2004). The descent into suicide.

International Journal of Psycho-Analysis 85: (3) 653-667

The descent into suicide

John T. Maltsberger

Suicidal breakdown requires attention both to attack upon the self (ego) as aggressive forces are
unleashed against it by the superego, but also to the phases of self-breakup (ego regression) that
follow. Less attention has been directed to ego-regression in suicide than to superego-directed
assault on the ego in the psychoanalytic literature; this paper directs attention to the phenomena
of ego failure and disarticulation of the self-representation. Clinical study of suicidal patients
shows four aspects of suicidal collapse as ego loosens: affective flooding, desperate maneuvering
to counter the resulting mental emergency, loss of control as the self begins to disintegrate, and
grandiose magical scheming for mental survival as the self-representation splits up and body
jettison becomes plausible. These phenomena are discussed theoretically in terms of failed affect
regulation, ego helplessness, narcissistic surrender, breakdown of the representational world, and
loss of reality testing.

From the beginning, psychoanalytic theory has emphasized the assault of destructive forces
against the ego, moderated through the superego, to explain suicide (Freud, 1915). The self-
breakup that follows this attack has attracted less attention, although Glover (1930) remarked on
the importance of ego regression in suicide at the 1927 Innsbruck Congress. Suicidal collapse can
be partly understood as arising from overwhelming superego attack against the self, to be sure,
but this alone gives little account of the catastrophic consequences to the self that ensue, which
can be understood as ego regression. The accumulation of empirical data bearing on the mental
experiences of suicidal patients in recent years, especially that which bears on intolerable affect,
and the development of psychoanalytic theory, invite fresh consideration of the matter of self-
breakup in suicide. Attention to overwhelming affective states in empirical psychiatric
investigations over the past 20 years has shown the high association between anxiety and anguish
and completed suicide (Fawcett, 2001). The theory that intense mental distress can have a
traumatic, destructive effect on ego organization is a familiar psychoanalytic theme, and suggests
a schema for self-breakdown in such states (Freud, 1926).

I propose a model of suicidal collapse that involves four interlocking aspects, or parts. These
aspects are not to be understood as following one upon the other in strict sequence, though
patients may be seen to be moving back and forth from one to another, so that shifting over time
can be observed. Some patients portray one part more than another, or more than one at a time,
but, as suicide nears,

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patients are more marked by the third and fourth parts of self-devolution. I propose the following
four aspects: the first, which can be compared to flooding, finds the patient awash in an
overwhelming deluge of intolerable painful feeling. This is the aspect of ‘affect deluge’. Aspect 2,
‘efforts to master affective flooding’, finds the patient attempting to subjugate and contain painful
feeling, succeeding sometimes, sinking sometimes, and struggling, as it were, to stay afloat. When
he can do this no longer, movement into the third aspect occurs, which can be likened to
drowning with the patient feeling out of control and desperate. Aspect 3 is named ‘loss of control
and disintegration’. In Aspect 4, we see the patient, his ego crippled by lost reality testing,
mounting grandiose schemes for self-preservation that may include self-preservation through the
jettison of his body. This aspect is labeled ‘grandiose survival and body jettison’.

In 1842, Edgar Allan Poe published his tale ‘The descent into the maelström’, a metaphor for
suicidal collapse. Poe recounts the experience of a fisherman (whom I take as an emblem of an
almost paralyzed ego) whose boat (standing for the self), caught in catastrophic currents (affects),
is whirled downward to its wreck and destruction, while the fisherman watches helplessly.
Because the story is so evocative, I have interpolated some excerpts from it into the text.

The phenomenology of self-breakup will be described first, and theoretical discussion will be
reserved for the later portion of this paper.

