Dogs that do not bark: ostracism, psychache and suicidality

The Way Out, or Suicidal Ideation: George Grie...

The Way Out, or Suicidal Ideation: George Grie, 2007. (Photo credit: Wikipedia)

1 boring old man referenced this historical and alarming analysis on the evolution of melancholia to major depressive disorder.  Science?  Evidence?  Fuggediboudit.

MDD, the most influential diagnosis of the past 30 years, emerged from intraprofessional pressures and the ability of research-oriented psychiatrists to gain dominance within the profession. Most importantly, psychiatry needed a credible classificatory scheme to maintain its legitimacy in both the broader medical profession and the culture at large. As prominent depression specialist Gerald Klerman (1984:539) succinctly summarized: “The decision of the APA first to develop DSM-III and then to promulgate its use represents a significant reaffirmation on the part of American psychiatry to its medical identity and to its commitment to scientific medicine.” Medical legitimacy required easily measurable and reliable diagnoses. The diagnostic criteria grounded in the Feighner measure that emerged in the DSM-III to resolve the many unsettled diagnostic controversies—and that have remained mostly unchanged until the present—did produce a far more reliable system of measurement than the amorphous criteria they replaced. Yet, this particular diagnostic system was not tested against the many alternative classifications that were available during the 1970s that might have been as good or even superior to the Feighner criteria. Instead, their adoption resulted from the shared commitment to a view of psychiatric diagnoses and the path that the psychiatric profession should follow among the research-oriented psychiatrists who controlled the development of the DSM-III classifications.

The developers of the MDD diagnosis did not foresee the profound consequences it would have. They inadvertently developed criteria that encompassed what had previously been viewed as a number of distinct types of depressive conditions. Endogenous, exogenous, and neurotic forms of depression could all meet the expansive criteria of the MDD diagnosis. Moreover, because it could incorporate short-lived responses to stressful conditions, MDD was the most suitable label for many of the heterogeneous and diffuse complaints that many primary medical care patients present. Likewise, depression became the most prevalent form of mental illness measured in epidemiological studies because so many community members suffer from common symptoms such as sadness, sleep and appetite difficulties, and fatigue that need only last for a two-week period to be considered disordered (Kessler et al. 2005). The sweeping qualities of the diagnosis also made it the most attractive target for the vastly popular SSRI medications that came on the market a few years after the publication of the DSM-III. Primarily through pharmaceutical advertisements, ubiquitous messages associated the most common forms of distress with major depression. This condition became psychiatry’s most marketable diagnosis, driving mental health treatment, research, and policy. Ultimately, the Age of Depression that has engulfed the United States and much of the Western world since 1980 resulted from relatively esoteric changes in diagnostic criteria.

It’s all about c.v. building by a chief resident of a backwater psychiatry program.

Then there’s this – relational ostracism – an unwanted enforced state of thwarted belonging.  It can take many forms, and its effects are severe, persistent and devastating.

The impact of stranger-ostracism is strong and painful,and has been shown to lead to aversive psychological responses (i.e., a threat to four primary human needs—belonging, control, self-esteem, and meaningful existence; see Williams, 2001), and a rangeof detrimental behavioral responses such as social susceptibility (e.g., Maner, et al., Carter-Sowell & Williams, 2007), inappropriate mate choice (e.g., Winten et al., 2006), risk-taking behavior (e.g. Daleet al., 2006), and anti-social behavior (e.g., Warburton, Williams, & Cairns, 2006).Despite the prevalence of ostracism in interpersonal relationships, ostracism research to date has not systematically investigated relational ostracism (i.e., the silent treatment, or ostracism carried out by one partner on another).

What’s missing in both of the above?  Their relationship to suicidality and psychache.

There is such a dearth of literature about ostracism – and virtually none about clinical intervention, treatment and support for people who are targets – that it isn’t surprising to find it absent.

But Kipling Williams, Thomas Joiner and C Fred Alford’s work can form a pillar by which to build a clinical and research model to aggressively address unbearable psychache, develop strategies (which may include public health and social justice policy and programming) to minimize and remove ostracism in all of its ugly forms, and to reformulate how suicidality is assessed and addressed.

The highest priority items for me would be to deep six “suicide assessment” in favor of distressors as described by Joiner’s three domains of perceived burdensomeness, thwarted belongingness and the capacity/rehearsal to tolerate self-inflicted death.

The second is to couple all assessment with immediate and adequate distress reduction which does not entail threats of or actual involuntary confinement, intrusive observation, forced medication, any type of restraint or anything other than active multi-sensory comfort, safety and mutually deemed appropriate and acceptable interventions, resources and supports.

