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Descent into Despair: Suicide Dynamics

M. Sagman Kayatekin, MD

Suicidal patients present frightening challenges for clinicians, and many of us have or will experience the devastating loss of a patient or family member to suicide at some time in our lives. Our knowledge about suicidal risk and dynamics was greatly abetted by John Terry Maltsberger, who was both a psychoanalyst and suicidologist who spent his professional lifetime studying suicidal patients. He asserted that suicidal breakdown involves a superego attack on the self and an ego regression. He designated four associated aspects of ego disintegration: affective flooding, desperate maneuvering to counter the mental emergency, loss of self, and grandiose mental scheming for psychic survival. The recent article by Emeric Bojarski and Zheala Qayyum discussed the suicidal dynamics specific to LGBT youth, who show much higher rates of suicide than other populations. Jane Tillman, who works at Austen Riggs Center and also researches and writes extensively about suicide, suggested several dynamics involved in the intergenerational transmission of suicide. Based on the case of writer Walker Percy and his family history of suicides, Tillman suggested the role of moral injury and the mysterious object. According to author James Hamilton, a patient’s suicide might have contributed to Freud’s formulation of the death instinct. Freud generally was considered insensitive and blaming with regard to patients’ suicides and other treatment failures.

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