Aspect 1: Affect deluge

And then down we came with a sweep, a slide, and a plunge, that made me feel sick and dizzy, as I
was falling from some lofty mountain-top in a dream. But while we were up I had thrown a quick
glance around—and that one glance was all sufficient … The Moskoe-ström whirlpool was about a
quarter of a mile dead ahead … I involuntarily closed my eyes in horror. The lids clenched
themselves together as if in a spasm (Poe, 1842, p. 442).

A number of different terms for the affective distress that besets suicidal patients appear in the
literature. We read of anxiety, psychic anxiety, dysphoria, and psychache (Fawcett et al., 1987;
Post et al., 1989; Busch et al., 1993; Shneidman, 1993). Anguish, an old word that denotes
excruciating mental distress, in English use since 1260, is better than any of the newer coinages or
German importations (Maltsberger, 1997; Hendin et al., 2001).

A general consensus now holds that suicide in the absence of painful emotional perturbation is
unusual. States of intolerable affective commotion appear to drive suicide; those who fall into
them must get relief or destroy themselves—there are no other alternatives.

At the American Foundation for Suicide Prevention, a continuing study of patients who were in
active therapy at the time they committed suicide is now in progress (Hendin et al., 2001). This
work has uncovered a consistent pattern linking suicide to acute, intense affect states that
compound the patients' underlying depression. Desperation is the acute affective compounder
most associated with a suicide. It is defined as a state of anguish coupled with an urgent need for
immediate relief. Intense rage, anxiety, a sense of abandonment,

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hopelessness and self-hatred are also commonly observed in patients shortly before suicide.
Often, but not always, a major life event (a precipitating event) can be identified as setting loose
an intolerable flood of mental pain (Hendin et al., 2001; Maltsberger et al., 2003). With or without
a clear precipitating event, intense affects, singly but more commonly in combinations, can drive
patients to desperation (Baumeister, 1990).

Intense desperation is a mental emergency. Those patients who can escape it by turning to others
for relief are fortunate. Some patients are lucky enough to receive psychiatric (usually
psychopharmacologic) treatment to relieve their agony. Others may turn to street drugs or alcohol
in flight from it. But many unfortunate patients may quickly take their lives because they cannot
wait for relief.

A 42-year-old surgeon, suddenly seized with a state of intense desperation, fell to the floor in a
public building because he could not endure the anguish. Later, he reported that, should such a
state recur, he intended to kill himself immediately, so horrible was the experience.

Though immediate, sudden affect-flight suicides of this kind seem to occur, we have no data
regarding the extent to which self-breakup takes place in these patients (Aspect 4, vide infra),
although it may do so. Many probably die before they can be studied.

One can usually, but not invariably, make correct inferences about the intensity of psychic pain by
simple observation of the patient. Most desperate patients, enraged patients or intensely anxious
patients show what they feel in face, body movement and demeanor. However, a few desperate
patients do not look or seem so to us; they may be quiet, outwardly calm. Potentially suicidal
patients must therefore be questioned about the intensity of their affective distress, and asked
whether it is becoming intolerable. They should be invited to compare its severity to that felt at
other times and places, such as on the occasion of a previously attempted suicide. Not every
patient's capacity to bear mental pain is the same as that of the examiner nor of other patients, so
empathic errors of judgment are common. Those who seem very calm may have dissociated and
may be already embarked on a suicide trajectory. Others, having made up their minds to kill
themselves, experience some sense of restored self-mastery and calmness before they take their
lives. Others yet deliberately conceal their desperation because they do not want their suicidal
plans to be interrupted.

Aspect 2: Efforts to master affective flooding (struggling)

It may appear strange, but now, when we were in the very jaws of the gulf, I felt more composed
than when we were only approaching it. Having made up my mind to hope no more, I got rid of a
great deal of that terror which unmanned me at first. I suppose it was despair that strung my
nerves.

It may look like boasting—but what I tell you is truth—I began to reflect how magnificent a thing it
was to die in such a manner, and how foolish it was in me to think of so paltry a consideration as
my own individual life, in view of so wonderful a manifestation of God's power (Poe, 1842, pp.
442-3).

