Ecstatic Suicide

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Ecstatic suicide

John T. Maltsbergera

a Department of Psychiatry, Harvard Medical School,

Boston, MA; McLean Hospital, Belmont, MA; andMarsachusetts General Hospital, Boston; Faculty, Boston

Psychoanalytic Institute, MA, U.S.A.

Version of record first published: 27 Sep 2007.

To cite this article: John T. Maltsberger (1997): Ecstatic suicide, Archives of Suicide

Research, 3:4, 283-301

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Archives

of

Suicide Research

3: 283-301. 1997.

G 1997Kluwer Academic Publishers. Printed in the Netherlands.

Review article

Ecstatic suicide

JOHNT.

MALTSBERGER

Department of Psychiatry, Harvard Medical School, Boston, MA; McLean Hospital,

Belmont, MA; and M arsachusetts G eneral Hospital, Boston; Facuhy, Boston Psychoanalytic

Institute, MA , U.S.A .

Accepted

1

January 1997

Abstract. Suicide is not an epiphenomenon of depression; it occurs in conditions other

than major depressive episodes. Some anguished, excited patients in the grips of ecdysial

or apotheotic fantasies attempt suicide when reality testing fails, feeling it a thrill. When

malignant narcissism colors severe borderline personality disorder such suicides may occur.

Three illustrative cases are presented here and are then placed in the perspective of mass sui-

cides and the ecstatic experiences of third century Christian martyrs. Elated, grandiose suicide

material is to be found in the lives and writings of Yukio Mishima and Sylvia Plath, and

in

some perverse sexual fantasies. Some persons kill themselves

not

feeling depressed

in

the

melancholic sense; they are delighted. Their suicides are acts

of

omnipotent, death-defying

magic. Correct suicide risk assessment must take elation of mood and grandiose beliefs about

the nature of death into account, because certain individuals are convinced that suicide is

passage to glory.

Key words: bipolar disorder, grandiosity, hypomania, mental state, metamorphosis, suicide

Introduction

The grandiose phenomena of manic-depressive illness have never been under-

stood to lie exclusively

in

the temtory

of

the

manic side of the disorder. That

melancholic patients may suffer grandiose delusions of their evil power “I

am the devil and should die before I cause the end of the world”) or personal

corruption

“I

am full of pus and have infected the entire city with syphilis”) is

a

textbook commonplace. Yet we have come to believe suicide does not

take

place in manic temtory, and we do not commonly associate grandiose fantasy

with

suicidal behavior. Clinical study of suicidal patients teaches otherwise.

The older literature contains references to suicide in excited or “ecsta-

tic” states (Tanzi, 1909; Zilboorg, 1936; Friedlander, 1940; Lewin, 1950),

but we search vainly for representative patients in

the

retrospective suicide

investigations that have appeared in the last forty years (Apter, et al., 1993;

Robins, 1981; Barraclough et a]., 1974; Dorpat Ripley, 1960; Robins et

al.,

1959). Not one of the 63 affective disorder suicides in Robins’s (1981) series

D o w n l o a d e d b y [ M a r i e l a B u r a

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284

had ever had a manic episode. W here today are those patients such as Tanzi,

the eminent Italian psychiatrist

of

the late nineteenth century, described? He

reported two “schizophrenic” men, a 30-year-old clerk who twice jumped

from a high window to demonstrate his courage and “disarm his enemies”,

and

an

army captain who twice attempted suicide in dang erou s wa ys

to

con-

found his “enem ies” and show them he was invulnerable Tanzi, 190 9, pp.

6-41).

Are such suicides

so

rare that none were captured in the more modem

retrospective series just cited? We lack epidemiological data, but ecstatic

suicides do indeed seem to occur in clinical practice. T hree near suicides of

this type will be described here.

Bronisch 1996) suggests that the contemp orary tendency to treat suicide

as a strict epiphenomenon of major depression is an error.

Are

the current

criteria for diagnosing m ajor depressive illness so broad that the diagnosis is

overinclusive? Are they ever underinclusive? Ronningstam and Ma ltsberger

in press) have recently reported three cases of deadly suicide attempts in

young men not on e of whom was clinically depressed according to the rubrics

of

the Diagnostic and statistical manual

of

mental disorders,

4 th

Edition

1

994) hereinafter, DSM-4 .

Here are reports of three wom en, two of whom are grandiose and ecstatic

in their suicidal mo ments. Th e third is also grandiose w hen suicidal, but not

ecstatic.

I .

Mrs.

A.,

a 53-year-old wom an w ho suffers from a bipolar disorder, mixed,

with psychotic features, has been preoccupied with suicide and death since

she started school.

As

a small child she prayed for a deadly illness, and in

the fifth grade , offended by a “mean” teacher, sh e plotted to jum p in front

of a fast car and later did so, narrowly escaping injury when the temfied

driver slamm ed

on

the brakes.

