CHAPTER 24
Psychoanalytic theories
of suicide
Historical overview and
empirical evidence
Elsa Ronningstam, Igor Weinberg
and John T Maltsberger
Abstract
Psychoanalytic theories and studies have influenced the explorations
of suicide over the past hundred years. Freud’s first observations
of self-objectification in melancholic depression were followed by
contributions from object relation theorists and self-psychologists,
highlighting foremost the role of narcissistic rage and structural
vulnerability. Several of the central clinical concepts that unfolded
have more recently been subject to empirical testing. This chapter
provides an overview and discussion of the different psychoanalytic
formulations applied to suicide. Empirical studies of several assump-
tions and constructs related to emotions, defences, and structural
deficits and vulnerabilities verify their association to or explanation
of chronic and acute suicidality. Further conceptualizations and
research, especially on subtypes of suicide and individual experi-
ences leading up to and dominating suicidal states, are called for.
Early psychoanalytic theories of suicide
Although somewhat peripheral in recent years, the understanding
of suicide has been an aim of psychoanalysis since its beginning.
As early as in 1910 the Vienna Psychoanalytic Society held a meeting
to discuss suicide, where Adler, Sadger, Stekel, and Freud him-
self exchanged views. The meeting ended inconclusively: Freud
suggested only when further clinical observations accumulated
would a psychoanalytic theory of suicide become possible
(Friedman 1967).
Seven years later Freud published ‘Mourning and melancholia’
(1917), a paper in which he formulated dynamics of melancholic
depression and of suicide. At the heart of that remarkable paper
lies a clinical observation. Freud wrote:
If one listens patiently to the melancholic’s many and various self-
accusations, one cannot in the end avoid the impression that often
the most violent of them are hardly at all applicable to the patient
himself, but that with insignificant modifications they do fit someone
else, someone whom the patient loves or has loved or should love.
Every time one examines the facts this conjecture is confirmed.
Freud (1917, p. 248)
Then he moved on to the critical inference:
So we find the key to the clinical picture: we perceive that the self-
reproaches are reproaches against a loved object which have been
shifted away from it on to the patient’s own ego.
Freud (1917, p. 248)
These few lines stand out as the central insight that has dominated
our understanding of suicidal phenomena ever since: suicide
depends, from whichever perspective one examines it, on the
capacity to stand aside from oneself, to objectify oneself, and to feel
and act upon oneself as though one were someone else.
Freud acknowledged a paradox in suicide. He wrote that the
ego’s self love is so immense that the ego’s consenting to its own
self-destruction is inconceivable (Freud 1917). While relating
suicide to melancholy, Freud tried to resolve the paradox by
connecting suicide to narcissistic identification with a lost and
ambivalently loved and hated object. A suicidal person is prone
to narcissistic object choice and tends to ambivalence toward
those whom he loves. In other words, he tends to experience
love and hate concurrently towards his objects and to vacillate
between these feelings without any resolution. Loss plays major
role in the dynamics of melancholy and, consequently, of suicide.
Loss of the object increases ambivalence, and the hostile side of
the loving and hating acts like emotional glue, hampering the
ability to give up investment in the object, to grieve, and to
become invested in new objects. Consequently, the melancholi-
cally disposed patient is likely to regress from object relatedness
with the lost object to identification with the object. The object
becomes part of the ego and the sadism experienced towards the
internalized object turns against the self: ‘the shadow of the object
falls upon the ego’ (Freud 1917, p. 249). From the structural point
of view, the superego uses all the available sadistic energy to fuel
150 PART 3 theories of suicidal behaviour
self-denigration (Freud 1923). Sadistic attacks of the superego
drive the ego to suicide.
Yet another formulation of suicide was suggested by Freud in the
same article (Freud 1923), namely, that the superego withdraws
libidinal cathexis from the ego and the ego, feeling abandoned by
its protective forces, surrenders and dies. These two formulations
explain suicide as a result of self-attack as opposed to suicide due to
withdrawal of self-love.
Menninger (1938) took up Freud’s later elaboration of the death
instinct and tried to explain suicide in terms of it. According to
his theory, physical and mental health depend on fusion between
the life and death instincts. Fusing ensures a balanced state of
neutralization of the death instinct by life instinct. While various
degrees of instinctual defusion manifest themselves in various
forms of physical and mental illness, suicide constitutes the most
extreme manifestation of death instinct and instinctual defusion.
Suicide stems from combination of three wishes, he believed: the
wish to kill, the wish to be killed, and the wish to die.
1 The wish to kill includes desires to attack, destroy or retaliate
against another. These desires are not neutralized by positive
feelings toward the other.
2 The wish to be killed is associated with masochistic tendencies,
related to the desire to experience pain and suffering as well
as submission to a destructive attack by the other. This wish is
also associated with a desire to expiate guilt through suffering
and self-inflicted punishment.
3 The wish to die includes the longing to die, which gives rise to
preoccupations about the essence of death and dying.
Object relations theories
After Freud’s contributions, the next significant development in
psychoanalytic study of suicide arose from the work of Melanie
Klein (1935, 1946), who in many respects might be called the
first ‘object relations’ theorist. Her understanding of suicide
followed from her distinction between the ‘paranoid–schizoid’ and
‘depressive’ positions. The paranoid–schizoid position is charac-
terized by the tendency to project hatred onto the object, giving it
a persecutory and omnipotent colour in the mind of the projecting
child. This provokes annhilatory anxiety (fear of self-disintegration
and loss of sense of self) as well as fear of loss of the good object
due to destructiveness of the bad object. One tends to attack the
bad object to protect oneself from annihilation or in order to pro-
tect the good object. In some cases (e.g. hypochondria or body
dysmorphic disorder), the bad object is projected into one’s own
body. In such an instance, to attack the body is to assault the seat
of the bad object.
In the depressive position, where we encounter increased
ability for integrative perception of the object and oneself, the
ego experiences the good and bad objects as centring in the same
object. This leads to depressive anxiety; loss of the object is feared,
and guilt arises over the sadistic fantasies and wishes towards the
object. The guilt feelings demand reparation and attempts to undo
real or imaginary consequences of aggressive fantasies. However,
in more pathological cases, guilt can lead to feelings of badness
and beliefs about being destructive towards others in general and
toward the good object in particular. Suicide might follow as an
attempt to cleanse the world and prevent its destruction.
Narcissism and the suicidal state
Any mental operation involved in the maintenance of the struc-
tural cohesion of the self, in protecting the temporal continuity of
the self, or in maintaining a positive affective colouration of the
self, is considered narcissistic. This understanding of the term is
somewhat different, however, from the way in which some of the
followers of Melanie Klein have used it.
Klein’s assertion (1957) that early primitive envy represents a
malignant and severe form of innate aggression (derivative of the
death instinct) provided a base for connecting suicide to narcissism.
