Professional Documents
Culture Documents
Ecstatic Suicide
Ecstatic Suicide
Ecstatic suicide
John T. Maltsberger
To cite this article: John T. Maltsberger (1997): Ecstatic suicide, Archives of Suicide
Research, 3:4, 283-301
To link to this article: http://dx.doi.org/10.1080/13811119708258280
Review article
Ecstatic suicide
JOHN T. MALTSBERGER
Department of Psychiatry, Harvard Medical School, Boston, MA; McLean Hospital,
Belmont, MA; and Marsachusetts General Hospital, Boston; Facuhy, Boston Psychoanalytic
Institute, MA, U.S.A.
Introduction
The grandiose phenomena of manic-depressive illness have never been understood 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 ecstatic 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 Robinss (1981) series
284
had ever had a manic episode. Where 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 dangerous ways to confound his enemies and show them he was invulnerable (Tanzi, 1909, 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. Three near suicides of
this type will be described here.
Bronisch (1996) suggests that the contemporary tendency to treat suicide
as a strict epiphenomenon of major depression is an error. Are the current
criteria for diagnosing major depressive illness so broad that the diagnosis is
overinclusive? Are they ever underinclusive? Ronningstam and Maltsberger
(in press) have recently reported three cases of deadly suicide attempts in
young men not one of whom was clinically depressed according to the rubrics
of the Diagnostic and statistical manual of mental disorders, 4th Edition
(1 994) (hereinafter, DSM-4).
Here are reports of three women, two of whom are grandiose and ecstatic
in their suicidal moments. The third is also grandiose when suicidal, but not
ecstatic.
I.
Mrs. A., a 53-year-old woman who 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, she plotted to jump in front
of a fast car and later did so, narrowly escaping injury when the temfied
driver slammed on the brakes.
Though she has usually worked effectively as a business executive, there
have been four occasions when her chronic hypomania worsened and she
required hospital care. These episodes were marked by emotional lability, loquacity, distractibility, psychomotor agitation, sleeplessness, overactivity, profound suicidal preoccupation, and severe emotional anguish
(psychache; see Shneidman, 1993).She is subject to outbursts of weeping, shrieking, and beating herself. The patients anguish can be so intense
that she drives about recklessly in her car for hours, screaming 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.
285
During attacks the patient has heard different hallucinatory voices which
she says represent self-fragments. Some 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 will survive her death. She says
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 eyes, and accelerate her car as fast as she can, not looking until the
last possible moment. She says these dangerous games restore her sense
of control and arouse her to a state of near orgasm; she is driven to play
them when she feels helpless and flooded with anguish. Such an episode
gets the adrenaline going, she says; she becomes ecstatic. She laughed
excitedly in describing her highway thrills, and then suddenly began to
cry.
She takes pleasure in torturing her 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 interstate highways into ravines. She 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 Thelma and Louise, a portrayal of the
double suicide of two women who speed over a cliff together in an open
convertible.
Mrs. As 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.
286
11.
Miss B. is a 30-year-old former athlete who at the beginning of her treatment satisfied the DSM 4 criteria for narcissistic personality disorder, borderline personality disorder and a major depressive episode. After extensive psychotherapy and exhaustive drug 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 compound for her depression, in the course of a bicycle
race the patient collapsed in ventricular fibrillation and narrowly escaped
death. In the course of the subsequent hospital treatment her depression
deepened.
A psychiatric hospitalization of many 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 amounts of aspirin (as many as forty tablets).2 On one occasion she
swallowed an overdose 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 come to her treatment session with rope
bums on her neck. She kept a suicide rope in a secret place and refused
to surrender it to her psychiatrist. The cutting and choking are the best
means she can devise for relieving intense feelings of depersonalization
and depressive anguish. These practices also 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 she
was given fluoxetine briefly. This aroused intense anxiety and the prospect
of self-injury and death began to seem thrilling and erotically arousing.
She formerly imagined herself to be intensely radioactive, so destructive
and evil that all who came in contact with her would be destroyed. Though
she has never hallucinated and has remained free of delusions, she still
cherishes a grandiose fantasy of suicide that is sometimes almost delu-
sional in force. Suicide promises escape from suffering, and is for that
reason much longed for.
But further, Miss B. imagines suicide to be a path to magical transformation 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 metamorphosis. By death the patient plainly means a kind
of passage to masculine apotheosis; it does not mean the end of her self,
but the end of her body only. She once ecstatically described a wish that
as she died her head might be quickly filleted out of her body, lifted away
by a crane, and transplanted into that of a powerful, beautiful young man.
Miss B showed great talent as a swimmer in early adolescence, and set her
heart on winning an Olympic gold medal. With the eager encouragement
of her family she trained to the point of exhaustion and entered numerous
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 have enjoyed in winning the medal.