Thoug h she has usually w orked effectively as a business ex ecutiv e, there

have been four occ asions when her chronic hypomania w orsened and she

required hospital care. These episodes were marked by emotional labil-

ity, loquacity, distractibility, psychom otor agitation, sleep lessness, over-

activity, profound suicidal preoccup ation, and seve re emotional anguish

“psychache”; see Shneidm an, 1993).She

is

subject to outbursts of weep-

ing, shrieking, and beating herself. The patient’s anguish can be so intense

that she drives about recklessly in her car for hours, scream ing with pain

and remorse for past “misdeeds”.

It

causes her to take risks in traffic.

She

can only bring this experience under

control

by injuring herself; she has

repeatedly burned herself to attenuate the mental pain.


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285

During attacks the patient has heard different hallucinatory voices which

she says represent “self-fragments”. Som e of the voices seem protective,

but others are murderously hostile. The voices sometimes shout at each

other all at once. Two of the voices propel the patient to kill herself;

the one she calls “Tormentor” is associated with experiences of intense

anguish. The other killing voice she calls “Hangman”. He pours out his

hate for everything about the patient including the other hallucinatory

presences) except himself and believes he w ill survive her death. S he sa ys

she is closest

to

suicide when the Tormentor and the Hangman get going

together; they can seize all her energy and paralyze the other presences.

In her states

of

torment the patient likes to play erotic, thrilling death

games. As an adolescent she

took

terrible risks with motorcycles.

As

an

adult she likes

to

drive up behind large trucks on the superhighway, close

her ey es, and accelerate her

car

as fast as she can, not looking until the

last possible mom ent. She say s these dangerous games restore her sense

of control and arouse her to a state of near orgasm; she is driven to play

them when sh e feels helpless and flooded with angu ish. Such an episode

“gets the adrenaline going”, sh e says; she becomes ecstatic. Sh e laughed

excitedly in describing her highway thrills, and then suddenly began to

cry.

She

takes pleasure in torturing h er therapist with suicidal threats

to

show

him who is in charge. In the hospital she was ecstatic on one occasion

when she succeeded in getting out on a window ledge and temfied the

staff.

She has attempted suicide twice by whipping her speeding car off inter-

state highways into ravines. S he has had a suicide scheme for years and

intends to “die in style”. She plans

to

leave taped messages and funeral

instructions,

to

dress in her best clothes, and to have her car specially

washed and polished for the “great day”. Planned death means having

total control of her life;

it

is the opposite of helplessness, which she

greatly fears. Her favorite film is “Thelm a and Louise”, a portrayal of the

double suicide of two women who speed over a cliff together in an open

convertible.

Mrs.

A’s

father was an outright sadist. He liked to hurt her physically

and emotionally, and liked to kill and torment animals. He encouraged

the patient to be physically merciless with herself, to endure pain silently,

and never to cry. From childhood he liked

to

talk

to

her about death and

suicide.

To

please him she killed small vermin. She was sexually abused

by a visiting adolescent boy repeated vaginal rape resulting in bleeding)

when she was eight, but never dared tell anybody.


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286

11.

Miss B. is a 30-year-old former a thlete wh o at the beginning of her treat-

ment satisfied the SM criteria for narcissistic persona lity disorder, bor-

derline personality disorder and a m ajor depressive episode. After exten-

sive psychotherapy and exhaustive dru g trials she became less impulsive,

her relationships with others stabilized, and she gave up cutting herself

on her forearms and inner thighs, her almost daily practice for several

years. Her depression never completely remitted, however, it cyclically

worsened and improved every few weeks. Not a typical patient, Miss B.

suffered no psychiatric symptoms apart from mild depression and mild

adolescent anorexia until her twenty-seventh year. Rejected by a young

man, it was then she then began to cut herself, to binge-eat, and to purge.

Taking a tricyclic compo und for her depression, in the course of a bicycle

race the patient collapsed in ventricular fibrillation and narrowly escaped

death. In the co urse of the subsequent hospital treatm ent her depression

deepened.

A psychiatric hospitalization of m any months followed throughout which

the patient was believed dangerously at risk to kill herself. Over the next

three years she attempted suicide on four or five occasions by ingesting

large amo unts of aspirin as many as forty tablets).2 On o ne occasion she

swallowed an ov erdo se of tricyclic antidepressants. She likes to “practice”

suicide by stretching ropes and scarves over a doorknob and choking

herself with them until she begins “to see black and flashing lights and

stars”. From time to time she has com e to her treatment session with rope

bums on her neck. She kept a “suicide rope” in a secret place and refused

to surrender i t to her psychiatrist. The cutting and choking are the best

means she can devise for relieving intense feelings of depersonalization

and depressive anguish. T hese practices a lso bring great pleasure; she begs

her psychiatrist for “permission” to injure herself. A secondary benefit

from her morbid behavior is the obvious glee she enjoys in frightening

those responsible for her care. She makes

gory

suicide threats and asks

psychiatrists and nurses

if

they will be coming to her funeral.

Though never frankly manic, the patient sometimes reports “racing

thoughts” and feels “speeded up”. Early in her psychiatric treatment sh e

was given fluoxetine briefly. This aro used intense anxiety and the prospect

of self-injury and dea th began to seem “thrilling” and erotically arousing.