One more thing that is never addressed in relation to psychache:  the extraordinary amount of physical and psychological energy toll it takes.  The relational ostracism study illustrates that for many, being a target is permanent as long as the “source” is present.

When one is powerless to escape ostracism, has no ability to affect a preferred future, and is effectively trapped, suicide becomes more salient as an alternative to put a permanent ending on an intolerable condition.

Here I discovered a study about people with severe/terminal illnesses who wish to hasten death – WTHD. Of course it doesn’t include people with psychiatric diagnoses (those people are nuts, donchaknow), but it fits right in with Joiner’s theory:

WTHD as a way of ending suffering

Among participants in the studies included, the WTHD also emerged as a way out, and in some cases [45][69] as the only way of ending their physical and psychological suffering. Death was not considered as an aim in itself, but rather as an escape. Indeed, the idea of putting an end to their life brought a sense of relief to some patients.

In the study by Schroepfer [71] the WTHD was regarded as a way out or as a means of relieving loneliness, fear, dependence, a lack of hope and the feeling that life was no longer enjoyable. The study by Nissim et al.[69] suggested that in the face of oppression and despair, death could be seen as the only alternative, with the WTHD being the essence of a plan to relieve suffering. Similarly, Lavery et al. [45] reported that the WTHD was seen by participants as a means of limiting disintegration and loss of self.

In five of the studies reviewed [14][46][69][70][71] the participants also described the WTHD as a way of reducing the suffering being caused to family and carers. Coyle and Sculco [14] interpret this as a gesture of altruism, since the WTHD is motivated by a desire to relieve the family of the burden of care and of witnessing their relative’s progressive deterioration. However, although the WTHD was driven by such a motive in some patients [71], in others (or simultaneously in the former patients) the desire to cause no more pain to their relatives led them to precisely the opposite conclusion, i.e. they repressed the WTHD. As such, their wish to protect their family took precedence over their own wish to hasten death [71].

And so we circle around to Alford’s “knowledge as disaster” concepts. See the About page for a listing.

Until the key elements of this circl(ing the drain) are interrupted permanently and predictably, suicidality will go on unabated, unaddressed and just as vicious.

The strangest part?  Psychiatry, with all of its disorders, doesn’t ever mention suicidality, psychache, thwarted belongingness, perceived burdensomeness and rehearsed capacity for self-inflicted death.

But suicide is on the Diagnosis and Statistical Manual of Mental Disorders (DSM5) radar – and of course, its proposed listing as suicide behavior disorder is nonsensical and is made up à la the Mad Hatter.

