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Suicide Following Recovery From Brain Injury
Why after all the efforts to regain functioning following a traumatic brain injury (TBI) would a survivor die of suicide? If you talk to a TBI survivor, a close relative or a medical professional about this recovery issue, you will find the answers are varied and informative but never conclusive. A survivor may focus on the hopelessness associated with the loss of self and the feeling that life in this state is not worthwhile. A friend or a loved one may suggest programming was not sufficient to help the survivor maintain gains or overcome deficits. The professional will address the pre-injury factors that may have placed the survivor at risk, such as, the quality of interpersonal relationships, previous psychiatric history, alcohol or drug abuse, or post accident factors such as the nature of the injury itself or the adequacy of finances. Probably all the answers warrant equal consideration but for those of us that deal with the issues related to suicide in TBI survivors, there never seems to be an adequate answer to the emotion laden question, "Why suicide?". Hopefully, this article will begin a dialogue about the medical, moral and existential realities of suicide following TBI.
Although most professionals assume the risk of suicide as a consequence of TBI is a given, data specifically related to suicide and TBI survivors remains limited. Studies of suicide rates in TBI survivors are few but indicate a higher number of TBI survivors will die of suicide when compared to the general population. Unfortunately, attributing the higher rate of suicide to TBI alone can be difficult because in many cases previous family history for suicide, alcohol abuse and psychiatric problems complicate our understanding of the data. It is clear that this increased incidence of suicide in TBI survivors is similar to that associated with other disabling illnesses, such as multiple sclerosis, severe diabetes and amyotropic lateral sclerosis (ALS or Lou Gerhig's disease). As a result, suicide must be addressed in the short and long term recovery plans for a TBI survivor and loved one's.
Medical professionals and psychotherapists in particular, deal with the potential for suicide in a patient from an actuarial basis, which means we deal with risk factors for suicide. Whenever a patient appears down or agitated or unable to deal with the rigors of recovering from a TBI the probability of suicide is weighted. If a person shows signs of being depressed, such as a loss of interest in activities, changes in habits, irritability or resignation, talk of giving up or indications that no one would miss them or everyone would be better off if they were gone, a professional will take action, as these are serious warning signs. In spite of the fact that so many TBI survivors experience these feelings, a good professional never takes such symptoms for granted. Immediately, a professional will assess possible physiological factors, such as specific sight of neurologic insult, medication side effects or sleep patterns that could account for the symptoms. They will look for changes in the patient's recent behavioral patterns and inquire about any drug or alcohol habits that may increase the likelihood of impulsive acting. Related to both of the above, a patient's cognitive functioning is addressed. It is important to know what expectations or attitudes toward life a patient maintains. If a patient has been traumatized by events surrounding her or his accident or rehabilitation, this could result in destructive negative thinking. Direct questions are asked regarding the presence of suicidal thoughts or if a patient has a plan formulated for killing themselves. A professional also wants to know what is the nature of a patient's social support network. Are family members or friends frustrated with the patient and unable to provide support? Does the patient demonstrate the capacity to have close relationships? Are there any pressing financial issues that make the patient vulnerable?
By being alert to risk factors and warning signs of suicide, a trained professional can often help a person with a TBI get beyond danger, although no matter how skillful the professional, there is no guarantee. Possibly the reason we professionals are unaware of the actual suicide rate in TBI survivors relates to the successful therapy outcomes. But what about the long term risk of suicide in TBI patients that have not received therapy or have reached a medical end point and are no longer in treatment or follow up programming? Unfortunately, we don't have this information but when we hear news of a TBI survivor dying of suicide, the risk factors and warning signs data lose relevance.
It seems unfair that such a stigma exists around an individual dying of suicide in the Western Hemisphere. Not only is the victim held accountable but also denied the sympathy and understanding associated with any untimely death. In addition, confronted with a loved one's death to suicide, family and friends must mourn the loss with a different mixture of denial, anger, depression, bargaining and acceptance than would have been present if the survivor's accident had claimed her or his life. Suicide seems to contradict a significant aspect of being human, the struggle to survive in spite of the trials a person must face in life. This may be why suicide across societies is always a moral issue regardless of cultural interpretation. How should we judge one who has died of suicide? In some cultures, suicide is a demonstration of honor and in others a sign of shame or ultimate aggression and in the case of suicide following TBI maybe an act of final indignation or resignation to fate. In fact the morality of suicide is only an issue for those left behind, a reminder of the responsibility of life and the inevitability of death. Suicide becomes the focal point for discussion of the meaning of life.
What seems to be forgotten in the reduction of suicide to a list of risk factors is the series of seemingly unrelated and coincidental events that impact on an individual over time and contribute to an untimely death. In the 1960's Edward Lorenz noted that small changes in air flow caused by a butterfly's wings occurring in one part of the world can have a major effect on the weather in another country. This phenomenon called the "butterfly effect" or the "sensitive dependence on initial conditions" helped define Chaos theory in mathematics and physics but seems relevant to the event of suicide. Regardless of the risk factors that would predict a person's likelihood of dying of suicide, the event itself seems to have a chance or "butterfly effect" requirement.
No where is this more evident than in the case of TBI survivors. The routine of living each day after a TBI is cluttered with small seemingly insignificant reminders that life is no longer automatic but rather a very mechanical or manual process. Those of us that have not experienced a TBI don't understand the significance of these "little" reminders. We don't see how necessary it is to have a paste note to remember our daily duties, or how discouraging life can be when a memory that could retrieve any of our friends' phone numbers now requires a notebook. Small issues? Yes. But not so small when this fact changes the way a TBI survivor feels about themselves. These seemingly insignificant insults to one's self may play a much larger role in an individual's ability to withstand the assault of life's trials. This may account for why suicidal feelings are not easy to understand and why even a seemingly healthy and loved TBI survivor may perish in spite of having faced overwhelming physical odds. It is also why each case of suicide must be seen as unique. There is no case that can be explained by the normal risk factors alone because there is case after case of individuals that do not die of suicide having had the same risk factors. It appears to be the coming together of a number of feelings and circumstances that result in the moment or moments when the alternative not to live just happens. Even in cases where a person plans in advance to end life, each small interaction must fall into place for the suicide to occur. It is only after the fact, that friends and relatives begin to sort out how these small issues begin to loom as important.
Unfortunately, all of us who have loved someone who has died of suicide feel a sense of responsibility, because intuitively, after the fact, we suspect that if only we could have changed one interaction the event might not have had to happen. Maybe so and always worth the effort whenever faced with the situation in the future but again, suicide, like the weather may be driven by a force already in place. By the time we observe the danger, the event is immune to our input.
Life is precious but those who survive a TBI understand this differently than others that escape injury or death. The cost for the "fate better than death" is often a loss of the pre-injury self. What is gained is simply another chance to be someone else that can struggle with the trials of life. It is not surprising that fatigue occurs over time and that this new self needs a great deal of nurturing to keep up to the task and not fall prey to the seductiveness of nonexistence.
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