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Eleven Deaths Ronningstam et of al.Mr. K

Eleven Deaths of Mr. K.Contributing Factors to Suicide in Narcissistic Personalities

Elsa Ronningstam, Igor Weinberg, and John T. Maltsberger
The objective of this paper is to discuss and illuminate the problem of abrupt suicide in relatively well-functioning individuals without a major DSM-IV mental illness. A case of a man diagnosed with narcissistic personality, who first allegedly staged a suicide attempt and later, without overt warning, killed himself in the context of financial losses and divorce, will be discussed. The paper addresses how and why a life event can generate an internal subjective experience that evokes a sudden deadly self-attack. Discussion of eleven explanatory hypotheses serves to further the understanding of these seemingly inexplicable events. We conclude that additional studies are necessary, especially of the interconnected interaction between life event, psychological functioning, and neurobiological correlates to expand understanding and develop proactive treatment strategies. Sudden, unexpected, and impulsive suicides in relatively well-functioning individuals continue to shock and puzzle clinicians and researchers. Such events challenge our clinical habit of seeing suicide foremost associated to severe psychiatric conditions. Studies attributing lethal actions to psychiatric diagnosis, that is, primarily mood disorders, psychosis, or substance abuse (Barraclough, et al., 1974; Robins, Murphy, et al., 1959) are indeed contrasted by those who argue that suicide is driven by subjective experiences of mental pain (Michel, Maltsberger, et al., 2002; Shneidman, 1993) or committed abruptly in a state of rage or despair (Apter, Bleich, et al., 1993; Hendin, Maltsberger, et al., 2004; Kernberg, 2001). A majority of people who commit suicide are not under psychiatric care, and nearly 50% have never had psychiatric treatment (Luoma, Martin, & Pearson, 2002; Runeson, 1992). Among those who have contact with healthcare professionals, over 75% do not communicate intent to end their lives (Isometsa, Heikkinen, et al., 1995), and over 50 % complete suicide at first attempt (Zonda, 1999). A particularly short and rapidly evolving suicidal process without prior indications of emotional or behavioral problems was found in adjustmen-disordered people (Portzky, Audenaert, & van Heeringen, 2005; Runeson, Beskow, & Waern, 1996) So far, antemortem predictions of suicides have proved to be impossible (Pokorny 1983; Simon, 2006). The postmortem understanding of psychological processes con-

Elsa Ronningstam, PhD, is Associate Clinical Professor of Psychology, Harvard Medical School and Associate Clinical Psychologist, McLean Hospital, Belmont, Massachusetts. Igor Weinberg, PhD, is Staff Psychologist at McLean Hospital and Harvard Medical School. John T. Maltsberger, MD, is Associate Clinical Professor of Psychiatry, Harvard Medical School, Clinical Associate, McLean Hospital, and Clinical Affiliate in Psychiatry, Massachusetts General Hospital and Boston Psychoanalytic Society and Institute. Address correspondence to Elsa Ronningstam, PhD, McLean Hospital, 115 Mill Street, Belmont, MA 02478. Email: ronningstam@email.com.

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tributing to suicides remains clouded inasmuch as it depends on posthoc inferences. Studies searching for explanations outside the usual psychiatric and psychopathological realm have suggested different possible causes of suicide. Experience of a recent challenging life affront is common among people who suddenly commit suicide (Heikkinen & Lonnqvist, 1994). Losses were reported as the most common life event associated with suicide (Cheng, Chen, et al., 2000). Interpersonal, marital, or legal problems preceded suicide attempts in people with personality disorders (Yen, Pagano, et al., 2005). Such challenges also frequently occur among people without severe mental illness in the week before suicide (Cooper, Appleby, & Amos, 2002). Precipitating life events to suicide, commonly involving interpersonal or work-related conflicts or losses, were determined by identifying linking evidence from treating therapists observations (Maltsberger, Hendin et al., 2003) Pathological narcissism, that is, a personality structure that unreliably protects selfesteem and internal control, has been connected to suicide (Apter, Bleich, et al., 1993; Arie, HaruviCatalan, & Apter, 2005; King & Apter, 1997). People with such functioning can balance suiciderelated selfesteem-preserving grandiose ideas, on the one hand, and the actual suicidal behavior and its real selfdestructive or lethal consequences on the other (Ronningstam & Maltsberger, 1998). Intolerable affects, aroused by selfesteem-threatening life events such as loss of vital support, aspirations, and perfectionist ideals, can be denied and split off (Kernberg, 1992; Krystal, 1998; Schore 1994). In such cases, suicide may preserve a sense of internal mastery and control, or it may shield against anticipated narcissistic threats and injuries, as the motto death before dishonor implies (Ronningstam & Maltsberger, 1998). Suicide-related aspects of morbid selfesteem regulation make narcissistic individuals reluctant (or even unable) to convey their suicidal intent to a clinician. Furthermore, impulsivity, especially impulsive aggression, has been linked to sui-

cide in personality disorders (Conner, Duberstein, et al., 2001; Horesh, Rolnick, et al., 1997; Kernberg, 2001). Narcissistic rage and shamebased aggression can lead to suicide if turned against the self (Kohut, 1972; Baumeister, 1990). More recent studies suggest that impaired ability for selfdisclosure may be associated with suicide (Apter, Horesh, et al., 2001). Reluctance or inability to share feelings and thoughts with others can force loneliness and isolation. Such a deficit was considered a mediating risk factor for suicidal behavior when other risk factors such as hopelessness were present (Apter & Ofek, 2001). Despite increasing evidence for contextual and dynamic causes of suicide, clinicians find application of this knowledge difficult in practice. As a significant number of suicides occur outside the realm of psychiatric treatment and psychotherapy, the circumstances that drive them remain unexplored and unknown. The objective of this paper is to discuss and illuminate a sudden abrupt suicide. A man with narcissistic personality traits, who first allegedly staged a suicide attempt and later, without overt warning, killed himself in the context of financial losses and divorce, will be discussed. We will specifically address how and why a life event can generate an internal subjective experience that evokes a sudden deadly self-attack.
CASE VIGNETTE