She formerly im agined herself

to

be intensely radioactive,

so

destructive

and evil that all who cam e in contac t with her would b e destroyed. Th ough

she has never hallucinated and has rem ained free of delusions, she still

cherishes a grandiose fantasy of suicide that is sometimes almost delu-


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sional in force. Suicide promises escape from suffering, and

is

for that

reason m uch longed for.

But further, Miss

B.

imagines suicide to be a path to magical transforma-

tion into Apollonian manhood. She longs to cast

off

her female corpse

as an emerging butterfly its chrysalis.

To

die

of

suicide would result in a

phaenix-like metam orphosis. By “death” the patient plainly m eans a kind

of passage to masculine apotheosis; it does not m ean the end of h er self,

but the end of her body only. She once ecstatically described a wish that

as she died her head m ight be quickly filleted out of her body, lifted aw ay

by a crane, and transplanted into that of a powerful, beautiful young man.

Miss B showed great talent as a sw imm er in early adolescence, and s et her

heart on winning an O lympic gold medal. With the eager encouragemen t

of her family sh e trained to the point of exhaustion and entered num erous

competitions, but never swam well enough to qualify for the Olympic

team. She blames this on her womanhood. She remains convinced that

had she been

born

male she would have had a “perfect body” and the

necessary muscles to win an Olympic “gold”. She imagines the cheering

crowds and the publicity she would hav e enjoyed in winning the m edal.

To die of suicide would be “just like that”, she says; she comp ares her

imaginary Olympic glory to the flashing stars and lights she see s when

she chokes herself almost unconscious.

Not every victim of ecdysial suicide

is

ecstatic or elated, though so me are.

Though the third patient reported

no

ecstatic experience, she nevertheless

denied that her bizarre behavior would kill her, and acted on a grandiose

delusion of ecdysial purification.

111.

Miss

C.,

a 57-year-old sp inster veterinarian’s assistant with a h istory of

bipolar disorder, had been sexually and physically abused as a child. At

the time of the present admission s he satisfied the criteria for a diagnosis

of major depressive episode and borderline personality disorder. Ove r the

course of her unhappy

life

the patient reported she had overdosed heavily

on several occasions, fully intending and expecting to die. About a year

after the death of a beloved sister whom Miss C. nursed through her

terminal illness melanoma here was continuous bloody oozing and

great pain at the end) the patient developed a severe major depressive

episode with psychotic features. She suffered precordial pain, a sense

of tremulousness inside the abdomen, and breathlessness

so

painful she

wanted to jum p in front of oncom ing traffic. She hallucinated her sister’s

voice summ oning her, and other voices comm anding her to phlebotomize

herself.


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288

In the course of her veterinary w ork M iss C. had learned the technique for

phlebotomy. S h e developed the delusion that all the evil which suffu sed

her body as a consequence of the sexual abuse was concentrated in her

blood. Sh e sought

to

purify herself by phlebotomy. Ov er the course of a

week she drained off

2.6

litres of blood; the most she ever took at one

sitting was 1.5 litres. Her hematocrit fell to 11 3

She denied this behav ior was suicidal and stoutly claimed she would not

die even if sh e rid herself of the ev il blood to the last millilitre. She insisted

she would, o nce purified, becom e reunited with her sister. With reluctant

disinterest she agreed that her beha vior m ight lead to physical d eath, but

averred the

loss

of her body, a meaningless husk, would be a matter of no

great consequ ence , and would not constitute “death”. Sh e therefore denied

that the ex-sangu ination she w as carrying out was suicidal in character.

M alignant narcissism, persona lity disorders, and affective disorders

All

three

of

these patients m anifest borderline, narcissistic, and probably bipo-

lar features M iss B . suffers from racing thoughts and feels speeded up from

time to time). Ronningstam and Gu nders on 1991) have found that grandios-

ity

is much more characte ristic of patients with narcissistic personality disor-

ders than of those w ith borderline p ersonality disorders. T he grandiosity of

the narcissistic personality disorder patient is global; they believe they are

unique, superior; they exaggera te their talents; in their self-cente redness they

boast and strut, expect special treatment, and exploit others. Mrs. A., Miss

B.,

and Miss C. are all assuredly grandiose, but their grandiosity applies to

their suicidal fantasy only. Each suffers from low self-esteem and most of

the time feels profoundly inferior. Kemberg

1 990)

would deny the narcis-

sistic personality disorder diagnosis to these patients because they a re from

time to time psychotic, or at least functionally so. He has stated that when

reality testing is comprom ised, as in p sychotic cases, the diagnosis does not

apply. Others, however, including the approach of the DSM-4, do not treat

occasional psychosis as exclusionary.

The first two case s, both of whom merit a

DSM-4

narcissistic personality

disorder diagn osis, plainly meet the criteria for Kemberg’s

“malignanf

narcis-

s i sm” . Both Mrs. A . and Miss B. are crippled w ith a “pathological grandiose

self highly infiltrated with aggression”. E ach exp eriences confirmation of her

grandiosity and a rise in self-esteem when she can injure herself

or

torment

others. They take pleasure

in

self-mutilation and cruelty to others. Kemb erg

writes:


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289

The sense these patients convey of being capable of calmly damaging

themselves, in contrast to the fear and despair and the ‘pleading’efforts of

their relatives and staff to keep them alive and to maintain their human con-

tacts, illustrates a dramatic distortion of the gratification of self-esteem.