Controlling healthcare costs

Despite trying to engage in distractions and diversions during every waking moment and engaging in supposedly cognitive and memory stimulating reading (I can’t concentrate, can’t comprehend and can’t retain much info, so consider everything I write with a healthy dose of skepticism), I am increasingly experiencing noticeable memory lapses and episodes of confusion.  The memory lapses are annoying and disheartening.  The confusion is frightening.  Because no one was interested in learning about those problems and instantly dismissed them as “due to the depression”, I am left to my own devices to manage them. Enter Google.  There are self-assessment tools which purport to distinguish between dementia and depression in memory loss.  I tried them out and came away with a 100% alignment with depression.  However, these tools, and the physician feedback I received, conflated correlation with causation.  The real answer is that no one knows. After a winter of experiencing much more back and joint pain, the inability to self-plan and perform even a basic yoga practice, and a months long stretch of not leaving the bed except for bodily functions needs, I find myself so fatigued, dull, and slow that forcing myself to stay alert, attentive and mobile is a monumental task.  And really, since I do not have any obligations to work, socialize or contribute in any way, no one cares or is affected, which brings me a perverse sense of relief of not failing anyone.  When all of society yanks those away and sends you off to a life of dying and social death, this apparently is the benefit. (For all of you psychiatrists who found your “EBM” on that most medically scientific principle of false hope and optimism serving as a default component of “insight”, this is it for optimism and flexible thinking.  Insight I’ve got in spades.) I have struggled to attend scheduled volunteer activities.  But I think I am bringing a poor benefit/risk ratio to the organization.  I can’t perform much of the physical work, and sometimes I can’t remember the very simple instructions to carry it out. The people I’ve met are seriously smart, wise, witty, knowledgeable and committed to the goals and work.  The leaders lead well (coming from me, that’s the equivalent of the Nobel Peace Prize).  Two of these people are dealing with immediate end of life issues, and I try to be a reliable and comforting presence.  That, at least, I can offer and carry out. So back to self management.  I started looking around again for resources and strategies to try.  Because I root around in PubMed, am located in a city where a vast amount of clinical research is occurring, and have a sense of what I need in the way of outcomes, I called the HMO and asked to speak with the mental health case manager.  The marketing and sales people weren’t happy with that.  The person I spoke with was sullen and only after repeated requests and my refusal to give her clinical info was I transferred.  And I got the same woman who when I first called to find a psychologist with expertise in both PTSD/trauma and depression gave me four names where either the person was no longer in the plan or was outside my ability to travel. When I called to report this and ask for appropriate options, she became belligerant and defensive, and so I ended the call since I had already been through the provider list and discovered that there weren’t any at all who met the above criteria. This time, I asked her if she knew of any research or clinicians who dealt with ketamine for severe depression, or with rapid responses to severe depression.  She started in on the spiel that it wouldn’t be paid – it was experimental.  After a few minutes of this abuse – no referrals, no answer,  I told her I’d had enough and hung up. Ten minutes later the police were at my door.  Luckily, my computer screen was on and open to the complaint and disenrollment line, the coffee pot was full, and no weapons were    in sight (that last one is a joke).  The sergeant grilled me about what I had said that “would make her call”.  I explained about inquiring about the ketamine research.  I offered him the phone number to call the woman.  He couldn’t get past the telephony.  I had to sign a form declining emergency transport to the ED. The officers declined coffee, inquired as to the rent I pay for this attic dump, rolled their eyes at the response, and then changed the conversation to “we have to do our jobs.” I replied that experiencing public humiliation (lovely lights, multiple police cars and ambulance in the drive and street) and terror (nothing like having 5 uniformed and armed men on your doorstep banging on the door and demanding to be let in.  NOW.) was obviously what the HMO’s objective was, and they agreed. Which is just the latest experience which illustrates why I still have no health support, no trusting relationship with anyone, and no hope of finding same. What I ended up doing was perusing the research studies for chronic pain and finding several that are non-pharmacologic and low risk to enroll in. I was assigned to the treatment arm of two, and two more are simply looking at different biomarkers and immune responses.  I’m an easy stick, so I’m happy to donate a little serum to that cause.  However, one study requires a combo PET/MRI along with an arterial lineinsertion.  Having been on the managing end of those before as a critical care nurse, I think receiving one (they are uncomfortable at best) is a dose of my own former medicine. I wasn’t permitted to disenroll from the HMO.  The abusive case manager is still a “valued employee”, and I effectively have no health insurance, because there I will not provide any information to, use any provider affiliated with, or voluntarily use any aspect of that HMO’s products and services.  They really have the keeping costs controlled portion covered.  Abuse, terrify and threaten enrollees, collect their premiums and watch the profit margin soar. And the research compensation (for “subject “expenses”) will pay for dental and vision exams.  At least those don’t come with threats of imprisonment and assault and battery. (Optimism and hope, psychiatrists.)

Hurts So Bad

Illustration of the pain pathway in René Desca...

Image via Wikipedia

Social rejection, that is.

Current theorizing suggests that the brain systems that underlie social rejection developed by coopting brain circuits that support the affective component of physical pain (1, 2, 9). The current findings substantively extend these views by demonstrating that social rejection and physical pain are similar not only in that they are both distressing, they share a common representation in somatosensory brain systems as well.


Although the experience of social rejection is commonly accompanied by reports of various emotions (e.g., fear, sadness, anger, anxiety, and shame), it is generally assumed that these feelings cumulatively give rise to a unique experience of “social pain” (3537). The results of the meta-analyses we performed in this study, which indicated that fMRI studies of specific emotions rarely activate OP1 and dpINS, are consistent with this view.

Decision making ability goes down the tubes:

Researchers have known for a long time that there is a link between social exclusion and the failure of self-control. For instance, people who are rejected in social situations often respond by abusing alcohol, expressing aggression or performing poorly at school or work.


The new study, however, is the first to use MEG to show that there are actual changes inside the brain when test subjects are manipulated to feel socially excluded. MEG is an imaging technique that measures the magnetic fields produced by electrical activity in the brain.

Analogous to a trapped, wounded animal, no?  Except in this case, being trapped means being trapped in ongoing living with intentionally inflicted and unrelieved distress.

Here’s the linkage:

“Although it has long been suggested that mu-opioids play a role in social pain — and there are convincing animal models that show this — this is the first human study to link this mu-opioid receptor gene with social sensitivity in response to rejection,” Eisenberger said.

