Tag Archives: depression

Anthony Bourdain and Suicide

By Dr David Laing Dawson

We are Borgs, if you will pardon the Sci Fi reference.

At our best we carry in our heads a sense of the thoughts and feelings and wellness of others as well as our own. I am not talking about empathy here but rather that a piece of our consciousness is devoted to the existence of others; that an awareness of others, even when they are not present, is an important part of consciousness.

This ability allows us to experience empathy but it is wider than that. When conscious, at our best, we are aware of not just what we see and hear and of ourselves, but of the people in our lives and our connections to them. And that circle of people can include a few family members or stretch to the refugees of South Sudan.

At our best.

In a psychotic illness that awareness can become strangely distorted, with one or many of these relationships over interpreted, imbued with magical power or ominous threat. This is easy to observe, from a stated conclusion that the people on television talk to me or the police are watching me and putting drugs in my orange juice.

What is not so easy to observe is the effect of clinical depression. But depression, the illness depression, diminishes and eventually eliminates that social form of consciousness; the awareness of others, our connections to them, the presence they maintain in our minds, is lost in depression. Consciousness, in depression, is reduced to simply the self, and the self in depression is a malfunctioning body of limited worth and a sense of dread. Others are gone from our shrinking cloud of consciousness.

Anthony Bourdain killed himself in a hotel room in Paris and I watched CNN last night. He left grieving friends, colleagues, fans, and an eleven year-old daughter. Oddly, with what I have written above, Anthony made a career out of connecting with, engaging with others and sharing their lives and cuisines.

Apart from remembering, paying tribute to Anthony Bourdain last night, much of the focus was on suicide. The number of a suicide hot line was displayed throughout. But we have had these help lines available for 30 years and, as CNN reported, the suicide rate continues to climb. And as I recounted in a previous blog, the numbers of people brought to emergency rooms for assessment of “suicide ideation” has been growing by 14 percent year after year. Yet actual numbers of completed suicides persist and grow.

The focus on suicide itself is wrong. This focus, this de-stigmatization and “talk about it” approach obviously has not helped and may even be a contributing factor.

Suicide is the product of despair, dread, pain, anxiety coupled with the cognitive impairment of depression I have described above. It is this cognitive impairment that allows the severely depressed person to not realize the damage his death by suicide will do to his daughter or son, sister, brother.

We are often bewildered by seemingly successful people with loving partners and family who kill themselves. But depression, the illness depression, renders success hollow, and gradually eliminates loved ones from consciousness. In depression one’s sphere of consciousness has deflated to the agony of self. And at that point we seldom call a hot line or seek out help.

For prevention of suicide we need to focus on depression. The recognition of depression and the cognitive deficit that develops with depression, and the treatment of depression.

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A Psychiatrist Discusses Hearing Voices

By Dr David Laing Dawson

In the winter of 1968 I finished a 24-hour shift in the emergency department of a major Toronto Hospital, changed quickly, and walked out into the still dark morning to catch the trolley on Bathurst St. I heard my name called, over and over. I looked for the source. It seemed to come from the electrical wires strung high above the street. I got on the uptown trolley. I looked at my fellow passengers. They were each oblivious, each locked in their own private early morning thoughts within their heavy winter coats.

Sleep deprivation and stress.

I don’t remember the particular stress of that 7 AM to 7 AM shift, but in 24 hours it must have included some bleeding, screaming, and dying, some vomit and rage and insanity, some crying and bewilderment, some failure.

I have no doubt that it is a simple slippage in our brains that can take our thoughts, our inner dialogue, our inner fears and our self-reassurance, and have us hear them, hear them as if either coming from outside our heads, or from an ‘other’ in our heads. In fact, when you think about it, it seems quite remarkable that usually our brains can make a clear distinction between the inner and the outer. So I am not surprised the boundary can be so easily broken in times of high anxiety, fear, stress, sleep-deprivation, psychosis, brain impairment, and trauma.