The patients’ grandiosity is fulfilled by the feeling of triumph over the

fear of pain and death and, at

an

unconscious level,

by their sense ofbeing

in control over death. (Kemberg, 1984, p. 257; italics added)

Kemberg’s emphasis

on

morbid character or personality organization in

these patients distracts attention from the fact that many such borderline

patients also suffer from subtle (or not so subtle) bipolar disorder, or else

function psychologically at the dynamic level of mania, even though they

may not manifest enough of the index phenomena to qualify for a full

hypomanic-manic diagnosis. Many such patients are nevertheless unques-

tionably grandiose.

That atypical bipolar

or

mixed bipolar cases sometimes masquerade as

patients with borderline personality disorder is well recognized (Akiskal,

1981). Akiskal and colleagues (1983) have suggested that underlying tem-

perament may influence the clinical expression of affective disorders and

influence their prognosis. Gunderson and Elliott (1985) further address the

diagnostic overlap between borderline personality disorders and affective dis-

orders, acknowledging that while the diagnoses appear to be discrete, some

patients are heterogeneous and possess symptom clusters fitting both

syn-

dromes.

Just as borderline personality disorder patients sometimes satisfy the cri-

teria for bipolar disorder,

so

do patients with narcissistic personality disorder.

Akhtar

1

989) has commented

on

this overlap, pointing out that both hypo-

manic and narcissistic personality disorder patients may be grandiose, self-

absorbed, and feel both bored and inferior. Ronningstam (1996) has reviewed

the literature that treats pathological narcissism and narcissistic personality

disorders as they occur in “Axis

I” DSM-4

diagnoses, finding that narcissis-

tic personality disorder is present in 4 4 7 of bipolar patients. The rate

of

comorbidity rises as the severity of manic symptoms increases.

Zanarini’s (1994) emphasis

on

the importance of intolerable affect as

a major morbid influence throughout childhood and adolescent personality

development deserves special notice and further study. She shines a light

on

the relationship between atypical bipolar disorder and borderline per-

sonality disorder, remarking that many borderline patients can do no more

than maintain tenuous life adaptations because they have constantly been

flooded by intense emotional pain through most

of

their lives. Chronic dys-

phoria throughout childhood and adolescence must interfere with normal

developmental progress; the necessary identifications and structuralizations


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290

for healthy adu lt living canno t be laid dow n. Zanarini’s observations are of

importance inasmuch as much so-called borderline behavior has the impul-

sive, irritable, and passionate character fam iliar in hypom ania and in mixed

states. Zanarini and DeLuca have developed an important research instru-

ment, the “Dysphoric Affect Scale”, which promises to be very useful in

studying suicida l behavior in borderline and dyspsho ric cases particularly in

press).

Metamorphosis ecdysis)or apotheosis in suicide

Mrs.

A .

is psychotic from time

to

time. Though Miss B. has not met

DSM

criteria for a psychosis on a purely descriptive basis, her intermittent loss of

reality testing when in the grips of grandiose fantasies of suicidal metamor-

phosis occasionally make her functionally psychotic. Both patients experience

distinct sexual arousal when giving them selves o ver to cherished suicide day-

dreams, and both experience pleasurable, ecstatic excitement a t the pitch of

suicidal-parasuicidal action. M iss C . was driven by a purification delusion in

draining away her “tainted” blood.

Baechler (1975,p. 168)refers to “transfiguration” suicides, remarking that

some people

kill

themselves

to

anive at an “infinitely desirable condition”.

He described a 2 0 year old student, solitary and religiously preoccupied, who

became very “excited and delirious”, wanting to convert everyone to her

ideas. She caused an uproar in a cafe; the police w ere sum mon ed and took her

home. Feeling “called by God ” and wishing to suffer in order to be purified,

she jumped out the window.

All but the religious examples Baechler adduces seem

to

puzzle him; he

does not consider that such persons are functionally psychotic at the time

they

die. He is careful

to

separate transfigurational suicides from suicides of

flight escap e), the purpose of which is to put an end to an intolerable state

of affairs escape suicide is a nega tive matter. Transfigurational suicide, he

observes, aims at a m ore positive goa l.

Many suicidal patients are can ie d along by m etamorph ic death fantasies.

Their aim in dying is self transformation, to escape from an insupportable

present into a better future beyond death.

To

shed ones body as a molting

insect breaks out of i ts shell, or cocoon, after maturing into an adult, is the

core wish Maltsberger Buie, 1980; Ronningstam Maltsberger, in press).

The suicide fantasy is one of e c d y ~ i s . ~

In their fantasies of post-mortem survival these patients repudiate parts

of themselves those parts destined to die) but do not repudiate other parts

which they expe ct will continue to live. Ecdysial suicides reflect the mental,


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29

1

or thinking self, acting on the body-self as object; the body-self is to die, the

mental-self is not (Maltsberger, 1993).