“These findings suggest that the feeling of being given the cold shoulder by a romantic interest or not being picked for a schoolyard game of basketball may arise from the same circuits that are quieted by morphine,” said Baldwin Way, a UCLA postdoctoral scholar and the lead author on the paper.

Eisenberger argues that this overlap in the neurobiology of physical and social pain makes good sense.

“Because social connection is so important, feeling literally hurt by not having social connections may be an adaptive way to make sure we keep them,” she said. “Over the course of evolution, the social attachment system, which ensures social connection, may have actually borrowed some of the mechanisms of the pain system to maintain social connections.”

Back to the usual: the interpersonal theory of suicidality.  The two conditions of thwarted belongingness and perceived burdensomness are met with social rejection that isn’t fully remediated. Baumeister explains that human attachment is a fundamental – essential for survival – need:

A hypothesized need to form and maintain strong, stable interpersonal relationships is evaluated in light of the empirical literature.  The need is for frequent, nonaversive interactions within an ongoing relational bond.  Consistent with the belongingness hypothesis, people form social attachments readily under most conditions and resist the dissolution of existing bonds.  Belongingness appears to have multiple and strong effects on emotional patterns and on cognitive processes.  Lack of attachments is linked to a variety of ill effects on health, adjustment, and well-being.  Other evidence, such as that concerning satiation, substitution, and behavioral consequences, is likewise consistent with the hypothesized motivation.  Several seeming counterexamples turned out not to disconfirm the hypothesis.  Existing evidence supports the hypothesis that the need to belong is a powerful, fundamental, and extremely pervasive motivation.


Suicide becomes the means to put a permanent end on an inflicted permanent unbearable degree of suffering – real physiologic and psychologic suffering.

Emotions and Social Behavior

Well, so much for keeping up with blogging.  An unexpected health insult, weeks of bedrest and sequelae of fatigue and brain fog haven’t done me any favors. But whatever, here’s a bit of catch up, even if presented through a dense fog….

Kipling Williams is one of the few researchers who is investigating ostracism.  I want to read his major opus, Ostracism: The Power of Silence, but will have to wait until I can do so in library residence, as it doesn’t circulate. (If you have a copy to lend or re-sell at a bargain, I’d be thrilled.)  The library has it catalogued under social isolation, and in a collection titled emotions and social behavior.

The latter label struck a chord, for what is suicidality but distress signaling (the emotion) which if unaddressed, leads to suicidal attempts (the social behavior)?

So when I start thinking more clearly again, I’ll try to put together some sort of framework for addressing the distress signaling:

  • alienation
  • burdensomeness (perceived)
  • demoralization
  • despair
  • grief (situational)
  • guilt
  • helplessness
  • hopelessness
  • ostracism (externally applied isolation)
  • pessimism
  • powerlessness
  • realism
  • self identity loss – externally removed (loss/denial of social roles)
  • self loathing
  • shame
  • social isolation (as opposed to voluntary avoidance and isolating behavior)
  • thwarted belongingness
  • worthlessness (perceived and externally applied)

To date, no one has studied people who have made suicide attempts or completed suicides to evaluate what behaviors they used to try to adapt to the distressors, what train of events (thoughts, feelings and behaviors) they experienced when the distress wasn’t adequately relieved, and what directly led to the suicidal ideation, the suicidal attempt, and the completed suicides. But at certainly needs must be done in order to treat suicidality upstream – preferably before the suicidality is entertained and certainly before it is acted upon.


This post is essentially an interim reference list. Demoralization is arguably the most important concept in suicidality that you’ve never heard of.

Demoralization and remoralization: a review of these constructs in the healthcare literature Margaret J Connor, Jo Ann Walton

Nursing Inquiry

Nursing Inquiry

Volume 18, Issue 1, pages 2–11, March 2011

The Social Separation Syndrome
Reprinted from Survival International Review Vol. 5, No. 1(29):13-15, 1980.
G. N. Appell
Brandeis University

Engel and his collaborators have been concerned with the related question: Why do people fall ill or die at the time they do? And they have identified a psychological pattern that appears associated with disease

onset that they call the Agiving up–given up complex@. Five characteristics are identified with this complex (Engel 1968): (1) the giving up affects, i.e. helplessness or hopelessness; (2) a depreciated image of the self; (3) a loss of gratification from relationships or roles in life; (4) a disruption of the sense of continuity between past, present, and future; and (5) a reactivation of memories of earlier periods of giving up.

