Friday, June 12, 2009


I was actually relieved when the guy's grandfather told me today "If you let him out of the hospital today, I guarantee he will be dead by tonight!" The last 72 family members who have said that to me have been wrong. I used to go cold with fear when I heard that, wondering whether we had seriously misjudged the patient's dangerousness, and shuddering to imagine the hospital's liability problem in that situation. But somehow, those are not the patients who do kill themselves. I'm not sure why - perhaps it is something of a family style of high drama that doesn't mean anything. I'm just guessing.

Not to entirely make light of it - I'm sure these family members are not just trying to manipulate us, but are deeply concerned when they say this - but it is reminiscent of my theory on hitting squirrels with your car.


Retriever said...

Curious, if it isn't usually the ones from high drama families, do you observe any patterns in the ones who do kill themselves?

Back in a stew of reading eight years ago, remember a mish mash of ideas about bipolar patients having the highest rate of completed suicide, and high emotion expressed families boding worse for continued remission in such patients returning to them.

What I wonder now is if the studies missed something. If perhaps engaged (even enmeshed?) families may manage with all the sturm und drang to keep the sufferer alive? And that isolation is what kills?

Assistant Village Idiot said...

The group I am referring to has been all, or almost all, personality disorders. I think the word "guarantee" is the key here. Who would guarantee such a thing out loud? People who are deeply concerned and worried about their family member might still not go so far as making such a wild statement. So my working hypothesis is that it's families with a large percentage of personality disorders and their enablers.

As to who does kill themselves, I don't have pet theories. I know the numbers nationwide, but have only had one of my patients commit suicide in the next few months after discharge. That is very lucky, statistically.

That one was quite a story, as well. Perhaps I will post on it sometime.

Anonymous said...

Just curious. Does "high drama" families equate into "no drama, no attention" hence the "high drama" as a means to attract attention of the other family members?

Assistant Village Idiot said...

Anon - that's the theory I'm tempted to, but I also wonder whether it is a chicken and egg problem. In a family where everyone has few barriers between their thoughts/wishes and telling everyone around them at full volume, the whole bunch of 'em might develop an unfortunately high threshold for being able to hear distress in others.

Retriever said...

Here are a couple of links to stuff on some relationships between remission and family support/expressed emotion (not new, but thank God, the kid has been more stable than when I first read everything I could get my hands on about the family curse). I'm inclined to think that many of the recommendations for bipolar apply also to family support for those with personality disorders, but you are the pro, AVI ,and my research is kind of stale and old at this point.

A good review article on Medscape....

Miklowitz is an accessible proponent of this idea that high expressed (negative) emotion negatively affects remission in people with bipolar disorder.

Shorter than one of the many books by M: Miklowitz DJ, Goldstein MJ, Nuechterlein KH, Snyder KS, Mintz J. Family factors and the course of bipolar affective disorder. Arch Gen Psychiatry. 1988; 45: 225-31.

But agree with you, AVI, on the chicken and egg stuff. It has often seemd to me that famlies of bipolar and borderline patients are often blamed as causes or aggravators of the conditions their relatives suffer from (much as moms used to be blamed for being refrigerator causes of childhood autism). Whereas some of the high expressed emotion in the families results from the traumatic effect on the family system of the illness of one or several members. In a house with a manic person, for example, everyone's voice rises to be heard. Family members (even if relatively healthy) suffer at least PTSD lite coping with violent illness in those they love. Particularly nowadays when most people spend most of their acute illness at home, with maybe 3 days to two weeks max in hospital. In my family, "episodes" tend to play themselves out over six months or so, regardless of the meds thrown at them, so this means family get battle fatigue. Family members are caring 24/7 and get just a tad stressed and exhausted to put it mildly. The effects on family members' own employment, marriages, and own mental health would be interesting to study systematically.

I often think that when a family member says that the identified patient won't survive the day, they are really saying that they feel as if they won't. Not because they are uncaring jerks, but because it destroys one to see a loved one rampage, or make attempt after attempt. Often a suicidal person will be feeling a little better (from a med or a nice shrink or atmospheric conditions or who knows what) but the relative who cut them down from the noose is still shaking, haunted, obsessed with keeping them from trying it again.