Mr. K began individual psychotherapy when he was in his late forties. He had been married for over 25 years and had three adolescent sons. After a selfdestructive act that followed his violation of a restraining order, he was placed on probation that recommended treatment. An anger management program and individual psychotherapy to address his intense aggressive reactivity were ordered by the court. Background Mr. K grew up in an entrepreneurial family that valued hard work, independence,

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and responsibility. His father, who had died 3 years earlier after several years of illness, had owned a large industrial company, and while still in college, Mr. K started his own company in a related industrial field. His mother, a vital and active woman in her late seventies, was still working. Three younger brothers had continued their fathers business, while Mr. K branched out on his own. There was no known family history of mental illness. After graduating from college, Mr. K married a beautiful and competent woman whom he greatly admired. Together they developed a company that gradually expanded with branches nationwide. They made a very good business team. Mr. K felt that a life dream had come true; he had an attractive wife, three fine, intelligent sons, and a successful business. He was very proud of the evidence of his hard and effective work. Unexpectedly, the company ran into financial problems. Mr. K had to downsize and lay off a major number of his employees. Family members who had worked with him left the company for other projects. After a mutual agreement, even his wife decided to take a managerial position in another corporation, with Mr. K continuing to oversee what remained of the company. Mr. K became uncomfortable as his wife increased her independence. He needed her supportive assistance and called to ask her business advice several times daily, so often that it interfered with her new job. He would even appear at her workplace in an agitated state, insisting that she immediately attend to his problems, or even come home with him. Once he had to be escorted out of her workplace by her companys security staff. When she complained about his behavior, he aggressively tried to control her by preventing her from leaving home, hiding her car keys or her cell phone. Although Mr. K admitted to and apparently gradually understood the inappropriateness of this behavior, he adamantly denied any intent to be offensive or abusive. He also denied feeling ashamed or concerned about his aggressive behavior. He missed his wife immensely; her business skills had been in-

valuable and he could not maintain his own sense of worth and wellbeing without her. After a few months, Mrs. K obtained a restraining order against her husband. Mr. K immediately went home to retrieve his personal belongings and impulsively decided to stage a fake suicide attempt to evoke his wifes remorse. He turned on the car engine in the garage, pretended to be asleep inside the car, but left the garage door open. A neighbor found him and called the police. Mr. K was fully conscious and required no medical treatment, but he was promptly arrested for violating the restraining order. Later, he regretted his suicide trick because it backfired on him; he consistently denied any suicidal intent. In time, the wife retracted the restraining order, and the couple continued to live together in their home. Diagnostic Evaluation Before entering psychotherapy, Mr. K had an extensive psychiatric evaluation according to which he did not meet formal criteria for a DSM IVR psychiatric disorder. Five independent clinicians agreed that Mr. K showed no symptoms of mental illness, mental defect, or major mental disorder. There was no psychosis and no neurovegetative sign of depression or mania. Mr. K had no history of major mental illness, traumatic experiences, substance abuse, suicidal behavior, or ideations, and he had no criminal past. Nor had he ever received treatment for psychological or psychiatric problems. The evaluation did suggest that Mr. K had prominent narcissistic character traits, indicated both by his behavior and a psychological test (The Millon Clinical Multiaxial Inventory, MCMIIII). The history and testing showed a sense of entitlement; a tendency to exploit others and situations for his own ends; at least a partial lack of empathy; resentment and envy of others; and arrogant behaviors and attitudes. The testing also indicated aggressive and sadistic tendencies, a potential for vindictive behavior, and a proclivity for impulsive action and possible violence in the context of losses. The diagnosis adjustment reaction was suggested, with distress and functional impairment in

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conduct in response to specific recent stressors, more specifically related to the restraining order. However, the evaluation also suggested that Mr. Ks behavior could represent an exacerbation of a personality disorder, including violent behavior under stress. All in all, the clinical presentation was narcissistic personality disorder with impulsive potential. The Psychotherapy Mr. K was placed on probation and began psychotherapy about a year after his company was downsized. At first he resented the treatment as an unfair burden forced on him by the court. He approached the therapist in a businesslike manner insisting on the minimum probation requirement of one session every two weeks. Convinced he was a misunderstood victim, he considered the treatment unnecessary. However, he also realized that if he was to sustain his marriage he had to change some of his behavior. At first, although he was frustrated and resentful, he nevertheless conveyed a sincere wish to repair and regain his previous relationship with his wife. Mr. K denied ever having felt or presently feeling suicidal, and he asserted that his simulated suicidal act was just stupid behavior which would not happen again. He showed no indications of suicidal ideation nor of aggressive, vindictive thinking. On the contrary, Mr. K conveyed strong hope and intention to repair the marital relationship to his wife. The therapist liked Mr. K. Intelligent, articulate, vital, and energetic, he was a man with intense, argumentative, and tenacious manners, but ready to give therapy a try. I suppose you never met someone like me before, he said to the therapist with a smile. Not particularly insightful or reflective, Mr. K was a man who ran a business, lived intensely in the moment, and relied on external matters to preserve his selfesteem, such as financial success, business achievement, his wifes beauty, and his sons accomplishments. About his therapist, he was suspicious and doubtful, but he was also curious. He knew he had to change and he had hired the therapist to help him do it.