Pubmed search for demoralization

The term demoralization was first used in the psychiatric literature by Jerome Frank in the 1970s (i.e., “the chief problem of all patients who come to psychotherapy is demoralization . . . the effectiveness of all psychotherapeutic schools lies in their ability to restore patient morale”)1(p271) and represented a persistent failure of coping with (internally or externally induced) stress; Frank believed demoralization left one feeling impotent, isolated, and in despair. This conceptualization was congruent with the psychodynamic approach of the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II),2 in which all disorders were considered reactions to environmental events. Frank defined the symptoms of anxiety and depression as direct expressions of demoralization.1
However, in 1975, Schildkraut and Klein3 defined demoralization as a state separate from depression. Whereas patients with depression experienced anhedonia, patients with demoralization lost their sense of efficacy. In the 1980s and 1990s, Frank and De Figueiredo further refined the meaning of demoralization.4 The term demoralization remained distinct from depression and was characterized by 2 states: distress and a sense of incompetence that results from an uncertainty about which direction to take. Individuals with depression and those with anhedonia cannot act (even if they know the proper direction to take).
Curr Psychiatry Rep. 2010 Jun;12(3):229-33.

Differentiation between demoralization, grief, and anhedonic depression.


Department of Veterans Affairs, Central Arkansas Veterans Healthcare System, 4300 West 7th Street, 116T/LR, Little Rock, AR 72205-5484, USA.


Demoralization is a phenomenon in which a patient reaches a state of subjective incompetence, hopelessness, and helplessness that can lead to that devastating moment in which he or she feels the only recourse left is to give up. This article reviews the medical literature regarding the current understanding, importance, and impact of demoralization. In addition, using the key characteristics of demoralization, this article attempts to compare and contrast demoralization with anhedonia and grief.


TO THE EDITOR: Dr. Slavney’s stimulating article, “DiagnosingDemoralization in Consultation Psychiatry,” is a valuable additionto the ongoing debate on demoralization.1 Dr. Slavney statesthat demoralization is a normal response to adversity and thathe disagrees with my proposal to substitute “demoralization”for “severity of psychosocial stressors” as Axis IV in the DSM.Although demoralization may, at times, be understandable, asin the cases described by Dr. Slavney, the view I proposed isthat demoralization is always abnormal. It is because demoralizationis abnormal that it requires treatment (psychotherapy). I proposedthat demoralization be conceptualized as involving two states:distress (which some other authors have called “demoralization,”incorrectly in my opinion) and subjective incompetence. Althougheach of these two states may be normal by itself, their overlapwould constitute demoralization, which is always abnormal. Demoralizationis thus viewed as a boundary phenomenon, that is, a state thatoccurs within the individual and at the boundary with the environment,something akin to inflammation.

World Psychiatry. 2005 June; 4(2): 96–105.
PMCID: PMC1414748
Copyright World Psychiatric Association

When People Aren’t De-Stressed

There was an extraordinary commenting discussion about suicide as reader responses to a NYTimes column by the physician and writer, Danielle Ofri. In her essay, she laments the death by suicide of a patient and expresses frustration about the seeming non-suicidality of him making the death an unexpected shock.

Two weeks ago, I called one of my patients to reschedule an appointment. A family member answered and told me that my patient had been found dead in his apartment, most likely a suicide. This robust and healthy 54-year-old had screened “negative” for depression at every visit, despite having risk factors: being unemployed, living alone, caring for an ill relative.

Here she makes a clinical error: screening for depression and suicidality are two distinct entities.  Once does not necessarily presage the other. In terms of perceived burdensomeness, thwarted belongingness, isolation, hopelessness, helplessness and worthlessness, this gentleman was existing in a stew of toxic risk factors.

Maslow’s hierarchy of needs is old, but useful, in my view.  This person exhibited unmet basic needs – financial burdens, caregiver burdens, physical burdens, social isolation burdens.  The question becomes, where art thy neighbor?  Who is thy neighbor?

Maslow's Hierarchy of Needs. Resized, renamed,...

Image via Wikipedia

One of the risk factors for suicidality is that physicians increasingly treat rather than care for patients.  Because the care is missing, patients aren’t supported around anything other than medications, surgery and medical procedures.  One thing Dr. Ofri could have addressed is linking the patient to a home health nursing agency or to a social worker who could help him access caregiver support, perhaps home delivered meals and financial and job search supports.

The bottom line is that it appears that no one was this man’s neighbor, or brother, or fellow citizen.

Now to the commentary:

Readers addressed a wide variety of insightful and thoughtful aspects around suicide and suicidality.  The right to end terminal suffering – psych ache – is addressed quite compellingly.