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This sector of suicidal breakdown shows the patient casting about in desperation to avoid spiraling
downward (Heckler, 1994). Behavioral signs of a worsening emotional state are common among
patients as they move toward suicide (Hendin et al., 2001). These may include verbal expressions
of suicidal feelings or intent, escalating self-destructive behavior, declining work and social
functioning, and increasing abuse of alcohol or drugs.

Patients may attempt to save themselves by frantically turning to others, or by telling therapists
they can no longer endure what they feel. Self-mutilation or an outright suicide attempt may
occur. In this phase, some patients split off their feelings from their conscious awareness, that is,
they dissociate. Dissociation may be subtle and not always evident to us—the patient may actually
feel quite composed and behave in a deliberate, organized way.

A 22-year-old law student, who had been in a depressive anguish for some days, decided to kill
himself. As soon as the decision was made, he experienced a sudden calmness of mind, and
reported that, for the first time in weeks, he felt competent and collected. After coolly driving to a
high bridge, he jumped off, feeling detached from himself, observing what was happening with the
admiration of an onlooker. As soon as he began to fall, the dissociation broke, and he began to
scream in terror.

Others may be able to master their subjective agony by some combinations of denial, projection
or even obsessional affect isolation. In this phase, patients begin to withdraw their emotional
investment in others, to give up on their attachments to work and other valued pursuits, including
psychotherapist and psychotherapy. Reality testing softens, and distorted views of others
supervene, wherein others seem hostile, uncaring or unavailable.

Still others, making the decision to commit suicide, seem to experience a refreshed sense of self-
mastery without dissociating, and quiet down as they go forward with their deadly plans.

Aspect 3: Loss of control and disintegration

We careered round and round for perhaps an hour, flying rather than floating, getting gradually
more and more into the middle of the surge, and then nearer and nearer to its horrible inner edge
… Round and round we swept—not with any uniform movement—but in dizzying swings and jerks
(Poe, 1842, pp. 443-5).

The sense of loss of control experienced by the patient, a sense of falling apart, is accompanied by
intense horror and fear. In this phase, the patient feels completely overwhelmed, unable to help
himself, and begins to give way to despair.
Some suicidal patients' dreams portray disorganization and fragmentation of the self, specifically
in the way their bodies appear in the manifest content (Maltsberger, 1993a). Such dreams can be
understood as metaphors for loosening of the self as a mental structure, and as alarm signals that
self-integrity is beginning to fail (Greenberg, 1989; Goldberg, 2000). Suicidal patients may dream
of a landscape littered with body parts, or parts of dead animals. Some dream of being shaken to

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pieces, as a dog might shake a rat. Others dream their bodies are literally going to pieces,
disarticulating (Alvarez, 1970). In other dreams, death and killing are more elaborately symbolized
(Grotjahn, 1960).

I dreamed I was standing on the edge of the cliff and parts of my body were coming off and
dropping over the edge. You were standing nearby with your hands in your pockets, doing nothing
to help me, and laughing (Litman, 1980, p. 285).

Some suicidal patients report dreams in which they see their doubles, and treat their doubles as
though they were other persons (Lukianowicz, 1958):

In my dream there were two of me sitting in my jeep parked at Lookout Point. I was in the driver's
seat holding a gold-plated gun to my head. Then the passenger pulled the trigger spattering stuff
all over. The one in the driver's seat said, ‘Oh no!’ (Litman, 1980, p. 290).

Aspect 4: Grandiose survival and body jettison

Trapped in a flood of unmanageable pain and experiencing disintegration of the self, all reality
solutions failing, urgent to do something, patients may act on magical fantasies to save themselves
from impending psychic annihilation.