A subtype of ecdysial suicide is apotheotic inasmuch as death’s purpose

is to elevate and transform the self into godlike perfection. Miss B. was

obsessed with the idea she could through death metamorphose herself into

a perfect young man who would take his place as an Olympic champion

suicide, she believed, would turn her into an Apollo. At the moment of her

apotheosis in death she imagined the cheersof the crowd celebrating her glory

(rapturous, orgasmic, absolute) as she grasped the gold medal. For

Mrs.

A.

suicide promised much the same ecstasy. Miss

C.

expected to rise immaculate

from the husk of her‘corpse, but her description of this transfiguration was

without rapture.

Ecstatic suicide beyond the clinic

Ecstatic suicidal themes have been ubiquitous through history. I shall draw on

certain perversions, ritual suicides, religious suicides, group suicides, and the

writing of a suicidal poet, Sylvia Plath, to show that they are very generally

met, are well known in history and literature, and should not be overlooked

in clinical settings where they not only occur also, but may indicate danger.

Litman and Swearingen (1 972) have published two cases of ecstatic

fetishistic death, one of which the coroner classified as an accident, the other,

as a suicide. They described twelve other death-preoccupied sadomasochis-

tic fetishists as well. Of their nine male patients six reported histories of

serious suicide attempts and depression; most had experimented with nooses

and self-hanging. The authors agree with Weisman (1967) that such patients

aim to master lonely, depressive circumstances through ritual sexual activity

accompanied by fantasies of victory, pleasure, and dominance. Masturbatory

or shared sadomasochistic activity provided these men transitory, ecstatic

relief from depression. Mostly these patients were thrilled by hanging, but

feared they would go too far and die. Several reported they were saving

hanging for the “ultimate scene or eventual suicide”.

Suicides for honor such as hara-kiri do not appear to arise from depression.

Euphoria, heightened self-esteem, and sexual arousal may be associated with

the ritual preparations. Yukio Mishima, the Japanese writer, incorporated such

themes in his writings before he himself died in this way. Hara-kiri suicides

would appear to have a manic coloration, at least in some cases (Asch, 1980).

Ecstatic, transformational themes are familiar enough

in

Eastern religious

suicides which did not become unusual until the end of the nineteenth century.

In India it was widely believed that to drown oneself in certain parts of the

Ganges promised advantageous transformation in the next transmigration


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292

(Gait,

1908).

Those widows who threw themselves into the flames of their

husband’s funeral pyres sari suicides) did so in the belief they would be

bettered in the afterlife (Crawley, 1908).

Ecstatic, metamorphic suicide is psychologically akin to the deaths of

certain third century Christian martyrs who provoked the imperial authorities

to put them to death. Some of these martyrs died in groups, others, alone.

Many were obviously suicides in effect; the would-be martyr deliberately

provoked someone else, often a Roman official, to kill him. Suicide of this

sort

is

sometimes called “victim-precipitated homicide” (Wolfgang, 1968).

Convinced by their culture and by teachings of some Church Fathers (Tertul-

lian, Ignatius of Antioch, Cyprian, and Origen, for example) that to die for

the faith expiated every sin, repaired every spiritual defect, and delivered the

sufferer into immediate eternal bliss, some passionate Christians

exasperated the fury of the lions, pressed the executioner to hasten his

office, cheerfully leaped into the fires which were kindled to consume

them, and discovered a sensation of joy and pleasure

in

the midst of the

most exquisite tortures. . . .The Christians sometimes . . .rudely disturbed

the public service of paganism, and rushing in crowds round the tribunal of

the magistrates, called upon them to pronounce and to inflict the sentence

of the law (Gibbon, 1993,Vol. 2, pp. 39-41).

Later, during the time of the Diocletian persecution 284-3 13

A.D.),

the

excesses of those who sought to provoke martyrdom and achieve an ecstatic

metamorphosis worsened. The Donatist (Circumcellion) heretics were infect-

ed with a suicidal frenzy never matched since.

Many of these fanatics were possessed with the horror of life, and the

desire of martyrdom; and they deemed it of little moment by what means,

or by what hands, they perished,

if

their conduct was sanctified by the

intention of devoting themselves to the glory of the true faith, and the

hope of eternal happiness. Sometimes they rudely disturbed the festivals,

and profaned the temples of Paganism, with the design

of

exciting the

most zealous of the idolaters to revenge the insulted honor of their gods.

They sometimes forced their way into the courts of justice, and compelled

the affrighted judge to give orders for their immediate execution. They

frequently stopped travellers on the public highways, and obliged them

to

inflict the stroke of martyrdom, by the promise of a reward

if

they

consented, and by the threat of instant death if they refused to grant

so very singular a favour. When they were disappointed of every other

resource, they announced the day on which, in the presence of their friends

and brethren, they should cast themselves headlong from some lofty

rock;

and many precipices were shown which had acquired fame by the number

of religious suicides. (Gibbon, 1993, Vol. 2, p. 361)


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293

Eusebius

1932)

records that when the Roman authorities burned the

Church in Nicomedia and butchered and burned Christians there, “men and

women leaped upon the pyre with a divine and unspeakable eagerness” p.

267).

On the night before she was taken to the arena St. Perpetua, martyred in

203

A.D., experienced a vision that resembles the ecdysial fantasy of Miss B.

