Medicine Nonfiction Seattle

Questions After a Suicide.

To my knowledge, three people who were under my care killed themselves.[1. Additionally, three people who were active patients of mine tried to kill themselves. Then there are the people who have killed themselves, and I am simply unaware that they have died from suicide.]

The first was a young man—late 20s, maybe?—who I met while I was a psychiatry intern. He was hospitalized in the psychiatric unit where I had just started my rotation. I did not have the opportunity to get to know him well. Our paths crossed, at most, for two days. He had a diagnosis of schizophrenia. I can conjure up his face in my mind, though I do not remember his name. He didn’t blink much. While his face did not betray fear, he often looked uncomfortable.

I don’t know how many days he had been out of the hospital before he died, though I think it was within a week of his discharge. He jumped off of the Aurora Bridge (before a suicide prevention fence was installed) into Lake Union in Seattle.

The second was a man in his late 40s who had repeated visits to a crisis center. He did well in college and earned a law degree. His career as a lawyer was cut short due to problems with depression and alcohol. From there he became homeless and destitute. He had a diagnosis of major depression. Some professionals thought he had a personality disorder.

He was smart and sarcastic. While he was often critical of everyone around him, there were moments when he was self-effacing. After we had worked together for a few months, he commented that he liked “debating” with me, though I suspected that arguing was the only way he knew how to interact with other people. On the rare occasions when he took a break from his self-loathing, he considered how his life could change. He didn’t drink as much alcohol now as he once had, but it still helped him forget his shame and regret.

When I learned that he had died from an overdose of methadone, I knew immediately that he had intentionally killed himself. He had no history of using opiates, but he knew how, with or without alcohol, they could end his life. Over a month had passed between our last conversation and his suicide. When I learned of his death, I asked him—as if he could hear me—why he didn’t come back to the crisis center. He knew that he could.

I have not forgotten his name. Earlier this week, I saw his name in a newspaper. It wasn’t him, of course; the name belonged to an author who was promoting his book. I hadn’t seen this name elsewhere before. It made me wonder if my patient was saying hello.

This past week, I learned that a third person who was under my care killed himself. He was in his 20s, smart, and funny. When his symptoms were active, he was very ill. In the minutes to hours leading up to his death, was he experiencing a resurgence of his symptoms? Or was he mulling over how his illness could impact his life in the future and decided to impact his life first?

The last time I spoke with him, we talked about how his condition did not define him. His identity wasn’t solely his illness. We talked about the things he wanted to do in the future and how he could accomplish those things.

The person who called me to tell me the news heard my breath catch in my throat.

Death, while uncomplicated in some ways—it’s a permanent cessation of all vital functions, the end of life—our attachments make it complicated in other ways. We have so many questions that will forever go unanswered. We wonder where the dead go. Does a part of them persist outside of our memories? And for those who kill themselves, what happened? What got in the way of them asking for help? What made death the best option? What made them believe that the rest of us could not or would not understand?

The end of a life never just impacts the individual who died. The ripples spread far and wide. We search for words to describe our grief, but language fails us.

Consult-Liaison Reading Reflection

Antisocial Behaviors.

The anxieties and discord within my tiny world and the world at large have felt heavier as of late. Thus, my words do not flow today with the relative ease that they have under different conditions. (To be clear, I’m fine. Perhaps I am just more sensitive to the energies and emotions of others.)

I recently learned about “adulthood antisocial behavioral syndrome”. If you’re familiar with the definition of antisocial personality disorder, it’s essentially that without the requirement for conduct disorder before the age of 15. (If you’re not familiar with antisocial personality disorder, allow me to refer you to my 2013 post (!) that describes the condition.)

The prevalence of these two conditions (derived from surveys of the general public) surprised me: In the United States, about 4% of the population have antisocial personality disorder, and a striking 20% apparently have adulthood antisocial behavioral syndrome. If the prevalence is 20%, should we consider that a disorder? (Is that why it’s called a “syndrome”?) That means if you invite four of your friends over to your home, one person in that group has adulthood antisocial behavioral syndrome. (Maybe it’s you!)

For many reasons (it’s exhausting, I have insufficient data, I can’t do anything to help, etc.), I avoid the intellectual exercise of considering what psychiatric conditions certain public figures may have. That being said, regardless of who is President and which political party has the majority, it is common in psychiatric education to note that there are people in power who likely have antisocial personality disorder. These individuals just haven’t gotten caught (or have the resources to avoid punishment… or there are institutional factors that protect them).

But, for “fun”, let’s run the numbers. If 4% of the US population meet criteria for antisocial personality disorder, that means

  • four Senators and
  • 17 House Representativies

demonstrate a “pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years”. (I’ll let you discuss amongst yourselves as to the identities of these individuals.) There are 15 Cabinet members and nine Supreme Court justices, so the chances are low that one person in either one of those groups has antisocial personality disorder.

If 20% of the US population meet criteria for adulthood antisocial behavioral syndrome, that means

  • 20 Senators
  • 87 House Representatives
  • one Supreme Court justice and
  • three Cabinet members

demonstrate a “pervasive pattern of disregard for and violation of the rights of others”… but did not do so before the age of 15.