Rosenfeld (1971) broadened the meaning of the term narcissism
by expanding on this idea, somewhat idiosyncratically includ-
ing in it destructive and aggressive elements. Rosenfeld believed
that narcissistic character structure is a defence against envy and
dependency inasmuch as dependency on an object recognized as
good invites envy. In his view, narcissism involves both a libidi-
nal and a destructive aspect—the destructive being the idealization
of the omnipotent and destructive parts of the self, which often
remain split off. However, in states of predominant destructiveness
Rosenfeld observed that envy is more violent and associated with
a wish to destroy the objects the patient depends upon, such as the
analyst, but also to destroy or harm the self, i.e, one’s own progress,
success, and relationships. Rosenfeld also noted that ‘Some of
these patients become suicidal and the desire to die, to disappear
into oblivion, is expressed quite openly and death is idealized as
a solution to all problems’ (1971, p. 173). This state, which evokes
Freud’s description of the death instinct, arises from the destruc-
tive, envious parts of the self. Rosenfeld continued:
The whole self becomes temporarily identified with the destructive
self, which aims to triumph over life and creativity … [and] ... these
patients have dealt with the struggle between their destructive and
libidinal impulses by trying to get rid of their concern and love for
their objects by killing their loving dependent self and identifying
themselves almost entirely with the destructive narcissistic part of
the self which provides them with a sense of superiority and self-
admiration.
Rosenfeld (1971, pp. 173–174)
Of importance for the following theoretical accounts on suicide are
Rosenfeld’s notes of both the destructive aspect of suicide and the
idealized view of death.
Influenced by Klein and Rosenfeld, Otto Kernberg (1984, 1992)
asserted that an extreme form of hatred is expressed in suicide.
‘The self is identified with the hated object and self-elimination is
the only way to destroy the object as well’ (1992, p. 23). He used
the term ‘malignant narcissism’ (Kernberg 1992, 1998) to indicate
a more severe level of superego dysfunction, characterized by anti-
social behaviour, ego-syntonic sadism, and paranoid orientation. In
patients with malignant narcissism, chronic suicidal preoccupation
may be accompanied by cold, sadistic, vengeful satisfactions, and
the development of secret means for exercising power and control
over the clinician. The transference of these patients often reflects
identification with primitive sadistic object representations, i.e, inter-
nalized negative and punitive early experiences of others, which are
enacted for purposes of revenge and control. These patients may
grow more suicidal when they feel that the therapist has been helpful
(i.e, negative therapeutic reaction) (Kernberg 2001). It seems that
the patients Kernberg has described as suffering from ‘malignant
narcissism’ lie in a fixed, characterological position on a worsening
continuum, stopping short of full psychotic fragmentation. Such

patients turn life into an omnipotent operation in which cruelty
drives out love and pleasure is only to be found in the domination
and destruction of others.
Representing another perspective on suicide Lewin (1950)
and Maltsberger (1997) suggested that self-execution can
serve as a retreat to the archaic grandiose self, or the pathological
grandiose self. In other words, the thought and act of suicide may
relate to an idealized state of self and actually serve to increase self-
esteem. The relatively common omnipotent fantasy of destroying
all reality through suicide was put into poetry by A E Housman
(1936, p. 185):
Good creatures, do you love your lives
And have you ears for sense?
Here is a knife like other knives,
That cost me eighteen pence.
I need but stick it in my heart
And down will come the sky,
And earth’s foundations will depart
And all you folk will die.
The everyday psychopathology of a psychiatric unit yields
many such examples. Consider the patient who kills herself with
the conviction she will rejoin a dead sister in the world beyond
the grave. Many persons kill themselves to escape the sufferings
of this world in full confidence that they will pass over into a better
life. Obviously this fantasy, which it is fair to call delusional, is
grandiose. In suicide the ordinary rules of reality, its painful limi-
tations, are denied, and, conquering limitations, the transfigured
dying patient soars above them all. Some suicidal patients fondly
believe that in death they will experience a body metamorphosis
so that physical limitations will be overcome and they will re-emerge
as golden, athletic gods. Sylvia Plath, the North American poet
who died of suicide some years ago, filled her last writings with
omnipotent and aggressive images of flying and destructive
she-demons (1992).
Suicides that serve to protect honour, 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 died in this way. Hara-kiri suicides would
sometimes appear to have a manic colouration (Piven 2001).
Suicidal breakdown sometimes represents a final and desperate
operation by the failing ego to save itself. Object attachments are
abandoned in these states, omnipotent narcissistic fantasies take
their places, and the primitive operations of malignant envy and
destructiveness come into play as the mad self attempts to assert its
control over the whole world (Maltsberger 2004).
Chronic suicidal preoccupation (as opposed to bona fide sui-
cide attempts) may help preserve an individual’s self-esteem,
sense of dignity, autonomy and internal control. It may even be
useful for preserving a sense of connection to others, and provide
a sense that it is worth staying alive. Lewin and Schulz (1992)
contended that chronic suicidal preoccupation gives a sense of
autonomy, control, and a grandiose sense of victory over the
therapist; it covers feelings of emptiness and loss, reverses sense
of helplessness or spoils the therapeutic progress. Rothstein
(1980) suggested that in some patients the idea of suicide can
represent an illusion of turning passive humiliation into active
mastery. Other authors comment that awareness of the ability
to end one’s life can have an organizing and structuring effect,
CHAPTER 24 psychoanalytic theroies of suicide 151
occasionally making life liveable and even enjoyable (Lewin
1992; Gabbard 2003).
Self psychology
Although Kohut did not particularly concern himself with suicide,
he penned a footnote in 1971 connecting shame, envy, ego-ideal
and narcissistic rage to suicide (Kohut 1971). This minor comment
has had major impact on more recent theoretical conceptualiza-
tions and approaches to treatment. Kohut wrote:
This state of shame and envy may ultimately be followed by self-de-
structive impulses. These, too, are to be understood not as attacks of
the superego on the ego but as attempts of the suffering ego to do
away with the self in order to wipe out the offending, disappointing
reality of failure. In other words, the self-destructive impulses are to
be understood here not as analogous to the suicidal impulses of
a depressed patient but as the expression of narcissistic rage.
Kohut (1971, p. 181)
He believed that individuals who need absolute control of their
environment to maintain self-esteem and self-cohesion depend
upon the unconditional availability of a mirroring, admiring self-
object. Deprived of it, they are prone to the most intense experi-
ences of shame and violent forms of narcissistic rage (Kohut 1972).
It is notable that Kohut introduced a distinction between suicide
caused by the ego attacking the failing self as opposite to suicide
caused by the cruel superego attack on the self (as in Freud’s mel-
ancholic model). Kohut consequently differentiated suicide in the
context of depression from suicide caused by narcissistic rage.
Based on self-psychological theory several new explanations of
suicide have been introduced, addressing additional self-states,
such as endangerment, narcissistic depletion, and vulnerability, as
possible contributors to suicidal ideations and acts (see Table 24.1;
Reiser 1992).