Perpetua foresaw herself led out before the crowd, where, when stripped, she

was miraculously transformed into a man. Thereupon she enjoyed unarmed

single combat with an Egyptian the devil personified) whom she overthrew

and then trod on his head.

The next day when in fact sh e was led into the amphitheater and gored by

a mad heifer,

so

absorbed was she

in

ecstasy that she appeared unaware of

what had happened. In her rapture she finally guided the executioner’s dagge r

to her throat Farmer, 1992).

Ecstatic, metamorphic mass suicides are recorded at various o ther times

and places in history. For example , in

1666,

many Russian zealots, convinced

the Antichrist would soon appear, determined to escape directly to heaven

by committing religious suicide. Encouraged by fanatical priests and other

unscrupulous individuals, whole commu nities starved themselves to death or

died in flames Rose, 1928).

The

Jonestown mass suicide of the “People’s Temple” in 1978 was lead

by the grandiose Jim Jones, self-styled prophet and miracle worker, who

promised h is followers togetherness in the afterlife, and spoke of the “orgasm

of the grave”. Jones probably believed tha t he was a god Res ton, 198 1 ) .

Sylvia Plath died of suicide on

1 1

February 1963, roughly four months

after she was separated from her husband, Ted Hughes Stevenson,

1989).

Almost certainly she suffered from a bipolar disorder. She was depressed,

sometimes furiously angry, excited, perhaps sometimes briefly ecstatic, and

preoccupied with suicidal images of metamorphosis in the months before sh e

put her head in the gas oven. Plath is increasingly inviting the notice of

suicide specialists see Leenaars and Wenckstern. in press)

When Plath insisted, Hughes left their home early in October 1962;

by

the

end of the m onth she was oscillating between spells of profound depression

and intense rage. She had been subjec t to angry, sometimes violent, paranoid

outbursts for years, but now friends found her “distraught” and noticed that

sometimes she talked hysterically. She had difficulty sleeping. She became

morbidly and unrealistically) afraid she was poor, or threatened with poverty.

She often seemed paranoid. In January 1963 she seemed excited and “ecsta-

tic”. A friend noticed she had a quality of “incandescent desperation”. The

night before her death she was found standing motionless in a freezing cold


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294

hall; she claimed she was having “a wonderful vision” Stevenson,

1989,

pp.

During October 1962 she was feverishly and brilliantly creative, some-

times writing several poems in one day. Some of these, for example “Lady

Lazarus”,

are ecdysial in theme: Written at the end of the m onth, it refers to

her suicide attempt of 1953,an act sh e narrowly survived, and con cludes with

the image of a violent, reborn red-haired phamix ready to eat men , rising from

ashes. She compares herself

to

the cat which has nine lives, and comm ents

she has “done it” three times before. On October 20 she had written in “Fever

103””:

26 1-299).

Does not my heat astound

you.

And my light. .

I

think

I am

going up,

I

think

I

may rise

The beads of hot metal

fly,

and I , love, I

Am a pure acetylene Vigin

Attended by roses, .

My selves dissolving, old w hore petticoats)

To

Paradise.

Plath. 1992, p.232)

Grandiose themes of elation, destruction, ecdysis, and heavenly a ssump-

tion repeat themselves in the self-referential bee poem “Stings” of

the

same

period, written on

6

October.

They thought death was worth it, but I

Have a self to recover, a q ueen.

Is she dead, is she sleeping?

Where has sh e been,

With her lion-red bod y, her wings of glass?

Now she is flying

More terrible than sh e ever w as, red

Sca r in the sky, red com et

Over the engine that killed h er

The mausoleum, the wax house.

In

an earlier version of this poem Plath said the bees were suicidal, destroy-

ing them selves by stinging the gloves

of

the bee-keepe r probably an image

of Ted Hughes condensed with that of her father, an apiologist; she was the

bees) Plath,

1992,

p.

293).

She was well informed on bees and was surely

aware that in the course of development they undergo two metamorphoses

after hatching: from larva to pupa, from pupa to ima go the adult form).

Plath, 1992,p.

214)


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95

What does ecstatic suicide mean?

Plainly there are a number of elements in ecstatic suicide which can be teased

apart. Reality testing is abandoned, the certainty of death is denied, a magical

lethal ecdysial act

is

carried out, the horror of self-disintegration (annihilation

anxiety) is warded off, sadism and hatred against the patient’s objects are

expressed, and in fantasy the patient arrives transformed and perfected in the

afterworld. Suicides of this kind represent desperate, paradoxical, last minute

efforts at self-rescue, analagous to sawing off the mainmast in a humcane,

and throwing the ballast overboard.

Freud contrasted the psychological circumstances of depression, in which

the superego (in its function as self-critic) is set over against the ego (self) in

a punishing way, with the circumstances of mania:

On the basis of our analysis

of

the ego it cannot be doubted that in cases

of mania the ego and the ego ideal [superego in the sense of what the self

might be if perfect] have fused together, so that the person, in a mood

of triumph and self-satisfaction, disturbed by no self-criticism, can enjoy

the abolition of his inhibitions, his feelings of consideration for others,

and his self-reproaches. (Freud, 1921, p.