There are many reports in the literature of grandiose dreams and fantasies associated with
suicide. Desperate for relief, the patient may adopt omnipotent schemes to achieve control over
life and death. In this phase, patients commonly imagine they can split their mental and physical
selves, and, by killing their bodies, survive in mind in another sphere. Some patients dream of
death as a rebirth in which they rise again as Christ. Others dream they are in powerful positions,
rejecting others who have in fact rejected them. Death is not pictured as a defeat or an end but as
a triumph or beginning (Maltsberger and Buie, 1980; Hendin, 1991, 1992).

Some patients identify their bodies as the source of emotional anguish and believe that by getting
rid of the body, now experienced as an enemy, they will escape an intolerable situation and
somehow go on to life somewhere else—suicide is imagined as an escape, and the suicidal act is
seen not as self-annihilatory, but as the killing of an enemy in self-defense.

As reality testing fails, some patients experience narcissistic overinflation in which certain schemes
of action, some plans of problem solving, appear to them brilliant. Exaggerating his own talent for
escape, convinced of his extraordinary power, and that he is an exception, such a patient may
launch out on a mad suicidal scheme absolutely convinced he can escape his intolerable state
(Maltsberger, 1997). Patients with narcissistic personality disorders must be particularly
vulnerable to such developments when shaming precipitative events crush them, or when they fall
into severe depressions (Ronningstam, 1998).

Discussion

Clinical experience shows that threatened self-breakup, and actual self-breakup in various aspects,
is common among suicidal patients. To date, no empirical studies

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have appeared to compare self-breakup in acute suicidal states to self-breakup in non-suicidal

disturbances. There is good reason to believe, however, that many patients experience a particular
kind of dissociation before killing themselves wherein mental and body selves are experienced
subjectively as separated (Laufer and Laufer, 1984, 1989; Laufer, 1995). Self-breakup can be
scrutinized from a variety of positions in psychoanalysis.

1. Failure in affect regulation

Freud implied two forms of injury to the self-representation (ego) in ‘Mourning and melancholia’
(1915) and in The ego and the id (1923). In the earlier paper, he describes how the ego (using the
term as synonymous with the self) can come under aggressive attack when it is identified with a
hated object. In the second, he refers to withdrawal of positive narcissistic investment in the ego
(the self) when it is adjudged weak and ineffectual, so that it is abandoned and left to die.

Bibring (1953) described some depressions in terms of Freud's 1923 formulation, suggesting they
occur when the ego lacks the force and capacity either to achieve unrealistic demands set by the
ego ideal, or to meet the reality challenges of the exterior world. The patient who tries and fails
again and again experiences a drop in self-esteem, and may give up on himself. Bibring defines
depression as the emotional correlate of collapse of self-esteem of the ego. Finding itself unable to
live up to its aspirations, it is overwhelmed by feelings of helplessness.

The foremost narcissistic demand of the self must be the protection of its own integrity (Stolorow,
1975). Entering into the early phases of self-breakdown, the self observes that it is unable to hold
together—unable to master powerful affect, unable to control impulses and actions. Patients in
the American Foundation for Suicide Prevention series found themselves flooded with painful
affects they could not control; they experienced rage, turmoil, anguish—that is, the beginning of
ego failure. Some of these patients in turn could not control themselves; they became passive,
horrified witnesses to the further failure of their egos. One of the patients, an attorney, lost
control of herself and made a scene in the courtroom. Another, a Vietnam veteran, behaved so
aggressively to his wife that she left him. Another, a nurse, slapped a troublesome child in the
hospital in spite of herself. The patients, to their horror, saw themselves behaving badly, making
their lives worse, but were unable to check themselves. In spite of themselves, they were
destructive, frightening to others, getting out of control. To experience oneself as breaking down
in this way is itself a profound narcissistic blow.

Bibring's formulation holds that the helplessness of the ego in the face of overwhelming forces,
from within or without, is the root of depression. When helplessness lasts long enough,
hopelessness supervenes. Hopelessness is, of course, a well-known marker of suicidal states
(Fawcett et al., 1990; Beck et al., 1993).