Mr. K spent the first sessions pouring out his anger at his wife. Her frustrating behavior made no sense to him; he could not understand why the recent changes in their lives had eroded their relationship. He resented his wifes independent strivings and blamed them on menopause. He mistrusted her new job and was offended that she had made new female friends. He had no grasp whatever of how his behavior had corroded the marriage. After a couple of sessions, Mr. K said his wife doubted that treatment would do any good. She was upset about his lack of change and threatened to call the therapist herself. For a moment Mr. K seemed to like the idea that she wanted to intrude into his therapy. Asked what changes his wife wanted to see, Mr. K replied, She thinks I am obsessive compulsive. When couples therapy was proposed, he adamantly refused and changed the subject. Mr. K was concerned about changes in his sons behavior; they missed their mother and showed it. He had formerly yielded most parenting responsibility to his wife whose abilities as a mother he strongly valued and admired. Now that she was often away from home, Mr. K grew profusely critical and blamed her for not being a responsible mother. He had some appreciation of his own passivity as a father, and he had experienced her care of their sons as indirect care for himself, feeling that he was one of her boys. Following these discussions, Mr. K became more involved with his sons and reported more meaningful interactions with them. Mr. K hated his wifes pursuits of her new independence, but he also conveyed love, admiration and desire for her. Controlling, dependent, and tenaciously possessive, he prized her as an immensely reliable and important part of his life. He seemed genuinely appreciative of his marriage, describing his life as centered around his wife, sons, and business. Outside his immediate and extended family he had very few friends. When the therapist validated Mr. Ks loving feelings, he began to convey the confusion, jealousy, and loneliness caused by his wifes sudden pur-

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suit of her own life. He had taken her for granted. Mr. K began to see how demanding and intimidating he could be in managing his business and daily activities, acknowledging his controlling behavior and his impatience when frustrated. However, from his perspective his yelling and screaming was not intended to have a negative effect, it was just who he wasa person demanding the most of himself and of others. He could not imagine or understand how his aggressive, controlling behavior could offend his wife or provoke her to anger and withdrawal. His impaired empathic functioning, that is, his capacity for perspective-taking and his ability to feel his own feelings, was part of his tendency to treat his wife as an extension of himself. Furthermore, his inability to feel and express grief and humiliation about the business losses limited his ability to see how humiliating his rage was to his wife. When the therapist commented that he had lost most of the things important to him, things that had made him proud, he began to cry. His relationship to the therapist changed; he became somewhat more helpseeking and confiding, reaching for understanding, explanation, and support. He tried to control his anger and frustration at his wife. He tried to be supportive and respectful of her independence, take an interest in her activities, and convey more appropriately his wish to continue their marriage and repair their relationship. Although resentful of having to attend an anger management program, Mr. Ks committed participation led to obvious gains and benefits. As he identified the differences and similarities between himself and the other group members, he found that he could learn from both the leaders and the other patients. He noticed how his sense of humiliation prevented him from realistically addressing his actual problems with anger. Nevertheless, the marriage continued stormy and unsettled. Mrs. K moved out of their home and then came back; she obtained several temporary restraining orders and then retracted them. She alternated between communicating and shunning him, between friendly, intimate, and collaborative moments

and hostile, rejecting ones. The therapist watched the distance increase between them as Mrs. K spent less and less time at home. Mr. K refused to give up hope of resuming their relationship, believing his wife was just going through a temporary phase. Yet he also conveyed resignation, sadness, and powerlessness. He felt at his wifes mercy, and waited for her next move. Nevertheless, Mr. K showed or reported no signs of major depression, suicidal ideation, or vindictive or hostile impulses. He continued to work, remained committed to his sons and wife, and made plans for traveling. He also discussed the need for a proactive approach in case of a possible divorce. The Therapists Dilemma At this point the therapist faced several dilemmas. First, the potential risk of Mr. Ks destructive and violent reactive behavior when sudden threats or losses confronted him was clear. Although the sadomasochistic marriage was unstable, a separation and divorce would be very challenging for Mr. K. While a gradually negotiable divorce process potentially might be manageable, a more adversarial one would be severely stressful. Would they be dangerous? Second, the therapeutic relationship was limited and tenuous. While the court-ordered treatment inevitably compromised the therapeutic alliance and influenced Mr. Ks motivation for participation and change, he nevertheless engaged in his treatment and shared some of his feelings and experiences with the therapist. Although he became more help-seeking and confided more in the therapist, he nevertheless remained secretive about his business and the details of his marital struggle. He kept the therapist at arms length as a distant witness to the couples oscillations. In addition, his composed, resolute attitude, his stolid hopefulness, and his defensive denial of rage, shame, and fear complicated optimal risk assessment and proactive exploratory and supportive treatment interventions. Mr. K did gain from the treatment inasmuch as he reported being better able to reflect upon and control his aggressive behavior, and to show some ability to grieve and emotionally process the devastating changes and losses in his life. The therapist

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hoped that Mr. K would continue treatment and be able to tolerate a gradual, negotiated divorce. However, the treatment had been relatively brief, and there were no indications of the deeper structural changes in his personality that could help balance his vulnerability and potential risk for sudden dangerous behavior. His efforts to change his aggressive behavior in treatment had in fact led to his wifes withdrawal, which had increased his suffering and distress.