I am also not surprised that these voices often carry one of two kinds of meaning: accusations, fears, nasty directives or calming, reassuring, comforting messages. The phenomena that might be more difficult to understand are the hearing of conversations, undecipherable mutterings, even crowds shouting at one another. But then again, if our thoughts are often conflicted, unclear, inarticulate, there is no reason to assume thoughts that become voices would be otherwise.

In the many years since 1968 I have talked to hundreds of people who hear or have heard “voices”.

The most common of these is the hypnagogic experience, occurring in the moments between wakefulness and falling asleep, and the hypnopompic experience during the process of wakening.  I’m sure we have all experienced, at times, the overlapping of dream states and wakefulness, with sounds and images from from each world colliding. As a psychiatrist though, I usually hear about it from a parent or patient worried that it is a harbinger of something serious. It is not. Though this overlap can be increased by drugs that alter the rhythms of sleep, and by anxiety and stress and sleep deprivation.

Then we have the shy, anxious, overly-selfconscious teenagers who imagine, and then feel, and then think they hear their peers speak about them in the crowded hallways and cafeterias of school. For the boys it is usually an accusation of failure, of stupidity, of weakness, of failed or unwelcome sexuality. For the girls it can have more to do with dress, complexion, blemishes, size, being alien, as well as stupid, a loser. If it is the product of anxiety, social anxiety, in this age group, the teen usually, once away from the experience, understands he or she probably imagined it.

But it is often the reason they refuse to go to school, isolate themselves, become depressed. It is painful for them. And it is alleviated by good counsel and medication.

(Of course there are also instances of groups of teenagers actually systematically taunting and commenting on a schoolmate’s shortcomings)

The next most common cause of hallucinations may be brain impairment, from injury,  disease, toxic substances, withdrawal from alcohol, or dementia. And these experiences of imaginary people, imaginary events, fearful reactions, and conversations with visual and auditory hallucinations are scattered, disjointed, intermittent, chaotic, changeable. They also may overwhelm reality, replace it. And if the brain impairment can be treated they go away.

And then the psychotic illnesses: In the exalted state of mania with its feelings of power, of influence, of supreme importance (often accompanied by sleep deprivation), the thought that becomes a voice often belongs, as one might anticipate, to God. And the messages are prophetic and instructive. Usually instructions to share one’s new found wisdom. But sometimes they draw on the Old Testament and include fire, flood, pestilence and vengeful punishment.

Fortunately we now have medicines that quell acute mania in short order, and prevent, if taken regularly, relapses.

In the past it was not uncommon for a manic person to die of exhaustion, pneumonia, exposure, or to wreak some havoc, before coming back to earthbound reality.

And then we have a psychotic depression. Again if the boundary between thought and auditory experience is broken, the thought-voices align with the person’s mood. They are dark, hopeless, foreboding. They speak of death and disease. Usually the sufferer’s death and disease, but sometimes, with some men and women, the death of their family as well.

Undiagnosed and untreated a psychotic depression often leads to tragedy. Again, fortunately, our modern treatments, including ECT, are very effective.

And then we have  the schizophrenias. In my experience the hearing of voices is just one part of schizophrenia, a small part, though often very distressing to the sufferer. Many don’t admit to voices until years later. (For over a year it had remained a puzzle why one young man jumped off a school roof. Until he was well enough and he trusted me enough to tell me about the instructions he was receiving at the time.)

And the voices, the transformation of thoughts to an auditory experience, again follow the pattern of the sufferer’s feelings, ideas, distorted interpretations. They are often accusatory in nature, exacerbating guilt and self-loathing. They are sometimes instructive. That is, they might propose an action that will stop the pain and suffering of others. Such as jumping off a roof.

For most people with schizophrenia who do suffer auditory hallucinations the voices are tormenting. They would like them gone. A few get used to them, learn to ignore them. A very few, eventually, allow them to become a comforting background buzz within their otherwise socially isolated lives.