While ‘giving up on the self’ as described by Freud would seem insufficient to explain the violent
psychodynamics of self-attack, withdrawal of positive regard (narcissistic libido) from the self-
representation would play a part in loosening its cohesion, rendering it vulnerable, leaving it
unprotected from the hostile forces arising from morbid, destructive introjects.

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Bibring offers the view that the turning of aggression against the self is secondary to a breakdown
of self-esteem. He believes that it is ultimately due to the feeling of powerlessness and
helplessness that the ego surrenders itself to the superego to be punished. His theory of
depression suggests that the puzzling states of calm which appear to supervene just before some
patients kill themselves might arise from ego emergency operations called into play to ward off
overwhelming states of helplessness. There appear to be at least two kinds of pre-suicidal calm.

The first type of pre-suicidal calmness is dissociative; the depersonalized law student described
above who jumped off a high bridge entered a state of calm detachment once he decided on a
plan, his anguished turmoil quieting down. Depersonalization can be understood as a defense
whereby overwhelming tensions are blocked off when the integrity of the self is endangered.
Depersonalization of this kind is well known not only in acute suicidal crises, but also in situations
of acute danger. States of cold alertness and clarity of mind can occur in life-threatening
circumstances, when the person endangered feels he acts as an automaton. Once the danger
passes, delayed reactions may occur in forms of tremors, crying spells, sweating and other
varieties of autonomic, anxious discharge. The ego protects itself against the danger of being
further overwhelmed by intolerable tension by temporarily blocking further affective experience.

Calming before suicide can probably occur without dissociation in the usual senses of descriptive
psychopathology. It may be that formulating a suicide plan in itself is sometimes sufficient to
master the sense of intolerable helplessness, so that a sense of total control is substituted. The
patient escapes the intolerable position of passive helplessness by turning passivity into activity.

Laufer and Laufer (1984, 1989) and Laufer (1995) take the position that, at least in adolescents
who attempt to commit suicide, the alteration of consciousness that accompanies the act
represents such a failure of reality testing that the attempt should be understood as a transient
psychotic episode. Calming occurs as the intolerable passive suffering of the patient is turned into
the activity of attack on the patient's body, which is experienced as alien to the core self, and, as
the seat of intolerable sexual and other painful feelings, an enemy which must be destroyed in
self-defense.

The expression ‘transient psychotic episode’ as used here does not necessarily denote any of the
specific diagnoses listed in such standard nomenclatures as the American Psychiatric Association's
Diagnostic and Statistical Manual, though episodes of this kind may occur in the indexed
diagnoses, such as major depressive episodes. By ‘psychotic’ I refer to a mental state in which the
‘thoughts, affective response, ability to recognize reality, and ability to communicate and relate to
others are sufficiently impaired to interfere grossly with the capacity to deal with reality’ (Sadock,
2000, p. 680). No hallucinations are ordinarily found in these states, and, to the extent that the
patients are deluded, the false convictions under which they labor are not likely to be long in
duration. They are typically affect-driven. Such states are often accompanied by depersonalization
and other dissociative phenomena, in the sense that suicidal mental and behavioral processes are
separated from the rest of the person's psychic activity. Suicidal ideas and plans are apt to be
separated from

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the emotional tone (anguish and anxiety), which expectably might accompany them (pp. 681-2).

2. Structural instability of the self-representation

Sandler and Rosenblatt (1962), in describing the representational world of the mind, ushered us
into a metaphorical theater of the patient's inner world, the great proscenium of mental life,
wherein living portraits of the self are seen to move, to feel, to remember, to interact and to have
their being, along with similar portraits of objects. Not only does conscious imagination play itself
out there; the inner world theater is also the stage whereon our dreams are enacted. These living
portraits of self and others, the actors on that stage, they called self- and object-representations.