learned that on the day of his suicide Mr. K had received an official notice from his lawyer that a legal attachment had been put on his property, the first formal step in the divorce he dreaded. He had gone to his house, collected all his valuables, and driven away in his car. On the way to his final destination (the building from which he was about to jump), he had discussed business matters on the telephone with his office manager. In retrospect, the manager thought Mr. K was somewhat incoherent, but there had been no hint of anger, despair, or suicide. Ending the conversation, The Last Session Mr. K parked the car, went to the roof, and Mr. K arrived 15 minutes late for the leapt to his death. eleventh and final session. He had just been inDiscussion formed by his lawyer that his wife was filing for divorce. Mr. K discussed how to take a proactive approach, financially protecting Although the therapist was aware of the himself and requesting custody of his sons. To risks for Mr. Ks potentially impulsive selfdethe therapists inquiry about intensified feel- structive behavior, the abrupt legal action and ings of despair and rage, and about violent immediate suicide were shocking. The deadly and suicidal impulses, Mr. K remained silent consequence of the sudden, belligerent divorce and composed. He politely declined the thera- action was, although potentially foreseeable, pists recommendation to increase the fre- still impossible to prevent. The therapist had quency of sessions to once a week, referring to not felt divorce would kill him, though the posforthcoming business meetings. He was en- sibility had been considered, especially if it becouraged to call or page the therapist as came adverse. Apart from his quick reactions needed. He appeared somewhat more quiet to the legal filing, how can we understand what and reserved, slightly more resolute and de- he did? While Mr. Ks suicide raises many spetached, and notably less aggressive and in- cific questions, we are left with a scarcity of tense. Nevertheless, these were subtle differ- facts in our efforts to comprehensively explain ences, and there was nothing in Mr. K speech Mr. Ks action. The task remains to further our or behavior that indicated depression, suicide understanding of what can prompt abrupt suithinking, despair, anguish, revengefulness, or cidal actions like Mr. Ks. other troubling signs. He foresaw a gradual and negotiated divorce process and was deterEXPLANATORY HYPOTHESES mined to get custody of his sons. He left the session about five minutes early due to Mr. K showed several pathological narbusiness obligations, an unusual event, as had cissistic features. In reviewing these we can been his late arrival. visit eleven perspectives and examine their Mr. K failed to appear for his next sesbearing on his death. sion. The therapist learned from Mrs. K, now his widow, that he had committed suicide the 1. Psychopathology day before by jumping from a tall building. AlAlthough suicide usually has been asthough she accepted the therapists condosociated with psychopathology lences, Mrs. K was extremely angry and upset; such as mood, psychotic or subshe said, He just took off and left me with stance abuse disorders, it may octhis whole mess! cur outside the scope of major From other sources the therapist

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mental illness (Axis I disorders) (Baumeister, 1990; Bromish, 1996; Kernberg, 1993, 2001; Maltsberger, 1998; Schneidman, 1993). While higher risk of suicide has been associated with Axis I diagnoses, nevertheless 5% to 19% of people who commit suicide have no such diagnosable psychiatric disorder (Apter, Bleich, et al., 1993; Brent, Perper, et al., 1993; Conner, Duberstein, et al., 2001; Marttunen, Henriksson, et al., 1998). However, a history of significant maladjustment (Ernst, Lalovic, et al., 2004) and significant narcissistic vulnerability without Axis I pathology (Apter Bleich, et al., 1993) have been reported in people who commit suicide. Mr. K was such a patient. Even in the absence of Axis I pathology, strong narcissistic traits may indicate suicide vulnerability. We know that Axis II disorders may suddenly appear under stressful circumstances that cause narcissistic injury. Mr. K had faced severe narcissistic mortification. His business was compromised, his marriage deteriorated, and then came divorce. The differential diagnosis would be either trauma/stress-induced narcissistic reaction (McWilliams, 1994; Simon, 2001) or decompensation of narcissistic personality disorder following significant stressors (Svrakic, 1985). 2. Loss of selfobject Maltsberger (1986) suggested that losing exterior selfsustaining resources can precipitate suicidal crises in those who depend on them to keep selfesteem in balance. Such losses precipitate three affects: murderous rage, aloneness, and worthlessness. Combined they give rise to intolerable anguish. Patients struggle to master affect flooding,

but when failing, they experience selfbreakup. Paradoxically suicide may seem to them a way of holding themselves together (Maltsberger, 2004). Mr. K sensed both a loss of control and a loss of his wife who had been an indispensable part of himself. He tried to master his distress by desperate and intrusive behavior, trying to control her. His suicide, in the context of trying to manage his business in the minutes before the jump, suggests he was trying to hold himself all together. 3. Loss of the ideal selfstate and the broken life dream Sandler, Holder, and Meers (1963) contended that people normally maintain a number of representations of ideal selfstatesconglomerates of experiences that are desired and associated with a sense of pleasure or positive selfregard. Any departure from these states triggers pain which can lead to progressive giving up (Joffe & Sandler, 1965). Mr. Ks ideal selfstate was closely tied to business success and his family. The gap between his ideal selfstate and the contrasting unfolding development of his life forced him into powerlessness and worthlessness, driving him towards a state of giving up. Eventually he decided to end his life to avoid the experience of failure and defeathe could not stand giving up. Smith (1985) added another dimension to the loss of an ideal life, that is, a specific vulnerability in suicide-prone people. She suggested that a vulnerable ego was combined with a compensatory investment in a particular image of their life. This ego vulnerability manifests itself in high selfexpectations, a tendency to inhibit negative emotions, an ambivalent attitude toward death, lack of

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ability to grieve past losses, a tendency to develop overly dependent relationships, and passivity and neediness. Other characteristics are cognitive rigidity, arrested sexual development, and overinvestment in appearance or intellectual ability. The compensatory fantasy can have an organizing effect, helping the person to function and live a relatively adjusted, though rigidly organized life. However, when this image or fantasy is shattered, a regression in ego functioning can occur, and the person escapes the pain through suicide. Mr. K. showed several indications of vulnerable ego: high selfexpectations (e.g., work values), inhibition of negative emotions (inability to express shame, envy, or humiliation), limited ability to grieve (violent reactions to loss), overly dependent relationship (needing support from his wife and intensely missing her), neediness (attempts to control his wife when she asserted her independence), cognitive rigidity (getting aggravated when things did not go his way), and overinvolvement in appearance or intellect (overinvestment in business success and wifes appearance as a way of regulating selfesteem). Mr. Ks projection of a life dream (success in business and a family) supported a relatively well-adjusted life and allowed him to function successfully in both of those fields. However, when his life dream was shattered, suicide seemed his only way out of intolerable painful internal and external circumstances. 4. Sudden defense breakdown While Mr. Ks defensive denial and distortion protected him from reality for awhile, such reality avoidance is always an alerting sign. When these primitive defenses fail, the person faces anguish without