Vulnerability to suicide
Several recent studies of suicide suggest particular personality
aspects that may lead to suicide. The vulnerability model suggests
that certain psychological traits and deficits specifically predispose
to suicide. Such a theoretical model invites a more integrative
approach to the understanding of the dynamics in suicidal states,
and attends to more complex relationships between several pos-
sible contributing factors to suicide, including developmental,
psychodynamic and internal subjective experiences of the suicidal
person.
Beyond self-directed aggression and emergency operations
to shore up crumbling self-esteem, the vulnerability studies
attend to flaws in self-organization which predispose patients to
structural fracture. The German psychoanalyst Heinz Henseler
(Henseler, 1974, 1981; Etzersdorfer, 2001) has addressed the role
of narcissistic vulnerability and compromised self-esteem regula-
tion. Suicide, he suggests, is an extreme form of reaction to injury
to the sense of self-worth. Departing from Freud’s ‘Mourning and
melancholia’ (1917) and the central role of depression in suicide,
he assumes that the suicidal individual gives up his individuality
by fusing with a diffuse primary object in order to gain safety.
In other words, in suicide, the patient acts to save self-feeling or
self-regard.
Buie and Maltsberger (1989) identified two aspects of sui-
cide vulnerability, loss of the psychological self through mental
152 PART 3 theories of suicidal behaviour

Table 24.1 Suicidal dynamics according to the self psychology

Self-experience Formulation Suicidal dynamics
The endangered self The self is organized at a primitive level. It is torn among the longing for Suicide represents coping with breakdown of this defence
closeness, threat of engulfment in the other, and annihilatory experience that and with the threat of annihilation.
stems from that. Therefore, the person avoids close relationships and retreats
into isolation, restriction, and compulsive lifestyle.
The enraged self The person has a negative self-image due to identification with the negative Suicide stems from a combination of turning of the negative
introjects that had been projected into him by his parents. The person strivings of the abusive introjects against the child-self, and
experience himself as a victim, as starved or attacked and tends to idealize the expression of the rage against these introjects.
abusers. He tends to choose self-objects that maintain the childhood abusive
experiences. Therefore, closeness evokes tremendous rage.
The vulnerable self The person feels empty, lack of self-fulfilment, and pervasive lack of Due to pervasive misery, the person is at risk of chronic
satisfaction. He is sensitive to separations, prone to hypochondria, obesity, suicide and repetitive suicide attempts.
poor physical health, and avoids direct expression of anger.
The grandiose self The grandiose self is critically dependent on self-objects that supply Suicide is an escape from painful feelings of self-disintegration,
experiences of mirroring, admiration, perfect empathy, and allow idealization. emptiness, and rage.
Empathic failure of self-object leads to self-disintegration, catastrophic feelings,
emptiness, and rage.
The mirroring self High sensitivity to the feelings of others. He is willing to become self-object Due to unrelenting self-sacrifice, the person experiences
for others and seeks this role in an almost compulsive fashion. While he is increasing depression, loneliness, emptiness, disappointment,
directing his empathy to others, he is depriving himself of it and, as a result, anger, and exhaustion.
experiences emptiness and depression (Miller 1979).

disintegration and overwhelming negative self-judgement. They
noticed that suicidal people are vulnerable to both unbearable
experiences of aloneness as well as to a deep sense of worthless-
ness and guilt.
Maltsberger (1986, 1993, 1998, 2004) further integrated the role
of self-disintegration and dissociation in suicidal states. In his view,
suicidal people suffer from structural deficits in self-representa-
tion, in internalizations of others, and in object constancy. Paucity
of positive introjects limits the capacity for emotional and self-
esteem regulation. It follows that pre-suicidal patients are critically
dependent on external resources for self-regulation, i.e, sustaining
resources (e.g. significant others, work, pets, etc.). Loss of exterior
sustaining resources precipitates three deadly affects: aloneness,
self-contempt, and murderous rage. Aloneness refers to the ina-
bility to evoke positive memories of significant others or positive
interactions with them. This eerie experience of aloneness implies
a profound, despairing sense that one has never been loved and
never will be loved, ever. Patients caught up in a state of alone-
ness are apt to be overwhelmed by annihilatory anxiety; they may
feel they are already dead, or even show the conviction that they
are dead in fact. In addition to the experience of anguished alone-
ness, suicidal patients can suffer from intense self-contempt—an
experience of extreme scorn, disgust, and denigration, blame, and
hate—all turned on the self. Murderous rage can lead to suicide
when the person turns it against themself—either because of guilt
feelings over the murderous wishes or feelings of hopelessness to
change the situation.
Structural deficits and vulnerability to aloneness, self-contempt,
and murderous rage affect the way suicidal states unfold. First, lack
of the ability to evoke positive introjects and excessive reliance
on receding external sustaining resources can lead to escalation
of anguish. The patient must then struggle with a flux of nega-
tive affect; we may observe frantic attempts to get help to endure
intolerable mental pain; we may see self-mutilation, dissociation
(Maltsberger 2004), or substance use (Hendin el al. 2001). If the
patient is unable to summon help or rescue from outside himself,
the third stage of the suicide breakdown will begin to unfold–
disintegration of the self-representation (Maltsberger 2004). Self-
break-up together with de-neutralization of the aggression that
colours these representations lead to pitting some parts of the self
against others. The superego becomes harsher and more sadistic,
unleashing an attack against the ego. In this case suicide represents
fulfilment of sadistic forces of the super ego as well as an attempt
to put an end to painful self-awareness. A more regressive scenario
consists of projection of the sadistic and persecutory part of the
self-representation into ones body and attacking it in self-defence
(Maltsberger 1998).
The last stage of self-break-up in suicide is marked by grandiose
survival manoeuvres that operate outside the scope of reality test-
ing. At this stage, reality testing having failed, patients entertain
psychotic, grandiose beliefs and act on them without hindrance.
Some patients imagine death as a continuation of life, rebirth,
reunion with loved ones, or perhaps self-cleansing or self-trans-
formation (Maltsberger and Buie 1980). Here one encounters
concrete conviction that the bad aspects of oneself reside in one’s
body and that by attacking it one can be rid of it and survive in
an imaginary sphere without it (Maltsberger 2004). Other patients
deny the irreversibility of death and see suicide as a survivable
scientific experiment (Ronningstam and Maltsberger 1998).
Smith (1985) proposes that there are a number of characteris-
tic defining the ‘vulnerable personality’. He enumerates high self-
expectations, a tendency to inhibit negative emotions, an ambivalent
attitude toward death, lack of ability to grieve past losses, a tendency
to develop overly dependent relationships, passivity and neediness.
Other characteristics described by Smith include cognitive rigidity,
arrested sexual development, and over-investment in appearance or
intellectual ability. In order to compensate for these vulnerabilities
one develops a ‘life dream’ to help regulate the self. Disappointments
and losses can smash life dreams. In the absence of capacity to grieve
and to moderate unrealistic aspirations, suicide can occur.