The self-representation is built up over a lifetime, but it remains fluid as experience and learning
alter its organization. Withdrawal of self-regard, or flooding with aggression directed from a
critical superego, can lead to disorganization of the self-representation. Self-breakdown in suicidal
crises can be reflected in the events of the inner world.

Suicidal patients in breaking apart their mental and their body selves objectify their bodies,
thereby enabling self attack (Maltsberger, 1993b). When the self-representation disarticulates and
the portion of it that represents the body takes on the characteristics of an object representation,
the way is open for attacking the body as though it were something or someone else, not the self.
The body, in the language of Klein (1951), takes on a ‘not-me’ quality. When this happens, the
patient can adopt a paranoid attitude toward his own disowned flesh, and may attempt to rid
himself of it, experiencing his body as a persecutory enemy. This is the device to which Freud
(1915) referred when he described the ego's falling under the shadow of an internalized object,
rendering it vulnerable to the attack of the superego. Structural cohesion of the self-
representation is lost, and the positive narcissistic coloring of the body-representation is
abandoned (Orgel, 1974).

Theoretically, the integrity of the representational world, the self-representation and the body
image, as well as the integrity of the superordinate ego-superego system, depends on the
neutralization of aggression over the course of development. Too much unneutralized aggression
in the ego-superego system invites ego regression and self-breakup.

Introjects excessively charged with unneutralized aggression (sometimes called ‘hostile’ or

‘sadistic’ introjects when they take on representational qualities) are discussed in the
psychoanalytic literature as playing a part in suicidal phenomena (Maltsberger and Buie, 1980).
These introjects tend to operate in a fluid way, sometimes loosely attaching themselves to the
superego system, sometimes becoming affiliated with the body portion of the self-representation,
and sometimes seeming to have an independent position in the mind. When attached to the
superego, such introjects promote self-directed cruelty, criticism and self-destructive attitudes.
When influencing the body self, they invite feelings of self-alienation and self-revulsion, including a
disposition to self-attack. When affiliated with neither superego nor self-representation, they tend
to take up a life of their own as hostile inner presences. We see them at work among the personae
of multiple personality

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disorder. They may be projected out on to others—that is, when they affiliate themselves to
object-representations, they give rise to fears of persecution from without (Asch, 1980).

Instability between the self- and object-representations invites dissociative experiences. In fact,
phenomena such as derealization and depersonalization can be understood as evidence that the
integrity of the representational world is loosening. Orbach (1994, 1996, 1997), Orbach et al.
(1995a, 1995b) and Links (1990) have studied suicidal dissociation, employing empirical methods,
and have shown that obj ectification and attacks upon the body-self not only occur very commonly
in states of dissociation, but that physical and sexual abuse in childhood predisposes patients to
dissociate and self-attack.

Normal adult narcissistic functioning presumes a reasonably stable superego system in which self-
criticism is kind while realistic. The normal adult ego-ideal does not demand perfect or omnipotent
achievement and mastery. When development is undisturbed, introjection and identification
operate to transform the child's relationships with the parents into stable ego-ideal structures.
Traumatized children, however, do not establish reliable superego systems. Dissociation
accompanies sexual and physical trauma in childhood and adolescence, and invites introjection of
unempathic, neglectful or brutal parental experiences. Unusual aggressive and self-punitive self-
attitudes are likely to result as maturation takes place, and the self-kindliness of the normal
superego does not develop (Schafer, 1960; Furman, 1984).
Highly dramatic illustrations of breakup of the self-representation are found in cases of major
depressive disorder with psychotic features. Delusions of infestation by alien enemies, for
example, reflect invasion of the self-representation by a hostile introject, experienced as hurtful
object-representations which establish themselves within the representation of the patient's
body-self. The patient tells us his body is infested by worms, animals that rip and tear at his
insides, or by evil spirits and aliens from space. By killing his body he imagines killing and escaping
from them.