selfregulatory resources. When Mr. K could no longer disavow his wifes withdrawal and rejection, we may presume he could not endure the affects that arose within him. The combination of intolerable anguish and failure of coping mechanisms probably drove his suicide. Narcissistic patients tend to manage emotional crises by denying, isolating, or splitting off intolerable feelings, while maintaining grandiose fantasies of superiority and invulnerability (Kernberg, 1992; Krystal, 1998; Schore, 1994). Plainly, this specific combination of narcissistic and affect pathology can result in a paradoxical state of calmness, control, and selfconfidence in the suicidal patient. I just need to know that I can kill myself and make the decision as to when, and all negative feelings just disappeared, one woman said. 5. Anger turned against self with revengeful intent Freuds formulation (1917 [1915]) that suicide (e.g., aggression turned against the self) represents an effort to kill an ambivalently regarded lost person internalized within the self could serve yet another explanation of Mr. K s action. Indeed, he struggled with strong ambivalent feelings towards his wife who had become increasingly distant. The idea of destroying the other by destroying the self is an effort to take control but can also have a retaliatory intent. Several studies have shown that revenge can drive suicide (Baechler, 1975; Bancroft, 1979; Bancroft, Skrimshire, & Simkin, 1976; Birtchnell & Alarcon, 1971; Boerges, Spirito, & Donaldson, 1998; Hawton, Cole, et al., 1982; Williams, 1986;). This suggests that suicide communicates anger and aims to punish. In addi-

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tion, Kernberg (1984) described suicide associated with malignant narcissism as a vehicle of omnipotent wishes for sadistic control. Mr. K once simulated suicide in anger to evoke his wifes remorse. As his wife pursued the next step towards divorce, Mr. Ks revengeful intent escalated into a real suicidal act. His wifes responseHe just took off and left me with this messsuggests how effective suicide can be for getting even. 6. Neurobiological indicator Right hemisphere dysfunction is considered a risk factor for both suicide (Weinberg, 2000) and narcissism (Schore, 1994; Weinberg, 2000). Such dysfunction manifests itself in frail selfrepresentation, dissociation, poor impulse control, and emotional dysregulation (for a review see Weinberg, 2000), as well as in narcissistic vulnerability (Schore, 1994; Weinberg 2000). All these characteristics are descriptive of Mr. K. As negative affects tend to escalate right hemisphere dysfunction (Weinberg, 2000), it could be possible that anticipation of the divorce led to further right hemisphere dysfunction, manifested in dissociation (e.g., managing business matters in a detached manner), emotional dysregulation, loss of impulse control (e.g., suicide attempt), and self-breakup (e.g., compartmentalized functioning in therapy vs. work vs. relationship to his wife). 7. Turning passive into active Kohut (1972) suggested the desire to turn passive into active as a response to narcissistic injury, especially in shame-prone individuals. Family values of independence, responsibility, and hard work might have made Mr. K intolerant of passive suffering and resignation in the

face of defeat. Rage and controlling behavior towards his wife may have aimed at reasserting and reclaiming involvement and control. His suicide can be seen as stopping the divorce process and seizing control over it: It is not you, who is filing for divorce, but me, through suicide. 8. Intolerance of humiliation, envy, and shame: A specific case of emotional dysregulation Linehan (1993) proposed and others (Westen, Muderrisoglu, et al., 1997; Zlotnick, Donaldson, et al., 1997) confirmed that emotional dysregulation predisposes to suicide. Inability to tolerate emotional states is a source of narcissistic threat, inasmuch as it challenges both ones sense of omnipotence and internal control. Trumbull (2003) suggested shame to be an acute stress response to interpersonal traumatization. As such, shame can mobilize depressive paralysis, narcissistic rage, and selfhurtful intent. Envy may lead to shame as it implies inferiority of the subject and superiority of the object of envy. Mr. K. was flooded with threatening and intolerable feelings as he faced vanishing hope of reconciliation with his wife. In addition, some of his shamebased aggression was triggered by loss of pride, value, and status. Humiliation and loss of pride and control left Mr. K. powerless to repair his broken narcissism, and suicide was a way to reassert his pride and reclaim control. 9. Selfdestructive core and gradual approach of death Mr. Ks stoic, selfsufficient attitude hints at a masochistic investment in suffering (Cooper, 1988). Was his helprejecting attitude and tendency to invite humiliation a sign that his

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own selfdestructiveness might have been pushing him towards suicide? Was his aggressive, battering behavior towards his wife actually a well-known and characteristic rejectionprovoking behavior common among suicide-prone people? The provoked rejection confirmed his victim role and deepened feelings of worthlessness and being unlovable. Such provocation also unleashes anger and dissipates feelings of guilt over selfdestructive wishes, making suicide easier (Maltsberger, & Buie, 1973; Novick, J., 1984; Swann, 1996). Maris (1981) described and confirmed that childhood traumata instills selfdestructive tendencies that erode positive lifestyle. In this context we can see Mr. Ks first suicide attempt as a rehearsal, a way of decreasing anxiety over performance of suicidal actand fear of death (Orbach 1988). He denied any suicide intent but must have remembered that portrayal as an investment in the future should things get worse. Suicide by jumping is characteristic of psychotic states (de Moore & Robertson, 1999). Laufer (1995) suggested that suicide occurs in psychotic states, when irreversibility of death is denied (see also Maltsberger, 2004). 10. Cognitive deconstruction Baumeister (1990) claims that suicidal people escape negative feelings, especially shame, by flight into a deconstructed state of mindthey abandon any sense of time, ability to represent higher levels of meaning, and, consequently, focus on the concrete aspects of the reality. Cognitive deconstruction shuts off intense emotions, and is often associated with total lack of emotions passivity and a withdrawal from active involvement and responsibility in life. Because cognitive decons-

