Depression parasuicide and suicide

The putative relationship between depression and disgust has been dealt with in detail in Chapter 7. We argued for an analysis of depression in which the basic emotions of sadness and disgust may become coupled and thereby maintain the individual in a painful emotional state which may prove difficult to alter or regulate. Instead of covering the same ground again therefore, we will focus on the related problems of suicide and parasuicide. However, we will make a brief comment on the increasing recognition of the role that shame may play in depression. For example, Gilbert (1992) has cogently argued that one of the important aspects for the development of the self is that children should come to see themselves as people with value and status in relationships. If, however, children experience parental devaluing, such as being put down and being shamed, this may lead to the internalisation of a sense of self that is of low status and low value to others. The work by Andrews (1995) on the links between childhood abuse, bodily shame, and adult depression provided evidence for the important role of shame in depression (see Chapter 7 for a further account of this study). Gilbert, Allan, and Goss (1996) have also reported evidence from a group of students that early experience of being shamed by parents and of being a non-favourite child is associated with later interpersonal problems and symptomatology. The net effect of these studies is to strengthen our view that there is considerable mileage to be had with the proposal that some forms of depression may result from the coupling of sadness and disgust or shame (cf. Tangney & Dearing, 2002).

To turn to the question of suicide and parasuicide, the first point to make is that not all suicide and parasuicide individuals are depressed, just as not all depressed individuals are suicidal; thus, we do not wish to suggest that all suicide is based on disgust towards the self, only that it is a major component that has failed to be investigated. The figures, however, suggest that 35-79% of parasuicide cases are depressed (Weissman, 1974; Williams, 1997) and, even with clinical assessment rather than self-report, the figures are between 30% and 66%, (Ennis, Barnes, Kennedy, & Trachtenberg, 1989; Williams, 1997). Population estimates of the prevalence of suicide and parasuicide are beset with difficulties not least because until relatively recently suicide was illegal in the UK and because of religious sanctions; thus, official suicide figures necessarily underestimate the true rates due to these and other factors. Nevertheless, in the United States there are more than 25,000 suicides per year, and upwards of 200,000 cases of parasuicide. Kreitman (1990) estimated that in Edinburgh there were 1.67 per 1000 cases of parasuicide serious enough to warrant treatment. The suicide rate is of course higher in some diagnostic groups than in others; thus, the rate in bipolar disorders is estimated to be between 10% and 30% with suicide being associated with the depressive rather than the manic symptomatology (e.g., Linehan, 1993).

Having now identified some links between depression, suicide, and parasuicide, we should note that there are a wide range of terms in use, especially those that refer to Kreitman's (1977) so-called parasuicide category. Such terms include "self-wounding", "self-mutilation", "self-injurious behaviour", "deliberate self-harm", and "cry for help". The terms "parasuicide" and "deliberate self-harm" avoid many of the assumptions that other terms imply and should therefore be preferred. That is not to say, though, that there are no useful subcategories. For example, Tantam and Whittaker (1992) provide a useful overview of the category of "self-mutilation" for which there are diverse cultural practices—thus, there is widespread evidence from archaeological sites that trepanning occurred in many ancient groups, and practices such as foot binding, ear piercing, and finger mutilation have been carried out in more recent times for the purpose of fashion or status. However, there are a number of widespread culturally prescribed practices that can be interpreted as disgust-based and which may target certain parts of the body as a consequence. To quote from Tantam and Whittaker:

The stated intention of self-mutilation is often to rid oneself of an offending organ or body part . . . common targets are the eye (the evil eye, the roving eye), the genitalia (John Thomas), or the tongue (the filthy tongue, the tongue that runs away with you). (1992, p. 452)

In this type of self-mutilation, therefore, the individual attempts to rid the self of badness which has come to be identified with a particular part of the body. However, in so-called self-injurious behaviour or deliberate self-harm the pain or injury may even more clearly be an attempt to purge the individual of an unwanted aversive feeling (Klonsky, 2007). As MacLeod (2004) and others have argued, the suicidal individual may have problems with the regulation of negative affective states, so feelings of being unreal or depersonalised are commonly reported prior to parasuicidal acts (e.g., Van de Kolk, Perry, & Herman, 1991).

Sheila felt unreal whenever she became very anxious or became angry. She would do anything to avoid these feelings and, on various occasions, had been hospitalised because of overdosing or because of wrist cutting. Her mother had spent long periods in hospital when Sheila was a child and Sheila had been sexually abused as a young teenager by a friend of her father's.

As in Sheila's case, there is a high likelihood that neglect or abuse may occur in childhood in cases in which the individual resorts to self-harm; thus, Van Egmond and Jonker (1988) reported that 52% of first-time self-harm cases and 77% of repeat-episode cases had been either sexually or physically abused in childhood. Such childhood abuse or neglect leads to an individual with poor self-esteem and, particularly in the case of abuse, with a feeling of disgust towards the self or the body, as noted above (Low, Jones, MacLeod, Power, & Duggan, 2000). In extreme cases, repeated abuse may lead to severe dissociative disorders (e.g., Terr, 1991), the dissociative states being triggered off by a range of emotion and drive-related experiences. Even in individuals without obvious abuse or neglect, the presence of self-derogatory views predicts an increased likelihood of suicidal ideation and parasuicide; Kaplan and Pokorny (1976) followed up a group of teenage school children over 12 months and found that those with self-derogatory views at the first assessment reported more suicidal ideation and parasuicide over the ensuing 12 months when compared to those children without self-derogatory views.

Theoretical approaches to parasuicide and suicide have focused on a range of psychological and social factors, beginning with Durkheim's classic sociological analysis of "social anomie". The epidemiology of suicide and parasuicide provides at least some evidence in favour of social and cultural factors. For example, the suicide rates are higher for groups with lower social status such as immigrants. Similarly, suicide rates for whites and blacks are inversely related to the proportions of whites and blacks in a given population (Davis, 1979); that is, the rates among whites are highest when they form the minority group and, equally, the rates among blacks are highest when they form the minority group. It seems likely therefore that cultural disgust-based values which have as their target particular social or ethnic minorities contribute to the greater incidence of suicidal behaviour in these groups. However, it is not sufficient to look only at sociological factors because, for example, suicide still occurs in high-status groups.

In summary, we propose that there is a significant role for disgust-based emotions in the occurrence of suicide and parasuicide. The effects of disgust are evident both at the cultural level and at the individual level, in that groups who are perceived to be of lower status show higher rates of suicide and parasuicide. In a similar manner, individuals who have experienced abuse or neglect in childhood are vulnerable to poor self-esteem and the viewing of aspects of the self and the body in a disgust- or shame-based way. Certain emotional states may be particularly aversive for such individuals, for example the experience of anger, fear, or sadness, and in the attempt to eliminate these unwanted affects from the self, parasuicide or suicide may follow. However, we are not suggesting that all acts of deliberate self-harm are based on disgust towards the self or towards certain minority groups. In the case of certain types of self-mutilation for example, such as the previous Chinese practice of foot binding, there is an attempt to increase the perceived status of the individual. Equally, certain suicides may be carried out for noble reasons, as Albert Camus (1955) argued, such as in the case of Japanese kamikaze pilots or Islamic suicide bombers who gain status for themselves and their families through suicide. However, the majority of everyday suicides and parasuicides are not the consequence of pursuing lofty or noble causes but are, in large part, desperate attempts by unhappy individuals to escape overwhelmingly painful emotions and circumstances.

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Anxiety and Depression 101

Anxiety and Depression 101

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