The role of shame and ego ideal
Lansky (1991) averred that shame is the most significant affect in
suicidal patients; other suicide-related emotional experiences such
as depression, guilt, psychic pain and anger he thought secondary
to shame in driving suicide. Shame is the feeling associated with
the failure to live up to ideals or to achieve important aspirations
and goals. It is a response to feedback from others suggesting
incompetence, inefficacy, and the inability to influence, predict,
or comprehend an event, in the face of expectations that one
should be able to control or understand (Broucek 1982). Shame
in this sense would appear to arise from helplessness to master
either inner or outer challenges, or sometimes, both (Bibring
1953). Shame may even be indistinguishable from helplessness.
We further note, however, that shame is often associated primarily
with exhibitionism and ambitious strivings that are unrelated to
the ego ideal (Kohut 1972). Excessive primitive shame triggered
by the experience of incompetence, inadequacy, or lack of control
can provoke cognitive impairment, autonomic reactions and even
self-disintegration. Lansky (1991) related shame to the loss or
impossibility of a meaningful bonding. Shame can be evoked both
by an actual rejection from others but also by inner charactero-
logical tendencies to distance, to detach from, to overreact to, or
to destroy relationships.
Unattainable and incompatible ego ideals are both major
causes of shame, and are also associated with suicide vulnerability.
The development of the self ideal is essential for self-esteem regu-
lation. Incoherent or incongruent deformations in the ego-ideal
system can make it impossible for the self to approximate what
is demanded. Awareness that the demands of the ego ideal, in its
own contradictory structure incapable of approximation by the
self, are beyond reach, may unleash self-critical attacks and self-
shaming, and spur the patient into suicide. In certain situations,
especially when aspirations are meant to repair or heal narcissistic
wounds, some patients may face conflicting ideals or be caught in
between incompatible self-demands and expectations (Morrison
1989, 1994, 2005; Orbach et al. 1998). The subjective experience of
helplessness that aroused in such circumstances invites narcissistic
collapse and suicidal acting out.
Deficient capacity for mentalization
Mentalization, according to Fonagy (1999), refers to the ability to
understand behaviours, thoughts, and feelings about oneself and
others in terms of intentions and wishes. He suggested that the
capacity for metacognitive control, reflective self-functioning and
mentalization that can help protect against narcissistic injury has
not developed in suicidal narcissistic patients. They are unable to
think and reflect beyond immediate experience, and unable to use
aggression as a protective shield against overwhelming thoughts
and feelings. Furthermore, capacity to reflect and understand the
consequences of aggressive and self-destructive actions is impaired.
Fonagy (1993) noted that a boy’s self-sabotaging behaviour could
be deadly; ‘his primitive reflective self did not see the death of his
body as leading to the death of his mental self’ (1993, p. 481).
Psychoanalytic family approaches
Sharp increases in the suicide rate of adolescents occurred in the
United States during the 1980s, alarming the general public as
CHAPTER 24 psychoanalytic theroies of suicide 153
well as the mental health community. Pfeffer (1981) theorized
that parents in conflict may project responsibility for their troubles
onto their child, who identifies with a sense of badness and lack
of resolution of the parental conflict. Suicide in such children
represents an attempt to resolve the conflict and to avoid feelings
of badness. Sabbath (1969) described families that suggest to a child
that he is unwanted; suicide may then occur because it seems to the
scapegoated child that this is what the parents want. Richman (1978,
1980) described weak boundaries, enmeshment, and conflictual
messages around independence in families of suicidal adolescents.
These families encourage independence but invite symbiotic cling-
ing at the same time. Suicide in such circumstances reflects strivings
to symbiosis and flight from it at the same time.
Further description of family dynamics of suicidal children and
adolescents were provided by Fischman (1988) who related suicide
attempts to extremely polarized, distant relationships coupled with
enmeshment with the parents, giving rise to a sense of confusion;
‘ideal families’ which prohibit expression of weakness and, thus,
generate feelings of shame and a counterdependent attitude; and
emotionally distant families that generate a sense of rejection.
Other hypotheses
Orgel (1974) suggested that identification with the victim role
paves the way to suicide. Such identification can function as a way
of consolidating an identity, a way of maintaining idealization of
the object. It can also be an instance of identification with both
the aggressor and the victim, as well as a manifestation of fear of
and avoidance of retaliatory impulses. Singer (1977) observed
that suicide attempts in borderline and narcissistic patients help
preserve sense of self and help to avoid experiences of emptiness
and deadness. Litman (1970) described suicidal states in terms of
acting out of an autonomous ego state that encompasses suicidal
potential: preoccupation with suicide, planning, integrative func-
tion of suicide, emotional regulatory function of suicide, as well
as contribution of fantasies, wishes, memories, and identification
with this ego state. Campbell (1995) emphasized the protective
effect to identification with a good father—this strengthens real-
ity testing and protects patients from primitive regressive pulls
toward fusion with the primitive mother imago of early childhood.
Suicide, according to Campbell, often represents for the patients
a longing to sleep forever in the arms of the primal mother.
Empirical support for theoretical positions
Most psychoanalytic clinical concepts are difficult to operationalize.
Nevertheless, several of the basic assumptions of these formulations
have been subjected to empirical testing. Below we review a number
of studies which confirm that certain emotional phenomena are
indeed implicated in suicide.
Anger
Reports that anger is associated with increased suicide risk cross-
sectionally (Horesh et al. 1997), but not longitudinally (Goldney et al.
1997), suggest such feelings are a specific characteristic of the suicidal
state rather than of the personality of the suicidal individuals.
Anger turned against oneself
Recklitis and colleagues (1992) found that suicide attempters had
a significant increase in use of the defence mechanism of turning
154 PART 3 theories of suicidal behaviour

against the self, as compared to suicide ideators or non-suicidal Identity confusion

patients. Increased self-directed anger was noted among suicide
attempters (Kaslow et al. 2000) as well as among people with-
suicidal ideation (Mihura et al. 2003). Rutstein and Goldberger
(1973) noted that subliminal stimulation of aggressive impulses
(e.g. exposure to such message as ‘destroy mother’) increased
levels of depression among suicidal subjects, whereas among non-
suicidal subjects the same message increased outwardly directed
aggression, as measured by self-report questionnaire of depression
and the Rorschach test.
Shame
The association between suicidal tendencies and shame was con-
firmed by Lester (1998) in suicide ideators and Hendin et al. (2001)
in suicide completers, but more definitive studies are needed.
Defence mechanisms
According to psychoanalytic theory suicidal people overly rely
on certain defence mechanisms and patterns (such as denial,
projection), and minimize sublimation. These occur parallel to
self-break-up (Maltsberger 2004). Repression and internalization,
i.e, accompaniments to internalization of aggression and of bad
objects (Klein 1935); and compensation, i.e, reflecting attempted
repair of ego vulnerability (Smith 1985), have been empirically
shown to correlate with suicidal states (see Table 24.2).