truction is also associated with disinhibition and with concrete irrational or illusional thinking, Baumeister (1990) saw this as a presuicidal state. Studies confirm that anticipated loss can lead to cognitive deconstruction (Twenge, Zhang, & Im, 2004) and increased selfdestructiveness (Twenge, Catanese, et al., 2003). At the end, Mr. K. was facing the loss of his wife through divorce. His impulsive attempts to control his wife could suggest selfdeconstruction , while his nondisclosure of suicidality in treatment seems to reflect his concrete, dissociated state of mind. The suicide followed as an impulsive escape from painful selfawareness as well as from the anticipated loss. 11. Underdeveloped capacity for mentalization Fonagy (1999) suggested that the capacity for metacognitive control, reflective selffunctioning and mentalization, and the ability to see and attribute intentions to self and others, protect against narcissistic injury. In narcissistic patients, these capacities have not properly developed, and they are unable to think and reflect beyond the immediate experience. They fall back on aggression as a protective shield against overwhelming thoughts and feelings. Mentalization failure leads to objectification of ones body and denial of reversibility of death. In moments of threat and despair, this was obviously one of Mr. Ks handicaps. This capacity to reflect and understand the consequences of aggressive and selfdestructive actions were probably impaired or lacking.

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CONCLUSION

Suicide is a relatively rare event, now occurring in the United States about 31,000 times each year. Inasmuch as we have no specific tag or indicator that distinguishes those persons destined to die of suicide from those who are notno psychological test, no biological marker, no other specific flagclinicians are forced to do the best they can to pick and choose among those who come to their attention as persons who might commit suicide. The only way is to rely on clinical assessments of risk, since prediction of who will commit suicide is still scientifically impossible at present (Pokornoy, 1983). There is an extensive literature on suicide risk assessment, requiring that on the basis of careful inquiry into a patients present circumstances, medical and psychiatric history, and mental state examination, an examiner should arrive at a probability estimate of a suicide occurring in the near future (Simon & Hales, 2006). As a practical matter, this means that the responsible clinician would elect to commit a patient to a psychiatric unit, involuntarily if necessary, should attempting suicide appear more probable than not. Indeed, the clinician would have a legal duty to take steps to protect such a patient, and would fail to do so at his own peril. This is the usual scenario of the common malpractice actions against mental health specialistsfailure to protect the patient when a suicide attempt was expectable and probable. We can generate multiple theories to explain many suicides after the fact. For this reason, we tend to avoid deterministic explan-

atory models. In fact, absent major mental illness (including depression), suicidal communications, evidence of suicidal preparations, and a life history indicating suicide proneness, it becomes virtually impossible to admit a patient to a psychiatric unit as at risk for suicide, on either a voluntary or on an involuntary basis, especially if the patient denies any such ideation or intent, as was the case with Mr. K. In his case, there clearly were indications of intense stress that might be narcissistically destabilizing, although the development of the potentially stressful specific life circumstances was unforeseeable. Not every patient who experiences narcissistic destabilization becomes suicidal, however, and in such circumstances, the only possible course for a prudent clinician is to be aware that a suicide crisis may arise and to remain in close contact with the patient until there is evidence of restored emotional equilibriumand to act if suicide becomes probable on clinical grounds. Research on suicide mostly involves longitudinal studies of identified highrisk groups. While the advantages of such studies are obvious, rare instant events like Mr. Ks suicide can provide important facts and raise significant questions, especially regarding the interconnected interaction between lifeevents/contexts, psychological functioning, and neurobiological correlates. Further indepth studies of the role of impulsivity, s h a m e a n d a g g r e s s io n , a n d t h e ir neurobiological correlates in high functioning narcissistically vulnerable people are necessary to expand our understanding and develop more proactive and preventive treatment strategies for such people.

REFERENCES Apter, A., Bleich, A., King, R., Kron, S., Fluch, A., Kotler, M., &Cohen, D. (1993). Death without warning?A clinical postmortem study of suicide in 43 Israeli adolescent males. Archives of General Psychiatry, 50, 138142. selfdisclosure and serious suicidal behavior. Comprehensive Psychiatry, 42(1), 70-75.

Apter, A., & Ofek, H. (2001). Personality constellations and suicidal behavior. In K. van Heeringen (Ed.), Understanding Suicidal BehavApter, A., Horesh, N., Gothelf, D., Graffi, H., & iour. The Suicidal Process Approach to ReLepkifker, E. (2001). Relationship between

180

Eleven Deaths of Mr. K

search, Treatment and Prevention (pp. 24120). empirical studies. Suicide and LifeThreatening Behavior, 31(4), 367385. Chichester, UK: Wiley and Sons. Arie, M., HaruviCatalan, L., & Apter, A. (2005). Personality and suicidal behavior in adolescence. Clinical Neuropsychiatry: Journal of Treatment Evaluation, 2(1), 3747. Cooper, A.M. (1988). The narcissisticmasochistic character. In R.A. Glick, and I.D. Meyers (Eds), Masochism. Current Psychoanalytic Perspectives (pp. 117138). Hillsdale, NJ: American Psychoanalytic Press.