1

32)

In the psychoanalytic sense metamorphic suicide can be understood as

a magical means whereby such a fusion of the ego and the superego are

attempted: through a transformative ecdysis the dying patient rises again as

the ideal self.

Lewin (1950)formulated the wish to die as a regressive yearning to return

to the state of peaceful, blissful infantile sleep wherein all differentiation

between self and object (the madonna-like mother of earliest childhood)

dissolves. The wish is to fuse with total, absolute maternal succor. The state

for which the suicidal patient yeams is total surfeit, protection, safety, and

happy oblivion. Lewin believes the wish to die

is

the wish to sink away with

utter passive surrender into the arms of the primal mother, becoming one

with her, and that suicide, for this reason, often involves a confusion between

death and the deepest sleep, for which it stands symbolically.

Lewin’s studies of a series of patients whose inner lives were marked

by extraordinary denial and grandiose fantasies concerning sleep and death

satisfied him that closely related to the fusion fantasy of sleep was the wish

to be devoured, another means whereby self-object differentiation would be

dissolved and the person eaten might become a part

of

the very tissue and

fabric of the eater. We may recall the early martyrs who sought to be eaten by

wild beasts. As a means to the same end, Lewin described a third element of

his “oral triad”: To the wish to be devoured and the

wish

to sleep, he added

the wish to devour the object. The achievement of this very deep primitive


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296

triple fusion fantasy would open the way

to

triumph over suffering, loneliness,

defectiveness, helplessness, and pain.

Freeman (1971) has more recently commented on the psychoanalytic

understanding of mania.

A comment

on

whether depression

is

a sine qua non

for

suicide

When depression dominates the clinical picture and hypomanic features,

however striking, are insufficient to justify a “mixed” diagnosis, a depres-

sive diagnosis usually will

be

made. Further, some depressed patients show

remarkable grandiose and other hypomanic features

in

mental confenf,but

not otherwise.

In

my opinion the present diagnostic style of international

psychiatric nosology, whatever its substantial advantages, tends

to

obscure

hypomanic and grandiose phenomena from research scrutiny.

A small proportion of patients evidently take their lives with no evidence

of

depression whatever (Ronningstam Maltsberger, in press.) But suicide

must hardly ever occur

in

mania

or

hypomania without some depressive col-

oration

of

the mental state. Nevertheless patients who suffer from Kraepelin’s

“mixed states” do indeed destroy themselves from time to time; sometimes the

depressive undertones are not o b v i ~ u s . ~raepelin (1921) refers to “excited

depression”; (p. 104) and to chronic “irritable temperament” (pp. 130-13

I ) .

More recent research demonstrates what clinical workers have long believed,

that patients with “depressive mania” are indeed at risk to commit suicide

(Schweizer et a]., 1988; Dilsaver et al., 1994; Strakowski et a]., 1996). Post

and his colleagues (1989) have coined a new term, “manic dysphoria”, denot-

ing affective lability, imtability, anger, and depression admixed with other

characteristic features of the manic syndrome. They appear to refer to

this

same group of patients.

A review of the protocols of the St. Louis suicide series (Robins, 1981)

shows that many subjects could be described as

irritable

dysphorics; 28

of

the 134 cases were subject

to

outbursts of rage, and 53 of the alcoholic

subgroup were. None could be labelled manic dysphorics. None appear to

have committed suicide in a mixed state, though I suspect that contemporary

psychiatrists would assign a diagnosis of bipolar

I1

disorder to one of Robins’s

cases (patient 119,

pp.

284286). Inspection of the protocols make it evident

that a high proportion of the suicides Robins classified

in

the alcoholic group

were probably comormid for personality disorder diagnoses, narcissistic per-

sonality disorder in particular.

One of the St. Louis patients (a schizophrenic) heard the voice of God

speaking to him (patient 113, p. 342-343) and an alcoholic expressed the

belief that

if

his life was hell he would be in heaven after suicide (patient


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297

022, pp. 228-229), but otherwise there are no suggestions of grandiosity in

the records.

Questions for empirical investigation

Once the descriptive epidemiology of ecstatic and grandiose suicide has

been worked out it will become necessary to

sort

out different suicidal

types according to the various psychodiagnostic groups and psychosocial

contexts in which they occur. What are the differences between suicides in

mixed-state, hypomanic, non-depressed narcissistic, borderline, depressed,

schizophrenic, and other patients with respect to grandiose, ecdysial, and

ecstatic phenomena?

At present we do not have a sufficiently clear or detailed understanding

either of the exact mood ranges or the mental content of any psychodiagnostic

group of patients who go forward to suicide or to deadly attempts. Research

advances have been made possible by the development of the Feighner diag-

nostic criteria (Feighner et al., 1972) and their nosological descendants. Fur-

ther advances might be expected if certain terms used in making research

diagnoses (e.g., dysphoria) were refined, just as diagnoses have been. The

phenomena of suicide have not been fully described, and, where described,

they have not been empirically studied with much effort to discriminate

between the various details of mood and those of mental content.

ood

We know that “psychic anxiety”isa significant predictor of suicide in patients

with affective disorders Fawcett and his colleagues have demonstrated this

(Fawcett et al., 1987). Just what psychic anxiety may be, however, remains

obscure; it is an item only briefly defined in the Schedule for Affective

Disorders Schizophrenia (SADS) inventory, an instrument administered to

the series of patients Fawcett’s group reported (Endicott Spitzer, 1978).