And an equally common symptom of schizophrenia is the reverse: the discomforting conviction that others in your proximity can hear every thought you have. Your thoughts are being broadcast as it were. (The treatment of schizophrenia is addressed in many other blogs on this site.)

Trauma. Abuse. It is again not really surprising that during acute trauma, during the experience of pain, fear and the threat of death and of absolute powerlessness to change this, our brains can take us elsewhere, that they have mechanisms at hand in these dire circumstances to transport us to kinder experiences in our imagination. For a child this may include being a different child with reassuring caregivers, better parents, a much more benevolent world. The more prolonged the abuse the more complex and real the imagined world may become. It could include multiple thought/voices that reassure and comfort. And others that threaten and punish.

The adult who survives this may carry with him or her both a hypersensitivity to threat, to the faces, noises, smells and symbols of threat, quick and exaggerated fear reactions, as well as an ability to call up, to return to, to run to, the other worlds of reassurance and comfort.

This is not schizophrenia. It is PTSD. We don’t have pills that fix this. Though we do have some that may improve sleep, alleviate some anxiety, and quell the most extreme reactions. And to focus on strength, to find a way to deny the memories, thoughts and voices that threaten, punish, and degrade, and to lean on the thoughts and voices that support, comfort and empower, is a good and courageous survival mechanism.

If the voice is comforting and supporting, and not interfering with one’s ability to live and survive and function in our tangible world, I would not want to try to quell it.

On the Efficacy of Suicide Prevention

David Laing DawsonBy Dr David Laing Dawson

In the past decade, make that two decades, we have witnessed a plethora of mission statements, lectures, programs, public health campaigns, TV ads, crisis services, anonymous telephone answering services, crisis lines, websites, information initiatives, task forces, white papers, all aimed at suicide, reducing the suicide rate in our communities, preventing suicide.

Yet the rate of suicides in Canada, completed suicides, remains statistically unchanged.

All of the above activities make us feel we are doing something about the problem. We are trying. But that is all they do.

The problem with a public campaign to prevent suicides is that it is akin to a public campaign to prevent heart failure. Both are end stages of other processes, but in the case of heart failure we know enough to target smoking, cardiovascular disease, obesity, hypertension, diabetes, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”

We know the demographics of completed suicide. We know the risk factors. We know the specific and usually treatable illnesses that all too frequently lead to suicide. So if we truly want to reduce the actual numbers of people who kill themselves (not threats, small overdoses, passing considerations), then we need to stop wasting resources on “suicide prevention programs” and put them into the detection and treatment of those specific conditions so often responsible for suicide:

  • Some suicides are bona fide existential decisions, a choice to end one’s life of suffering: terminal illness, intractable pain, total incapacity.
  • Some suicides are the result of chronic complex social factors: unemployment, divorce, poverty, loss, alcoholism, addictions, isolation, and chronic illness. We can chip away at these factors with better support and rehabilitation services, improved minimum wage, retraining – but there is nothing we can do quickly and easily.
  • Some youth suicides are the result of impulsivity, intoxication, and an available instrument of death. Impulsivity comes with youth. Parents can keep an eye on intoxication. But we can make sure no instruments of death are available. Guns. Pills. Cars. Get rid of the gun(s) in the house. Lock up the serious drugs. Driving the family car is a privilege, not a right.
  • Some teen suicides today are the result of public shaming, bullying. Watch for this. Chaperone the parties. Monitor Facebook, Snapchat. No cell phones or internet in the child’s bedroom. It bears repeating: NO cell phones or internet in the child’s bedroom.
  • And then we have the specific mental illnesses that all too frequently, especially when undetected or under-treated, lead to suicide. These are Depression, Schizophrenia, Bipolar Disease, Severe Anxiety, PTSD, and OCD. And if we really want to make a dent in that suicide statistic then our programs, our money, our resources, should be directed to detection, comprehensive treatment, and monitoring of these illnesses.