Friable self-representation
Six studies confirmed the below mentioned pathologically flawed
self-representation in suicidal patients.
Dingman and McGlashan (1986) found that a major proportion of
patients who attempted suicide had identity confusion at the time
of admission to Chestnut Lodge Hospital. Identity confusion also
prospectively predicted suicide attempts and threats in patients
diagnosed with borderline personality disorder (Yen et al. 2004).
When compared to non-suicidal adolescents, those adolescents
who attempted suicide had a more confused identity defined by the
following parameters: stability, continuity, meaningfulness, social
recognition, commitment, and sense of resilience (Bar-Joseph and
Tzuriel 1990).
Incongruent self-representations
Orbach et al. (1998) compared self-representations in suicidal and
non-suicidal inpatients including real self (i.e, actual self repre-
sentation of the person), ideal self (i.e, representation of whom
the person wants to be), and ought self (i.e, representation of
whom the person thinks he or she ought to or should be). Suicidal
adolescents had a larger gap between the ideal and the ought to
be self-representation, indicating a larger confusion between goals
and standards of the self.
Increased self-focus
Stirman and Pennebaker (2001) observed increased use of the first
person pronoun ‘I’ in literary works of poets who committed sui-
cide as compared to poets who lived during the same time period
with similar education and country.
Self disintegration
Use of the word ‘whirling’ and similar words (that might indicate
propensity for self-disintegration) in Rorschach protocols predicted

Table 24.2 Defence mechanisms in suicide attempters

Defence mechanism Study
Apter et al. (1989) Pfeffer et al. (1995) Apter et al. (1997) Study 1 Apter et al. (1997) Study 2 Corruble et al. (2004)
Regression ↑ ↑ ↑ ↑
Displacement ↑ ↑↑
Repression ↑↑ ↑ ↑
Projection ↑ ↑ ↑
Compensation ↑ ↑↑
Undoing
Intellectualization
Sublimation ↓
Reaction formation ↑
Denial ↓ ↑ ↑
Introjection ↑↑
Autistic fantasy ↑
Passive aggression ↑
Acting out ↑
Defence Mechanisms
Measure Lifestyle Index Ego Defence Scales Ego Defence scales Lifestyle Index Defence Style
Questionnaire
Suicide attempts sample 30 25 55 55 60
size
↑, increased use; ↑↑, increased use that is specific to the suicide attempters group; ↓, decreased use.

suicide among medical students over the period of 20–35 years
(Thomas and Duszynski 1985).
Self and object confusion
The presence of confusion between the self and others, described
by several authors (Roth and Blatt 1974; Maltsberger 1993), was
supported by studies that used Rorschach measures of boundary
confusion (Rydin et al. 1990, Fowler et al. 2001; Blatt and Ritzler
1974; Rierdan et al. 1978; Hansell et al. 1988).
Object relations
Suicide attempters tend to have more primitive object relations,
i.e, less complex object representations, more negative affect tone
associated with object relations, and less complex understanding
of social causality (Kaslow et al. 2000). Predominance of projec-
tive identification and repetition of rejecting relationships were
specifically confirmed by Kullgren (1988), who noted that suicidal
people tend to evoke more negative responses from others which
increase risk for suicide. Lower level of separation–individuation
was confirmed by Kaslow et al. (2000).
Body experience
A series of studies by Orbach and colleagues showed suicide
attempters have negative body perceptions. Depressed suicidal
people had significantly increased negative attitudes toward
their bodies when compared to both depressed non-suicidal and
normal subjects. Suicidal people also showed a significantly higher
discrepancy between the ideal perception of the body and the actual
one (Orbach et al. 1995a). These findings also applied to suicidal
patients diagnosed with schizophrenia and personality disorders
(Orbach et al. 1997; see also Orbach et al. 1996a, b). Suicidal indi-
viduals manifested decreased investment in their body as indicated
by negative feelings and attitudes toward the body, negative body
images, decreased body care, less body protection, and less experi-
ences of comfort when touched physically (Orbach and Mikulincer
1998). With regard to body perception, suicide attempters revealed
more negative attitudes and feelings about their bodies, lower body
protection and sense of control over the body, and more aberrant
body perception (Orbach et al. 2001). Sheffer (2001) also found
that suicide attempters demonstrated lower touch sensitivity,
more negative experience of touch, and a higher tendency to avoid
touch. All these studies indicate a close association between suicidal
tendencies and negative body perception.
Dissociation
A number of studies demonstrated that suicidal people, including
those diagnosed with schizophrenia and personality disorders,
utilize dissociation to a higher degree than non-suicidal people
(Orbach et al. 1995b, 1996a, 1997; Orbach 1997). More specifically,
suicidal tendencies were closely connected with dissociative ten-
dencies (Orbach et al. 1995b). Suicidal people displayed more
affective dissociation (feeling of changes in affective life), and more
control dissociation (feeling of changes in control) (Orbach et al.
1995b). This relation between dissociation and suicidal tendencies
has been further supported in other studies (Ensink 1992; Herman
et al. 1989; Orbach et al. 1996b; Sheffer 2001).
Death perception
The perception that death is desirable was correlated with suicide
tendencies and suicide attempts in several studies (Orbach et al.
CHAPTER 24 psychoanalytic theroies of suicide 155
1983, 1984, 1985, 1991, 1993, 1995a, 1997, 2001; Guttierrez et al.
1996; Osman et al. 1994). Gothelf et al. (1998) reported higher pre-
occupation with death in suicidal patients. Suicidal children tend
to attribute living qualities to the dead (Orbach and Glaubman
1979) and refer to life after death and resurrection (Orbach and
Glaubman 1978). Neuringer (1968) observed an increase in nega-
tive perception of death during the recovery from a suicide attempt,
suggesting that the death perception in suicide attempters is state
dependent.
Deficient reality testing and thought disorder
Studies confirmed deficient reality testing (Plutchik et al. 1995)
and increased unusual thinking (Mendonca and Holden 1996) in
otherwise non-psychotic suicide attempters. This is consistent with
clinical formulations of suicidal states (Maltsberger 1999, 2004;
Laufer 1995) describing transient psychotic phenomena contribut-
ing to suicidality.
Ego vulnerability
Smith and Eyman (1985) developed a detailed Rorschach manual
that operationalized the four areas of ego vulnerability (Smith
1985) mentioned above. They noted that serious suicide attempters
had either over controlled or lively aggressive fantasies, high expec-
tations of themselves, conflict around passivity and dependency,
and ambivalent attitudes toward death. Male serious attempters
showed more conflicts related to dependency and passivity while
female serious suicide attempters manifested affective over control
only. It seems that ego vulnerability is useful for prediction of sui-
cide in males.
Family approaches
The ‘expendable child’ hypothesis (Sabbath 1969) was confirmed
in a study by Woznica and Shapiro (1990). Suicidal adolescents
experience themselves as burdens, unwanted, not essential, not
valued, yet responsible for the problems of others. Observations
by Richman (1978, 1980) of controlling and symbiotic relation-
ships in the families of suicidal adolescents were further verified by
Kaplan and Maldaver (1993).