Feelings of body-splitting are well known in depression. Among 200 consecutive patients admitted
to a psychiatric unit with depression or anxiety, 15 complained of bizarre bodily experiences. A
depressed woman said her body felt as though it had been split in two like a tree-trunk struck by
lightning. She said that the two parts felt a few inches apart, but that there was nothing between
them except a black, empty, dead hole (Lishman, 1998, p. 75). A schizophrenic man, having
developed a delusional head growing out of his shoulder, shot ‘it’, that is, shot himself, and nearly
died as a result (Ames, 1984). Borderline patients often speak of feeling ‘empty’ inside. Therapists
generally understand such statements metaphorically, but, on a number of occasions, I have
encountered suicidal patients who quite concretely believed there were anatomically empty
spaces in the thorax or abdomen.

Self-attack is well known among borderline patients, who frequently describe their bodies as not
real. One suicidal borderline patient felt that someone from the outside had foisted her body on
her, that it was a sinister counterfeit of her true body. From such observations as these, we have
ample evidence that patients objectify their body-selves and confuse them with representations of
hostile others. We also

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may recall that borderline patients often develop confusions in the transference, so that they are
unable to tell where they leave off and where their therapists begin. These patients often disavow
their own feelings, especially hateful ones, attributing them to their therapists, and cannot
distinguish affective boundaries (McGlashan, 1983).

Rorschach testing can reflect loss of self-integration and failing capacity to discriminate between
self and object. Inferences of such failure appear in the modes of space organization in patients'
reports of Rorschach responses, as well as in fantasies and dreams. Experiences of seeing through
transparent or translucent three-dimensional spaces suggest this kind of breakdown, which has
been tentatively empirically associated with suicide (Blatt and Ritzler, 1974; Roth and Blatt, 1974),
although efforts at replication have raised some questions about this finding (Hansell etal., 1988).

Fowler et al. (2001) developed a suicide index comprising four psychoanalytic Rorschach signs that
predicted with considerable accuracy which patients would later make lethal suicide attempts.
They found that unconscious processes signaling penetrating affective overstimulation,
disturbance in capacity to maintain ego boundaries, and affect states characterized by morbid
preoccupation with death and inner decay were strong predictors of dangerous attempts. Rydin et
al. (1990) reported that violent suicide attempters were more paranoid, less able to cope with
conflict situations, less able to endure dysphoric affect and poor in differentiating between reality
and imagination. These findings are consistent with what has been described here as self-breakup.

Thomas and Duszynski (1985) have published a prospective study in which the records of
Rorschach examinations administered to 1,154 medical students, 20 to 35 years previously, were
analyzed for the frequency of occurrence for the word whirling and similar words (they call these
‘whirlall’ words). When the subjects were followed up, it was found that 16 had died of suicide.
Seven of these 16 suicides (43.8%) had given whirlall responses at the time of the examination, in
contrast to 9.62% of the group as a whole. What this finding means is uncertain, but whirlall
responses in the Rorschach may signal potential instability of the self-representation. (Oddly,
whirlall responses in the original protocols also predicted premature death from causes other than
suicide. Of the 48 subjects dead from causes other than suicide, a third had given whirlall
responses on the Rorschach.)

Although a scheme of self-breakdown has been delineated here, one that can be encountered
across a variety of diagnoses and mental disturbances, it is not possible to say whether such a
breakdown process is empirically (statistically) more characteristic of those who commit suicide or
make grave attempts than it is of other mentally anguished persons who do not. That states of
anguish as outlined above are very typical of those who commit suicide can be asserted with some
confidence. Nevertheless, other patients, with better capacity to bear anxiety and depression, may
endure some of the experience of the suicidal maelström without being swept down into the
lower depths of the aspect 4 (Zetzel, 1949, 1965). To date, we lack the necessary empirical
knowledge to differentiate between those who suffer without breaking down into suicide and
those who are swept away into lethal disintegration.

