Suicide in Schizophrenia:
Considerations on Communication Pathology
by Bernhard J. Mitterauer, MD, Prof. em., University of Salzburg
Volitronics-Institute for Basic Research
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Keywords: schizophrenia, suicidal behavior, loss of self-boundaries, communication pathology, pseudo communication.
The lifetime suicide risk for schizophrenia patients is approximately 5% significantly higher than the general population suicide risk (Ventriglio et al., 2016); Here, I will focus on committed suicides. (Hor and Taylor, 2010). Our understanding of the subjective experience of a patient immediately before self-killing depends on the underlying psychobiological brain model of schizophrenia and the diagnostic methodology (Reeve and Addario-Berry, 2008).
I hypothesize that the brain functions of patients with schizophrenia are generalized because of imbalances in tripartite synapses (glial-neuronal synaptic units). Subjectively, the patient exists in an absolute timeless universe. Supposing that schizophrenia is a chronic disease, self-destructive behavior occurs, but a suicidal intent is not at work, since any change of existence may not be relevant in schizophrenia at all. Therefore, the act of self-killing is not communicated as suicidality, but suicidality may represent the interpretation of the observer.
Various brain models of schizophrenia as the neurodegenerative model (Pino et al., 2014) with white matter abnormalities (Kochunow and Hong, 2014; Lener et al., 2014) are proposed. My brain model is based on impaired neuro-glial interactions. In normal brain functions glia is modifying information transmission (Volterra, 2013) structuring neuronal networks in distinct time periods, so that the brain is capable of distinguishing subjects and objects in the environment. If information processing in tripartite synapses is imbalanced, a generalization of information processing is generated in the brain (Mitterauer 2005a; 2010; 2015). As experimentally evidenced, (Bauer et al., 2012) an unconstrained flux of neurotransmission in synapses (Mitterauer, 2003) may cause a generalization of information processing in the brain, since oligodendrocyte-axonic information transfer is also affected (Mitterauer and Kofler-Westergren, 2011). This severe impairment of the brain functions makes the patient unable to distinguish between the self and the others. We speak of the loss of self-boundaries in schizophrenia (Mitterauer 2003; 2005b). According to Meltzer (2003) the concept of schizophrenia does not characterize this psychobiological disorder. Is holophrenia (Mitterauer, 2005b) more appropriate?
Most importantly, The American Psychiatric Press Textbook (Hales et al.,1999) describes hallucinations and delusions as symptoms that reflect a loss of ego-boundaries and the patient is unable to distinguish between his or her own thoughts and perceptions and those that he obtains by observing the environment. According to DSM - V schizophrenia develops in stages with episodic courses of disease and full remission (Tandem et al., 2013). Contrarily, Zipursky and coworkers (2013) speak of a myth of progressive brain disease in schizophrenia. Currently, the etiopathophysiology of schizophrenia remains unresolved.
Phenomenologically, suicide attempts and committed suicides are observable realizing suicidal intentions (Stone and Aldiss, 1999; Stengel 1974). Fundamentally, a person attempting suicide tries to manipulate people in his or her environment in communication-intending behavior, whereas the person absolutely decided to commit suicide avoids other people in the sense of a communication-rejecting behavior (Mitterauer 1989; 2002). However, it is questionable if a suicidal behavior in schizophrenia is communicated by the patient.
Representative postmortem studies of patients with schizophrenia indicate that suicidology is faced with limitations, since reliable information of the psychobiological state and suicidal ideation or intent are mostly not available before the act of self- killing ( Pompili, 2016). For instance, suicide notes have not been found (Ishii et al., 2014). In a meta-analysis of 9 representative studies of single case analyses (N= 344) we diagnosed a paranoid psychosis in 68 cases (75%),(37 male, 31 female). At the time of suicide 51 patients were fully remitted and in 17 (25 %) suicides the psychobiological state could not be diagnosed because of a lack of information. The diagnosis of paranoid psychoses compromised all non-organic delusional-hallucinatory diseases including paranoid schizophrenia (Mitterauer,1985). Retrospectively this diagnostic result may not be reliable because of overdiagnoses of paranoid schizophrenia.
If we suppose the patients with schizophrenia exist in an absolute subjective and “timeless” universe, to finish their existence may not be an intent at all. However, delusional misinterpretations of the psychosocial situation may cause a self-destructive behavior. Even hallucinations that command self-killing may tend to be impulsive rather than planned (Ishii et al., 2014). From a communication point of view delusions and hallucinations represent a pseudo-communicative behavior (Mitterauer 1980,1983).
My proposed model allows interpretation that the act of self-killing in schizophrenia may not be based on suicidal ideation or intention and its communication does not really occur. In conclusion, I suggest that a better understanding of the communication pathology could contribute to programs in schizophrenia research and psycho-bio-social treatment and care.
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