Masochism and self-defeating behaviours
Weinberg (2005) confirmed that increased self-defeating
processes in suicidal people, including guilt, rejection provocation,
and intolerance of ambiguity, contribute to suicidal tendencies.
Critique of the existing research
Methodological difficulties in many studies attempting to validate
psychoanalytic constructs, or parts of them, cast shadows over much
of the research to this date. Some of the problems are as follows.
Measurement difficulties
Many psychoanalytic constructs are difficult to measure in a valid
fashion. Most of the studies mentioned above relied on self-report
measures or on various projective indices of the constructs. We
think that use of validated experimental measures of the constructs
will increase validity of the results and enrich the field.
Sampling ambiguities
The distinction between suicide ideators (probands who entertain
ideas of committing suicide), suicide attempters, and successful
156 PART 3 theories of suicidal behaviour
completers is often blurred in the research. Each of these classes
of patients differ from each other in a variety of ways, not the least
in the potential or actual lethality that mark them. When patients
from these groups are conflated together, research results are mud-
died. Though the patients are alike in many respects, they differ
from each other in important ways. Some studies do not distinguish
between the categories making extrapolation from one subgroup
to another problematic. Our ability to confirm psychoanalytic
formulations for suicidal attempters and completers in studies
based on samples of suicide ideators is therefore problematical.
Flawed research designs
Most studies reviewed used cross-sectional designs. Consequently,
the predictive validity of the reported characteristics found in the
suicidal individuals is unclear. This fact limits the clinical relevance
of the findings.
Control for other variables
Most studies did not control for confounding variables such as
psychiatric diagnosis.
Several aspects of suicide still remain unknown or sparsely
investigated. Those include: suicide subtypes (e.g. superego
conflict vs narcissistic rage vs shame); self-experience (Reiser 1992);
development and validation of measures of relevant constructs
(e.g. ‘life-dream’, over-reliance on external sustaining resources,
emptiness); and studies of people’s experience during suicidal
states as compared to non-suicidal states. Such follow-up studies
would inform about and differentiate state-dependent and char-
acterologically related characteristics of suicide attempters.
Conclusions
Although suicide for a long time remained relatively unexplored
in psychoanalytic studies, several theoretical trends are now
discernable. The emphasis on the role of the attacking as opposed
to the protective superego, and the economy of the libido,
suggests that depression plays a central role in suicidal states.
This stand has gradually been complemented by the increasing
awareness of the role of narcissism. Narcissistic rage and nar-
cissistic vulnerability in suicide vulnerable persons are now at
the centre of attention. Integration of self-psychological theory
with observations of self-disintegration, shame and deformity in
egoideal development suggest several possible avenues that lead
to both acute suicidal collapse and chronic suicidality. Despite
the challenges involved in the empirical measuring and validating
of psychoanalytic constructs, a substantial number of empirical
studies do verify several of the central assumptions and constructs
such as dissociation, ego vulnerability, primitive object relations
and deficient self-representations in driving suicide.
References
Apter A, Gothelf D, Offer R et al. (1997). Suicidal adolescents and ego
defence mechanisms. Journal of American Academy of Child and
Adolescent Psychiatry, 36, 1520–1527.
Apter A, Plutchik R, Sevy S et al. (1989). Defence mechanisms in risk of
suicide and risk of violence. American Journal of Psychiatry,
146, 1027–1031.
Bar-Joseph H and Tzuriel D (1991). Suicidal tendencies and ego identity in
adolescence. Adolescence, 25, 215–223.
Bibring E (1953) The mechanism of depression. In P Greenacre, ed.,
Affective Disorders, pp. 13–48. New York Universities Press, New York.
Blatt SJ and Ritzler BA (1974). Suicide and the representation of
transparency cross-sections on the Rorschach. Journal of Consulting
and Clinical Psychology, 42, 280–287.
Broucek, F. (1982). Shame and its relationship to early narcissistic
developments. International Journal of Psycho-Analysis, 63, 369–378.
Buie D and Maltsberger JT (1989). The psychological vulnerability to
suicide. In D Jacobs and HN Brown, eds, Suicide, Understanding and
Responding, pp. 59–72. International Universities Press, Madison.
Campbell D (1995). The role of the father in a pre-suicide state.
International Journal of Psychoanalysis, 76, 315–323.
Corruble E, Bronnec M, Falissard B et al. (2004). Defence styles in
depressed suicide attempters. Psychiatry and Clinical Neuroscience,
58, 285–288.
Dingman CW and McGlashan TH (1986). Discriminating characteristics
of suicides. Chestnut Lodge follow-up sample including patients with
affective disorder, schizophrenia and schizoaffective disorder. Acta
Psychiatrica Scandinavica, 74, 91–9.
Ensink BJ (1992). Confusing Realities: A Study on Childhood Sexual Abuse
and Psychiatric Syndromes. VU University Press, Amsterdam.
Etzersdorfer E (2001). The psychoanalytical positions on suicidality in
German-speaking regions. Paper presented at the International
Congress on Suicidality and Psychoanalysis, Hamburg, Germany, 2001.
Fishman HC (1988). Treating Troubled Adolescents: A Family Therapy
Approach. Basic Books, New York.
Fonagy P (1999) Attachment, the development of the self and its pathology
in personality disorders. In J Derksen, C Maffei and H Groen, eds,
Treatment of Personality Disorders, pp. 53–68. Kluwer Academic/
Plenum Publisher, New York.
Fonagy P. (1993) Aggression and the psychological self. International
Journal of Psychoanalysis, 74, 471–485.
Fowler JC, Hilsenroth MJ, Piers C (2001). An empirical study of seriously
disturbed suicidal patients. Journal of the American Psychoanalytic
Association, 49, 161–186.
Freud S (1917). Mourning and melancholia. In J Strachey (ed. and trans.),
The Standard Edition of the Complete Psychological Works of Sigmund
Freud, Vol. 10. Hogarth Press, London.
Freud S (1923). The ego and the id. In J Strachey (ed. and trans.), The
Standard Edition of the Complete Psychological Works of Sigmund Freud,
Vol. 19. Hogarth Press, London.
Friedman P ed. (1967) On Suicide, with Particular Reference to Suicide
Among Young Students. International Universities Press, New York.
Gabbard GO (2003). Miscarriages of psychoanalytic treatment with suicidal
patients. International Journal of Psychoanalysis, 84, 249–261.
Goldney R, Winefield A, Saebel J et al. (1997). Anger, suicidal ideation,
and attempted suicide: a prospective study. Comprehensive Psychiatry,
38, 264–268.
Hansell AG, Lerner HD, Milden RS et al. (1988). Single-sign Rorschach
suicide indicators: a validity study using a depressed inpatient
population. Journal of Personality Assessment, 52, 658–669.