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From the clinical point of view, patients in a state of severe anguish who have moved into a
suicidal crisis and who further demonstrate evidence of self-breakup as outlined here, should be
assumed to be at great risk of committing suicide and managed accordingly (Hendin et al., 2001).

Conclusion

As self-breakdown (following on from ego failure and ego regression) takes place, the anxiety
experiences of patients are far more intense than those belonging to ordinary life. The anxiety is
so intense that mental functioning is paralyzed, and, to the extent that the patient can think at all,
he recognizes that he is helpless and feels that he is in terrible danger. Sometimes called
annihilation anxiety, Freud's term for it was primary anxiety or traumatic anxiety. Because terrific
anxiety onslaughts of this kind are so paralyzing, they are usually experienced as pouring in from
outside the self, and must be endured, to the extent that they can be endured at all, passively. In
the face of such anxiety, the self is rendered helpless. Freud (1923) regarded such anxiety
experiences as psychically very dangerous and injurious to the ego.
Kohut took the view that disintegration anxiety was the deepest anxiety of all, and believed that
none of the forms of anxiety Freud described were equivalent to it. Potentially he felt that it could
be greater even than the fear of death. If this is so, it is congruent with the view that, in order to
escape disintegration anxiety, a patient might elect to kill himself, as the disintegrative anxiety
would be more intolerable than the horror of dying (Kohut, 1984, p. 16, p. 213, fn; Kluft, 1995).

Freud's (1923) view that anxiety can be so intense as to be psychically injurious is theoretically
attractive, because it lends itself to one formulation of a suicidal state: that the failing ego is
abandoned by the superego system as incompetent and worthless.

To defend itself against anguish of this order, whether one describes it as annihilation,
disintegration, primary or traumatic anxiety, the ego will go to any lengths. Freud's famous
analogy of the horse and the rider applies to the suicidal moment. The compromised ego is
compared to the rider on a runaway horse:

The horse supplies the locomotive energy, while the rider has the privilege of deciding on the goal
and of guiding the powerful animal's movement. But only too often there arises between the ego
and the id the not precisely ideal situation of the rider being obliged to guide the horse along the
path by which it itself wants to go (1933, p. 77).

In many suicidal cases, the overwhelmed ego, deprived of its reality-testing function, and with its
capacity for self and object differentiation failing, proves an ineffective rider. The terrified,
anguished horse, out of control, seems to run itself and the rider over the cliff into the suicidal
precipice.

The psychoanalytic theory of suicidal breakdown presented here implies massive failure of the ego
in terms of affect modulation and the preservation of the integrity of and distinction between self-
and object-representations. Reality testing and self-object differentiation fail. The surviving mental
self, turning against the body self as an enemy, may then turn to body-killing in self-defense.

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Many patients survive suicide attempts that expectably should have died—some are rescued by
sheer chance, others survive hangings or leaps or gunshots that by all odds should have been
lethal. Other patients, as we have seen, commit suicide while in intensive treatment. These sorts
of patients might be more extensively studied, with matched controlled groups of depressed
patients who had made no suicide attempt, with a view to seeing how often they show evidence
of self-fragmentation before the attempt. Of particular interest would be the comparison of
attempters with the controls with respect to dissociation experiences at times of maximum
affective distress.

The vernacular expression ‘nervous breakdown’ anticipates a number of the phenomena

belonging to suicidal states, very notably, a deluge of painful affect that cannot be regulated or
moderated. The German word for it, Zusammengebruch, is even better. Important mental
functions including self-object differentiation fail; fears of self-disintegration become primary; self-
and object-representations blur; grandiose and magical behavior supervenes. Suicide reflects
profound narcissistic collapse, loss of reality testing, self-fragmentation and ego failure.

Acknowledgements: Dr Ann Pollinger Haas, Dr Herbert Hendin and Dr Igor Weinberg have made
valuable suggestions for the preparation of this manuscript.

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