth. Whatever the motivation, was the journalist Vivian accurate in believing that Anna’s trying to kill herself suggested she was a person with real feelings and hurts, damaged in childhood? I don’t think so; when a person with a history of not caring for others attempts suicide, it’s just another sign of their indifference to the pain they might be causing others.

As clinicians, it can be helpful for us to be aware of these three important motivations for suicidal behaviour, sometimes because we may be in a position to intervene and prevent, and sometimes to help survivors deal with the aftermath.

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