Hendin H, Maltsberger JT, Lipschitz A et al. (2001). Recognizing and
responding to a suicide crisis. Suicide and Life-Threatening Behaviors,
31, 115–128.
Henseler H (1974) Narzisstische Krisen. Zur Psychodynamik des
Selbstmordes. Westdeutcher Verlag, Opladen, Germany.
Henseler H (1981). Psychoanalytische Theorien zur Suizidalitaet. In
H Henseler and C Reimer, eds, Selbstmordgefardung. Zur Psychodynamik
and Psychotherapie, pp. 113–135. Frommann-Holzboog, Stuttgart.
Herman JL, Perry JC, van der Kolk BA (1989). Childhood origins of self-
destructive behavior. American Journal of Psychiatry, 146, 490–495.
Horesh N, Rolnick T, Iancu I et al. (1997). Anger, impulsivity and suicide
risk. Psychotherapy and Psychosomatics, 66, 92–96.
Housman AE (1936) XXVI in More Poems. Reprinted in The Collected
Poems of A. E. Housman, p. 185. Henry Holt and Co, New York.
Kaplan KJ and Maldaver M (1993). Parental marital style and completed
adolescent suicide. Omega, 2, 131–154.

Kaslow NJ, Reviere SL, Chance SE et al. (2000). An empirical study of the
psychodynamics of suicide. Journal of the American Psychoanalytic
Association, 46, 777–795.
Kernberg OF (1984). Severe Personality Disorders. Yale University Press,
New Haven.
Kernberg OF (1992). Aggressions in Personality Disorders and Perversions.
Yale University Press, New Haven.
Kernberg O (1998). Pathological narcissism and narcissistic personality
disorder: theoretical background and diagnostic classification.
In EF Ronningstam, ed., Disorders of Narcissism: Diagnostic, Clinical
and Empirical Implications, pp. 29–51.0 American Psychiatric Press
Inc., Washington.
Kernberg OF (2001) The suicidal risk in severe personality disorders:
differential diagnosis and treatment. Journal of Personality Disorder,
15, 195–208.
Klein M (1935). A contribution to the pathogenesis of manic-depressive
states. In M Klein, Love Guilt, and Reparation, pp. 262–305. Virago
Press Ltd, London.
Klein M (1946). Notes on some schizoid mechanisms. International
Journal of Psychoanalysis, 27, 99–110.
Klein M (1957). Envy and Gratitude. Basic Books, New York.
Kohut H (1971). The Analysis of the Self. International Universities Press,
New York.
Kohut H (1972). Thoughts on narcissism and narcissistic rage.
The Psychoanalytic Study of the Child, 27, 360–400.
Kullgren G (1988). Factors associated with completed suicide in
borderline personality disorder. Journal of Nervous and Mental
Disease, 176, 40–44.
Lansky M (1991). Shame and the problem of suicide: a family systems
perspective. British Journal of Psychotherapy, 7, 230–242.
Laufer M ed. (1995). The Suicidal Adolescent. Karnac Books, London.
Lester D (1998). The association of shame and guilt with suicidality.
Journal of Social Psychology, 138, 535–536.
Lewin BD (1950). The Psychoanalysis of Elation. W. W. Norton
and Co, New York.
Lewin RA (1992). On chronic suicidality. Psychiatry, 55, 16–27.
Lewin RA and Shultz C (1992). Losing and Fusing. Aronson, New York.
Litman RE (1970). Suicide as acting out. In ES Shneidman, NL Farberow
and RE Litman, eds, The Psychology of Suicide, pp. 293–304. Jason
Aronson Inc., New York.
Maltsberger J.T. (1986). Suicide Risk: The Formulation of Clinical Judgment.
New York, New York University Press.
Maltsberger JT (1993). Confusion of the body, the self and others in suicidal
states. In A Leenaars, ed., Suicidology: Essays in Honor of Edwin S.
Shneidman, pp. 148–171. Jason Aronson Inc., Northvale.
Maltsberger JT (1997) Ecstatic suicide. Archives of Suicide Research, 3,
283–301.
Maltsberger JT (1998). Pathological narcissism and self-regulatory processes
in suicidal states. In E Ronningstam, ed., Disorders of Narcissism—
Diagnostic, Clinical and Empirical Implications, pp. 327–344. American
Psychiatric Press, Washington.
Maltsberger JT (1999). The psychodynamic understanding of suicide.
In DL Jacobs, ed., The Harvard Medical School Guide to Suicide
Assessment and Intervention, pp. 72–82. Jossey-Bass, Inc., San Francisco.
Maltsberger JT (2004).The descent into suicide. International Journal of
Psychoanalysis, 85, 653–668.
Maltsberger JT (August 2001). Psychoanalytic Studies of Suicide in English.
Presented at the First International Congress on Suicidality and
Psychoanalysis, Hamburg Germany.
Maltsberger JT and Buie DH Jr (1980). The devices of suicide: revenge,
riddance, and rebirth. International Review of Psychoanalysis, 7, 61–72.
Mendonca JD and Holden RR (1996). Are all suicidal ideas closely linked to
hopelessness? Acta Psychiatrica Scandinavica, 93, 246–251.
Menninger K (1938). Man Against Himself. Harcourt, Brace and Company,
New York.
CHAPTER 24 psychoanalytic theroies of suicide 157
Mihura JL, Nathan-Montano E, Alperin R (2003). Rorschach measures
of aggressive drive derivatives: a college student sample. Journal of
Personality Assessment, 80, 41–49.
Miller A (1979). Prisoners of Childhood. Basic Books, New York.
Morrison AP (2005). On ideals and idealization. Paper presented at the
American Psychoanalytic Association Winter meeting, New York,
January 2005.
Morrison AP (1989). Shame, the Underside of Narcissism. The Analytic
Press, Hillsdale.
Morrison AP (1994). Breadth and boundaries of a self-psychological
immersion in shame. A one-and-a-half-person perspective.
Psychoanalytic Dialogues, 4(1), 19–35.
Neuringer C (1968). Divergencies between attitudes towards life and death
among suicidal, psychosomatic, and normal hospitalized patients.
Journal of Consulting and Clinical Psychology, 32, 59–63.
Orbach I (1997). A taxonomy of factors related to suicidal behavior. Clinical
Psychology: Science and Practice, 4, 208–224.
Orbach I and Glaubman H (1978). Suicidal, aggressive, and normal
children’s perception of personal and impersonal death. Journal of
Clinical Psychology, 34, 850–856.
Orbach I and Glaubman H (1979). Children’s perception of death as a
defensive process. Journal of Abnormal Psychology, 88, 671–674.
Orbach I and Mikulincer M (1998). The body investment scale:
construction and validation of a body experience scale. Psychological
Assessment, 4, 415–425.
Orbach I, Carlson G, Feshbach S et al. (1984). Attitudes toward life and
death in suicidal, normal, and chronically ill children: an
extended replication. Journal of Consulting and Clinical Psychology,
52, 1020–1027.