The paper that describes the survey also notes that these two antisocial conditions are

highest among male, white, Native American, younger, and unmarried respondents, those with high school or less education, lower incomes, and Western residence

When we consider mass shootings (most certainly an antisocial behavior) in the US, most of them were committed by men… but also note that the vast majority of men don’t ever kill people.

The odds ratio for Native Americans struck me: What does that mean? Is this simply due to the low numbers of Native Americans in this country (i.e., small numbers inflate percentages)? What are the other confounders?

And what about the contexts? Aren’t there occasions when antisocial behaviors are adaptive? If someone threatens your life on a routine basis, is it (1) unreasonable to lie, (2) put your safety at risk when you try to escape the situation, and (3) perform poorly at work due to the stress in your life? You only need to meet three criteria to receive a diagnosis of antisocial personality disorder.

I’m also curious about the prevalences of adulthood antisocial behavioral syndrome in other countries. Does a 20% prevalence in the US mean anything? Do we demonstrate more antisocial behaviors than others on this planet? Maybe this is just human nature?

Some people say that intellectualization is a mature defense mechanism. I’ll let you decide if this post is simply a manifestation of whatever unconscious conflict roils in my psyche.

Medicine Nonfiction

Follow Up.

To my surprise, he called my name and asked to talk with me.

I didn’t bring up the incident that had occurred the last time we spoke: He got upset because he believed that I had put voices into his head. I wanted him to associate me with attributes other than hallucinations. There was no way I could help him if he believed that I was doing things against his wishes.

“So, hey,” he volunteered after we had spoken for a few minutes, “I’m sorry for yelling at you the other day. I was already thinking about robots and when you asked me about them, I freaked out. I’m sorry.” A sheepish smile bloomed on his face, but his eye contact did not waver. He looked and sounded sincere.

“It’s okay,” I replied. “This is a stressful situation and sometimes we all get upset over things that we feel like we can’t control.”

He nodded. We talked about the voices—they were still talking to him, but they were quieter now—and what other things he could do so they wouldn’t bother him as much.

Even though I’ve been doing this work for years now, there are still moments when I am astonished with the effectiveness of medications for symptoms of psychosis. I already knew they can save lives. I already knew they can transform lives. And yet!

“I am going to ask the nurses to offer you medicine,” I said the last time we met while he was yelling at me. “You don’t have to take it, but I think it will help.”

And, for whatever personal reasons he had, he took it. (The manner and skills of the nurses undoubtedly helped with this, though it appears that persuasion of any form was unnecessary.)

“Do you have any other questions for me before I go?” I asked. Last time, I simply told him that I was leaving. First, do no harm.

“No,” he said, smiling. “Thank you for talking with me. I hope you have a nice day.” He waved.

“Thank you,” I said, waving back.


Medicine Nonfiction Reflection

Assuming Intentions from Behaviors.

The fear first appeared in his eyes, then washed over his entire face.

“Hey, how did you do that?” His voice grew louder. “You’re supposed to help me! How did you tell the voices what to say?”

I realized that this was not going to end well.

“The voices in my head are now saying that there are robots in my brain!” he shouted. “That’s illegal! You’re not allowed to do that!”

“I have no ability to put voices in your head or anyone else’s head.”

“But you did! Before you told me about what I supposedly said the other day”—he had told my colleague that there were robots in his brain—“the voices never talked about robots. YOU did this!”

“I did not.”


My heart sank further. Many people who experience auditory hallucinations learn to avoid sharing this with others. This man did not realize how others would dismiss his suffering.

“I’m going to go.”

“NO! You can’t go! You’re doing something illegal!” He saw an officer approach. “GUARD! GUARD! This nurse is doing something illegal! She’s putting voices in my head!”

Though he has worked on the unit for years, I suspect that he had some innate skills in talking with people who were overwhelmed.

“Hey, you don’t need to yell, I’m right here. She’s trying to help you….”

He managed to shout, “HEY, COME BACK HERE, YOU NEED TO STAY!” as I slipped away, but he stopped yelling before I was out of earshot. The officer later told me the man demanded that I call his parents to tell them that I was putting voices in his head.

There’s no way this could ever happen to you, right?

But aren’t there times when we believe that someone did something to us… except they didn’t?

Like those times when we say, “She makes me so mad!”

Or, “He’s trying to make me jealous.”

We assume intention from behaviors. Sometimes our assumptions are correct, but not always. We feel whatever emotions we feel, but that does not always mean that somebody else is responsible for our emotions.

“But, Maria,” you might retort, “there’s a big difference between hearing voices and feeling emotions. We all feel emotions. Only sick people hear voices.”

… except there’s data[1. Prevalence of auditory verbal hallucinations in a general population: A group comparison study and A comprehensive review of auditory verbal hallucinations: lifetime prevalence, correlates and mechanisms in healthy and clinical individuals.] that suggests that anywhere between 5% and 28% of the general population hears voices. They are your coworkers, friends, members of your family, people you routinely see in your community.

And even if we don’t hear voices, our running internal dialogue—while not “voices”, per se, but “thoughts”—can transform an event into something else that never actually happened.

I felt sad as I was walking away from this man. First, do no harm. Our conversation went sideways and caused him distress. I replayed the interaction in my mind—my own internal dialogue was loud—and recognized several points where I could have taken a different approach. The outcome still may have been the same.

The truth remains, though: I did not put voices into his head. I don’t know how to do that. My hope is that he will recognize and accept that in time.