“Manic dysphoria” is not much clearer we understand that

it

has ele-

ments of depression, anxiety, anger (Post et al., 1989). but the phenomenon

requires refined definition. Dysphoric mood, according to the Feighner diag-

nostic research criteria, is “characterized by symptoms such as the following:

depressed, sad, blue, despondent, hopeless, ‘down

in

the dumps,’ imtable,

fearful, womed, or discouraged” (Feighner et al., 1972). The definition goes

no further. (Note the absence

of

the term “anguish” or any of its synonyms.)

Robins grouped sixteen different symptoms together under the rubric “dys-

phoria”, and someof them are highly dissimilar. From his list compare: easily

hurt feelings, indecisiveness, “high strung”, outbursts of rage, having fears,


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298

seeming to feel like hurting som eone, feeling sad, joyles sness Robins, 198 ,

pp. 52-53). Obvious ly such definitions of dysphoria remain

too

general to

help very much in discriminating which dysphoric patients are the suicidal

ones, however appropriate a broad definition may have been at the time of

Robins’s work.

Anguish as a term do es not appear in any of these

lists,

but intuitively one

would expect that anguish, especially when coupled with intense self-hate

and a high level of hopelessness, might be more associated with suicide than

indecisiveness or being “high strung”.

The

hiad of anguish often acco m-

panied by psy chom otor agitation), self-hate, and de spair is typical of many

mixed-state patients. Shneidman 1993)believes that “psychache” , his neolo-

gism for mental anguish , lies at

the

heart of most suicides. Zanarini in press)

has taken a step in the right direction in developing her “dysphoric affect

scale”.

It

is sobering to reflect that a patient with intense anguish, ecdysial day-

dreams about the afterlife which he found exciting, profound suicidal intent,

powerful self-hate, and sleeplessness but with little loss of interest in his

daily affairs, good ability to concentrate, intact appetite, an d no psych omo tor

disturbance would qualify n either for a diagnosis of major depressive episode

nor a mixed state under the current rubrics.

Kraepelin 192 1) made it clear that many patients experienced intensely

painful physical sensations in connection with anguished mood. Precordial

distress, a sense that the core

of the

body has turned to ice, and a sense

of tremor in

t he

abdomen and thorax are familiar complaints in suicidal

melancholia. We do not know how commonly associated with suicide these

body sensations may be sometim es they appe ar to rise to the level of visceral

haptic hallucinations).

ental content

What w e know about the mental content and fantasy life of patients on the

verge

of

suicide is anecdotal. Fantasies of metam orphosis,

or

ecdysis, appea r

to be quite common, however, and many suicidal patients are grandiose

in

thought,

if

only occasionally are they ecstatic in mood. Further studies are

needed to define and describe what patients think about death when in suicidal

states.

Acknowledgements

The author acknow ledges the helpful suggestions of Dr. Michael B ostwick,

Ms. Joanne Despres, and Dr. Elsa Ronningstam.


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299

Notes

The

first

two patients Mrs.

A.

and Miss B.) meet the DSM 4 riteria for both narcissistic

personality disorder and borderline personality disorder. The third patient Miss C.) qualifies

for a

DSM-4

diagnosis of borderline personality disorder. All

three

have recurrent major

depressive episodes. The

first

and third patients Mrs. A. and Miss C.) also give histories of

hypomanic spells. nd therefore qualify for bipolar diagnosis.

All

three patients have been treated with many drug combinations, including mood “sta-

bilizers”, for long periods of time, by sophisticated psychophmacologic experts. Th e thera-

peutic response has been disappointing in each instance.

For aspirin acetylsalicy lic acid) the LDw, is 200-500 mg/Kg. Miss B.’s aspirin overdoses

were in the range of 250 mg/Kg of her body weight.

The normal hematocrit volume of packed red blood corpuscles per 100ml of blood) for an

adult woman is 42 0.5. We estimated that Miss

C.

ex-sanguinated herself of more than half

her total blood vo lume over a w eek.

Ecdysis

is

a borrowed entomological term.

It

ordinarily refers

to

the

shedding of an outer

cuticular layer in the m etamorphosis of insects; molting is a synonym . The word comes from

Greek ekdysis, which m eans a getting

out,

an escape. Its more general Greek meaning invites

its application

to

those suicides in which patients believe that

to

die will result in something

like the transformation of a pupa into a brilliantly beautiful adult butterfly.

We would now label a patient formerly diagnosable with a mixed state of manic-depressive

disease as a “mixed episode” of mood disorder, or a “manic episode with prominent irritable

mood”

or “major depressive episode with prominent irritable mood.” See

DSM-4.

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Address

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John T. Maltsberger, 38 Fuller Street, Brookline, MA 02146,

U.S.A. Telephone: 617 731 2488; Fax:617 277 2619; E-mail: [email protected]


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