To die of suicide would be just like that, she says; she compares her
imaginary Olympic glory to the flashing stars and lights she sees when
she chokes herself almost unconscious.
Not every victim of ecdysial suicide is ecstatic or elated, though some 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.
288
In the course of her veterinary work Miss C. had learned the technique for
phlebotomy. She developed the delusion that all the evil which suffused
her body as a consequence of the sexual abuse was concentrated in her
blood. She sought to purify herself by phlebotomy. Over 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 1 1.3
She denied this behavior was suicidal and stoutly claimed she would not
die even if she rid herself of the evil blood to the last millilitre. She insisted
she would, once purified, become reunited with her sister. With reluctant
disinterest she agreed that her behavior might lead to physical death, but
averred the loss of her body, a meaningless husk, would be a matter of no
great consequence, and would not constitute death. She therefore denied
that the ex-sanguination she was carrying out was suicidal in character.
289
290
for healthy adult living cannot be laid down. Zanarinis observations are of
importance inasmuch as much so-called borderline behavior has the impulsive, irritable, and passionate character familiar in hypomania and in mixed
states. Zanarini and DeLuca have developed an important research instrument, the Dysphoric Affect Scale, which promises to be very useful in
studying suicidal behavior in borderline and dyspshoric cases particularly (in
press).
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 deaths 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 cheers of 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 hercorpse, but her description of this transfiguration was
without rapture.
292
(Gait, 1908). Those widows who threw themselves into the flames of their
husbands 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 (Tertullian, 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 infected 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)
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 she 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 executioners dagger
to her throat (Farmer, 1992).
Ecstatic, metamorphic mass suicides are recorded at various other 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 communities starved themselves to death or
died in flames (Rose, 1928).
The Jonestown mass suicide of the Peoples Temple in 1978 was lead
by the grandiose Jim Jones, self-styled prophet and miracle worker, who
promised his followers togetherness in the afterlife, and spoke of the orgasm
of the grave. Jones probably believed that he was a god (Reston, 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 she
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 month she was oscillating between spells of profound depression
and intense rage. She had been subject 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 ecstatic. A friend noticed she had a quality of incandescent desperation. The
night before her death she was found standing motionless in a freezing cold
294
hall; she claimed she was having a wonderful vision (Stevenson, 1989, pp.
26 1-299).
During October 1962 she was feverishly and brilliantly creative, sometimes writing several poems in one day. Some of these, for example Lady
Lazarus, are ecdysial in theme: Written at the end of the month, it refers to
her suicide attempt of 1953, an act she narrowly survived, and concludes 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 comments
she has done it three times before. On October 20 she had written in Fever
103:
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 whore petticoats) To Paradise.
(Plath. 1992, p.232)
Grandiose themes of elation, destruction, ecdysis, and heavenly assumption 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 queen.
Is she dead, is she sleeping?
Where has she been,
With her lion-red body, her wings of glass?
Now she is flying
More terrible than she ever was, red
Scar in the sky, red comet
Over the engine that killed her The mausoleum, the wax house.
(Plath, 1992, p. 214)
In an earlier version of this poem Plath said the bees were suicidal, destroying themselves by stinging the gloves of the bee-keeper (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 imago (the adult form).
295
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.
297
022, pp. 228-229), but otherwise there are no suggestions of grandiosity in
the records.
298
seeming to feel like hurting someone, feeling sad, joylessness (Robins, 198I ,
pp. 52-53). Obviously 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
Robinss work.
Anguish as a term does 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 accompanied by psychomotor agitation), self-hate, and despair is typical of many
mixed-state patients. Shneidman (1 993) believes that psychache, his neologism 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 daydreams 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, and no psychomotor
disturbance would qualify neither for a diagnosis of major depressive episode
nor a mixed state under the current rubrics.
Kraepelin (1921) 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 the abdomen and thorax are familiar complaints in suicidal
melancholia. We do not know how commonly associated with suicide these
body sensations may be (sometimes they appear to rise to the level of visceral
haptic hallucinations).
Mental content
What we know about the mental content and fantasy life of patients on the
verge of suicide is anecdotal. Fantasies of metamorphosis, or ecdysis, appear
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
299
Notes
The first two patients (Mrs. A. and Miss B.) meet the DSM-4criteria 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. and therefore qualify for bipolar diagnosis.
All three patients have been treated with many drug combinations, including mood stabilizers, for long periods of time, by sophisticated psychophmacologic experts. The therapeutic response has been disappointing in each instance.
For aspirin (acetylsalicylic 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 100 ml of blood) for an
adult woman is 42 f 0.5. We estimated that Miss C. ex-sanguinated herself of more than half
her total blood volume over a week.
Ecdysis is a borrowed entomological term. It ordinarily refers to the shedding of an outer
cuticular layer in the metamorphosis of insects; molting is a synonym. The word comes from
Greek ekdysis, which means 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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