Baechler, J. (1975). Suicides. New York: Basic Cooper, J., Appelby, L., & Amos, T. (2002). Life Books, Inc. events predicting suicide in young people. Social Bancroft, J.H. (1979). The reasons people give Psychiatry & Psychiatric Epidemiology, 37(6), for taking overdoses: A further inquiry. British 271275. Journal of Medical Psychology, 52(4), 353365. Ernst, C., Lalovic, A., Lesage, A., Seguin, M., Bancroft, J.H., Skrimshire, A.M., & Simkin, S. Tousignant, M., & Turecki, G. (2004). Suicide (1976). The reasons people give for taking overand no axis I psychopathology. BMC Psychiadoses. British Journal of Psychiatry, 128, try, 30, 7. 538548. Fonagy, P. ( 1999) Attachment, the development Baraclough, B., Bunch, J., Nelson, B., & of the self and its pathology in personality disorSainsbury, P. (1974). Hundred cases of suicide: ders. In J. Derksen, C. Maffei, & H. Groen, Clinical aspects. British Journal of Psychiatry, (Eds.), Treatment of Personality Disorders (pp. 125, 355373. 5368). New York: Kluwer Academic/Plenum. Baumeister, R.F. (1990). Suicide as escape from Freud, S. (1917 [1915]). Mourning and self. Psychological Review, 97(1), 90113. Melanchiolia. Standard Edition XIV, 239260. Birtchnell, J., & Alarcon, J. (1971). The motivaHawton, K., Cole, D., OGrady, J., & Osborn, tion and emotional state of 91 cases of attempted M. (1982). Motivational aspects of deliberate suicide. British Journal of Medical Psychology, selfpoisoning in adolescents. British Journal of 44(1), 4552. Psychiatry, 141, 286291. Boergers, J., Spirito, A., & Donaldson, D. Heikkinen MA, & Lonnqvist J. (1994). Recent (1998). Reasons for adolescent suicide attempts: life event, social support and suicide. Acta associations with psychological functioning. Psychiatrica Scandinavica Supplementum 377, Journal of the American Academy of Child and 6572. Adolescent Psychiatry, 37, 12871293. Hendin, H., Maltsberger, J.T., Haas, A. Brent, D.A., Perper, J., Moritz, G., Baugher, M., Pollinger, Szanto, K., & Rabinowicz, H. (2004). & Allman, C. (1993). Suicide in adolescents Desperation and other affective states in suicidal with no apparent psychopathology. Journal of patients. Suicide and Life Threatening Behavior, the American Academy of Child and Adolescent 34(4), 386394. Psychiatry, 32(3), 494500. Horesh, N., Rolnick, T., Iancu, I., Dannon, P., Bromish, T. (1996). The relationship between Lepkifker, E, Apter, A., & Kotler, M. (1997). suicidality and depression. Archives of Suicide Anger, impulsivity and suicide risk. PsychotherResearch 2, 235254. apy and Psychosomatics, 66, 9296. Chengm, A.T.A., Chenm, T.H.H., Chenm, CC, Isometsa, E.T., Heikkinen, M.E., Marttunen, & Jenkins, R. (2000). Psychosocial and psychiM.J., Henrikson, M.M., Aro, H.M., & atric risk factors for suicide: Casecontrol psyLonnqvist, J.K. (1995). The last appointment chological autopsy study. British Journal of before suicide: Is suicide intent communicated? Psychiatry, 177, 360365. The American Journal of Psychiatry, 152(9), Conner, K. R., Duberstein, P.R., Conwell, Y., 919922. Seidlitz, L., & Caine, E. ( 2001). Psychological Joffe, W.G., & Sandler, J. (1965). Notes on pain, vulnerability to completed suicide: A review of depression, and individuation. Psychoanalytic Study of the Child, 20, 394424.

Ronningstam et al.

181

Kernberg, O.F. (1984). Severe Personality Dis- cide. International Journal of Psychoanalysis, orders. Psychotherapeutic Strategies. New Ha- 85, 653668. ven, CT: Yale University Press. Maltsberger, J.T., & Buie, D.H. (1973). Kernberg,O.F. (1992). Aggressions in Personal- Countertransference hate in the treatment of suiity Disorders and Perversions. New Haven, CT: cidal patients. Archives of General Psychiatry, 30, 625633. Yale University Press. Kernberg, O.F. (1993). Suicidal behavior in borderline patients. Diagnostic and psychotherapeutic considerations. American Journal of Psychotherapy, 47, 245254. Maltsberger, J.T, Hendin, H., Haas, A. Pollinger, & Lipschitz, A. (2003). Determination of Precipitating events in the suicide of psychiatric patients. Suicide and Life Threatening Behavior, 33(2), 111119.

Kernberg, O.F. (2001). The suicidal risk in severe personality disorders: Differential diagnosis Maris, R.W. (1981). Pathways to Suicide. A Surand treatment. Journal of Personality Disorders vey of SelfDestructive Behaviors. Baltimore 15(3), 195207. and London: The Johns Hopkins University Press. King, R.A., & Apter A. (1997). Psychoanalytic perspectives on adolescent suicide. Psychoana- Ma r tt u n e n , M.J ., H e n r ik s s o n , M.M., lytic Study of the Child , 51, 491511. Isopmetsa, E.T., Heikkinen, M.E., Aro, H.M., & Lonnqvist, J.K. (1998). Completed suicide Kohut, H. (1972). Thoughts on narcissism and among adolescents with no diagnosable psychinarcissistic rage. Psychoanalytic Study of the atric disorder. Adolescence, 33(131), 669681. Child, 27, 360400. McWilliams, N. (1994). Psychoanalytic DiagKrystal, H. (1998). Affect regulation and narcisnosis. New York: Guilford. sismtrauma, alexithymia and psychosomatic illness in narcissistic patients. In E. Ronningstam Michel, K.M., Maltsberger, J.T., Jobes, D.A., (Ed), Disorders of NarcissismDiagnostic, Leenars, A.A., Orbach, I, Stadler, K., Dey, P., Clinical and Empirical Implications (pp. Young, R.A, & Valach, L.(2002). Discovering 2 9 9 - 3 2 6 ) . W a s h i n g t o n D C : A m e r i c a n the truth in attempted suicide. American Journal Psychiatric Press. of Psychotherapy, 56(3), 424438. Laufer, M. (Ed.) (1995). The Suicidal Adoles- de Moore, G.M., & Robertson, A.R. (1999). cent. London: Karnac Books. Suicide attempts by firearm and leaping from heights: A comparative study of survivors. Linehan, M.M. (1993) CognitiveBehavioral American Journal of Psychiatry, 156 (9), Treatment of Borderline Personality Disorder. 14251431. New York: Guilford. Novick, J. (1984). Attempted suicide in adolesLuoma, J.B., Martin, C.E., & Pearson, J.L. cence: The suicide sequence. In J.T. Maltsberger, (2002), Contact with mental health and primary & M.J. Goldblatt (Eds.), Essential Papers on care providers before suicide: A review of the evSuicide (pp. 524548). New York: New York idence. American Journal of Psychiatry, 159(6), University Press. 909916. Orbach, I. (1988). Children Who Dont Want to Maltsberger, J.T. (1986). Suicide Risk: The ForLive. San Francisco: JosseyBass. mulation of Clinical Judgment. New York: New Pokorny, A.D. (1983). Prediction of suicide in York University Press. psychiatric patients: Report of a prospective Maltsberger, J.T. (1998). Pathological narcisstudy. Archives of General Psychiatry, 40, sism and selfregulatory processes in suicidal 249257. states. In E. Ronningstam (Ed), Disorders of NarcissismDiagnostic, Clinical and Empirical Portzky, G., Audenaert, K., & van Heeringen, K. Implications (pp. 327344). Washington, DC: (2005). Adjustment disorder and the course of the suicidal process in adolescents. Journal of American Psychiatric Press. Affective Disorders, 87(23), 265270. Maltsberger, J.T. (2004). The descent into sui-