Orbach I, Feshbach S, Carlson G et al. (1983). Attraction and repulsion
by life and death in suicidal and in normal children. Journal of
Consulting and Clinical Psychology, 51, 661–670.
Orbach I, Gross Y, Glaubman H et al. (1985). Children’s perception of
death in humans and animals as a function of age, anxiety
and cognitive ability. Journal of Child Psychology and Psychiatry,
26, 453–463.
Orbach I, Kedem P, Gorchover O et al. (1993). Fears of death in suicidal
and nonsuicidal adolescents. Journal of Abnormal Psychology,
102, 553–558.
Orbach I, Kedem P, Herman L et al. (1995b). Dissociative tendencies in
suicidal, depressed, and normal adolescents. Journal of Social and
Clinical Psychology, 14, 393–408.
Orbach I, Lotem-Peleg M, Kedem P (1995a). Attitude toward the body
in suicidal, depressed, and normal adolescents. Suicide and Life
Threatening Behavior, 25, 211–221.
Orbach I, Mikulincer M, Cohen D et al. (1997). Thresholds and tolerance
of physical pain in suicidal and non-suicidal adolescents. Journal of
Consulting and Clinical Psychology, 65, 646–652.
Orbach I, Mikulincer M, Stein D et al. (1998). Self-representation of
suicidal adolescents. Journal of Abnormal Psychology, 107, 435–439.
Orbach I, Milstein I, Har-Even D et al. (1991). A multi-attitude suicide
tendency scale for adolescents. Psychological Assessment, 3, 398–404.
Orbach I, Palgi Y, Stein D et al. (1996a). Tolerance of physical pain in
suicidal individuals. Death Studies, 20, 327–340.
Orbach I, Stein D, Palgi Y et al. (1996b). Perception of physical pain in
accident and suicide attempt patients: self-preservation vs.
self-destruction. Journal of Psychiatric Research, 30, 307–320.
Orbach I, Stein D, Shani-Sela M et al. (2001). Body attitudes and body
experiences in suicidal adolescents. Suicide and Life-Threatening
Behavior, 31, 237–249.
Orgel S (1974). Fusion with the victim and suicide. International Journal
of Psychoanalysis, 55, 531–541.
Osman A, Barrios FX, Panak WF et al. (1994). Validation of the
Multi-Attitude Suicide Tendency scale in adolescent samples.
Journal of Clinical Psychology, 50, 847–855.
 158 PART 3 theories of suicidal behaviour
Pfeffer CM, Hurt SW, Peskin JR et al. (1995). Suicidal children grow up:
ego functions associated with suicide attempts. Journal of American
Academy of Child and Adolescent Psychiatry, 34, 1318–1325.
Pfeffer RC (1981). Suicidal behavior in children: a review with implications
for research and practice. American Journal of Psychiatry, 138, 154–159.
Piven J (2001) Phallic narcissism, anal sadism, and oral discord: the case of
Yukio Mishima, Part I. Psychoanal Rev, 88(6), 771–791.
Plath S (1992) The Collected Poems. T Hughes, ed. Harper Perennial, New
York.
Plutchik R, Botsis AJ, van Praag HM (1995). Psychopathology, self-esteem,
sexual and ego functions as correlates of suicide and violence risk.
Archives of Suicide Research, 1, 27–38.
Recklitis CJ, Noam GG, Borst SR (1992). Adolescent suicide and defensive
style. Suicide and Life-Threatening Behavior, 22, 375–387.
Reiser E (1992). Self psychology and the problem of suicide. In A Goldberg,
ed., Progress in Self Psychology, Vol. 2, pp. 227–241. Guilford Press,
New York.
Richman J (1978). Symbiosis, empathy, suicidal behavior, and the family.
Suicide and Life-Threatening Behavior, 3, 139–149.
Richman J (1980). Suicide and infantile fixations. Suicide and Life-
Threatening Behavior, 10, 3–9.
Rierdan J, Lang E, Eddy S (1978). Suicide and transparency responses
on the Rorschach: a replication. Journal of Consulting and Clinical
Psychology, 46, 1162–1163.
Ronningstam E and Maltsberger J (1998). Pathological narcissism and
sudden suicide-related collapse. Suicide and Life-Threatening Behavior,
28, 261–271.
Rosenfeld H (1971). A clinical approach to the psychoanalytic theory of the
life and death instincts: an investigation into the aggressive aspects of
narcissism. International Journal of Psycho-Analysis, 52, 169–178.
Roth D and Blatt SJ (1974). Spatial representations of transparency and the
suicide potential. International Journal of Psychoanalysis, 55, 287–293.
Rothstein A (1980). The Narcissistic Pursuit of Perfection. International
Universities Press, Inc., New York.
View publication stats
Rustein EH and Goldberger L (1973). The effect of aggressive stimulation
on suicidal patients: an experimental study of the psychoanalytic
theory of suicide. In EH Rubinstein, ed., Psychoanalysis and
Contemporary Sciences, Vol 2, pp. 157–174. Macmillan, New York.
Rydin E, Asberg M, Edman G et al. (1990). Violent and non-violent
suicide attempters—a controlled Rorschach study. Acta Psychiatrica
Scandinavica, 82, 30–39.
Sabbath JC (1969). The suicidal adolescent—the expendable child.
In JT Maltsberger and MJ Goldblatt, eds, Essential Papers on
Suicide, pp.. New York University Press, New York and London.
Sheffer A (2001). Touch experience in suicidal adolescences. Doctoral
dissertation, Psychology Department, Bar Ilan University, Israel.
Singer M (1977). The experience of emptiness in narcissistic and
borderline states: II the struggle for the sense of self and the potential
for suicide. International Review of Psychoanalysis, 4, 471–479.
Smith K (1985). Suicide assessment. Bulletin of the Menninger Clinic,
49, 489–499.
Smith K and Eyman J (1985). Ego structure and object differentiation in
suicidal patients. In H Lerner and P Lerner, eds, Primitive Mental
States, pp. 175–202. International Universities Press, Madison.
Stirman SW and Pennebaker JW (2001). Word use in the poetry of suicidal
and nonsuicidal poets. Psychosomatic Medicine, 63, 517–522.
Thomas CB and Duszynski KR (1985). Are words of the Rorschach
predictors of disease and death? A case of ‘whirling’. Psychosomatic
Medicine, 47, 201–211.
Weinberg I (2005). Self-defeating behaviors and suicide: mechanisms,
their classification and consequences. Doctoral Dissertation, Bar Ilan
University, Israel.
Woznica JG and Shapiro JR (1990). An analysis of adolescent suicide
attempts: the expendable child. Journal of Pediatric Psychology,
6, 789–796.
Yen S, Shea MT, Sanislow CA et al. (2004). Borderline personality disorder
criteria associated with prospectively observed suicidal behavior.
American Journal of Psychiatry, 161, 1296–1298.