182

Eleven Deaths of Mr. K

Robins, E., Murphy, G.E., Wilkinson, R.H., Gassner, S., & Kayes, J. (1959). Some clinical considerations in the prevention of suicide based on a study of one hundred and thirtyfour successful suicides. American Journal of Public Health , 49, 888899.

Quest for Higher SelfEsteem. New York: Freeman. Trumbull, D. (2003). Shame: An acute stress response to interpersonal traumatization. Psychiatry, 66(1), 5364.

Twenge, J., Zhang, L., & Im, C. (2004). Its beRonningstam, E., & Maltsberger, J.T. (1998). yond my control: A crosstemporal metaanalyPathological narcissism and sudden suicideresis of increasing externality in locus of control, lated collapse. Suicide and LifeThreatening Be19602002. Personality and Social Psychology havior, 28(3), 261271. Review, 8(3), 308319. Roy, A. (1999). Depressed patients who suicide Twenge, J.M., Catanese, K.R., & Baumeister, at first attempt have had few admissions. DeR.F. (2003). Social exclusion and the deconspression and Anxiety 9(2), 75-77. tructed state: time perception, meaninglessness, Runeson, B., Beskow, J., & Waern, M. (1996). lethargy, lack of emotion, and selfawareness. The suicidal process in suicides among young Journal of Personality and Social Psychology, people. Acta Psychiatrica Scandinavica, 93(1), 85, 409423. 3542. Weinberg, I. (2000). The prisoners of despair: Runeson, B. (1992). Youth suicides unknown to Right hemisphere deficiency and suicide. Neuropsychiatric care providers. Suicide and science and Biobehavioral Reviews, 24 , Life-Threatening Behavior, 22(4), 494503. 799815. Sandler, J., Holder, A., & Meers, D. (1963). The Westen, D., Muderrisoglu, S., Fowler, C., ego ideal and the ideal self. Psychoanalytic Study Shedler, J., & Koren, D. (1997). Affect regulaof the Child, 18, 139158. tion and affective experience: Individual differences, group differences, and measurement Schneidman, E. (1993). Suicide as psychache. using a Qsort procedure. Journal of Consulting Journal of Nervous and Mental Disease, 181, and Clinical Psychology, 65, 42939. 147149. Williams, J.M.G. (1986). Differences in reasons Schore, A. (1994). Affect Regulation and the Orfor taking overdoses in high and low hopelessigin of the Self. The Neurobiology of Emotional ness groups. British Journal of Medical PsycholDevelopment. Hillside, NJ: Erlbaum. ogy, 59, 269277. Simon, R.I. (2001). Distinguishing traumaasYen, S., Pagano, M.E., Shea, M.T., Grilo, C.M., sociat ed narcissist ic sympt o ms f rom Gundferson, J.G., Skodol, A.E., McGlashan, posttraumatic stress disorder: A diagnostic chalT.H., Sanislow, C.A., Bender, D.S., & Zanarini, lenge. Harvard Review of Psychiatry, 10, 2836. M.C. (2005). Recent life events preceding suiSimon, R.I (2006). Imminent suicide: The illu- cide attempts in a personality disorder sample: sion of shortterm prediction. Suicide and Findings from the Collaborative Longitudinal Personality Disorder Study. Journal of ConsultLifeThreatening Behavior, 36(3), 296301. ing and Clinical Psychology, 73(1), 99105. Simon, R.I., & Hales, R.E. (2006). Textbook of Suicide Assessment and Management. Washing- Zlotnick, C., Donaldson, D., Spirito, A., & Pearlstein, T.(1997). Affect regulation and suiton, DC: American Psychiatric Press, Inc. cide attempts in adolescent inpatients. Journal of Smith, K. (1985). Suicide assessment. Bulletin of the American Academy of Child and Adolescent the Menninger Clinic, 49, 489499. Psychiatry, 36, 793798. Svrakic, D.M. (1985). Emotional features of Zonda, T. (1999). Suicide in Nograd County, narcissistic personality disorder. American Jour- Hungary 19701994. Crisis: Journal of Crisis nal of Psychiatry 142, 720724. Interventions and Suicide Preventions, 20(2), Swann, W.B., Jr. (1996). SelfTraps: The Elusive 6470.