Abstract
Suicide is a major concern to mental health professionals, patients, legislators, coroners, the media and the public. Mental disorder (particularly mood disorder) is a risk factor in suicide in children, adolescents [1] and adults. But suicide is not always the result of mental illness [2], [3]. Higher levels of impulsive and aggressive traits play a role in suicide, particularly among younger individuals [1], [4]. We present a case report of a patient who impulsively performed a suicidal act using lethal means, but survived, and who cooperated with psychiatric examination.
Case report
The patient was a 22-year-old single man living in a fishing village in Tasmania, with his parents and two younger sisters. He had a good relationship with his family and found them supportive. The patient's developmental history was unremarkable with no history of trauma or abuse. There was no history of conduct disorder, and no clear history of impulse control problems or antisocial behaviour. The patient completed year 12 and a TAFE course (Business Certificate). He currently had part-time clerical work. He enjoyed playing basketball and going to the cinema, and was a recreational abalone diver. The patient had been involved in several heterosexual relationships in the past but was currently not in a relationship. He maintained good friendships, and still had a few friends from his primary school days. His father was a plumber; his mother was a pharmacy assistant. There was no significant personal or family history of psychiatric illness, substance abuse, suicide or forensic issues. His medical history was also unremarkable. The patient had been smoking 12 cigarettes a day for the last year and drank beer socially, with infrequent heavier drinking on special occasions.
For the last year the patient had been managing the Christmas Club funds at his workplace. At interview he stated that in the previous 5 months he had misappropriated approximately $6000 from this fund, which he lost gambling. He had no history of gambling, and this new activity had not outwardly affected his socio-occupational functioning. He stated that he felt guilty about betraying his workmates, with whom he had good relations. The misappropriation had not been detected at the time of his presentation, but with Christmas approaching, detection was inevitable.
Sometime in the last 5 months money was reported missing at his place of work. He denied taking this money but stated that he had been suspected. During these months the patient had been worried but he denied depressive symptoms; specifically, he denied low mood, sleep and appetite disturbance, and suicidal ideation. He continued to enjoy his usual hobbies and sporting activities, and maintained contact with his friends.
The event of interest occurred one evening when the patient was walking to a friend's home after leaving the cinema in the city nearest his residence. He was crossing a high bridge – this was not an unusual situation because he frequently travelled by bus or on foot. One-third of the way up across the bridge, he started to worry about the misappropriated funds. When he reached the top of the bridge he impulsively decided to take his life. He climbed over the rails by stepping on the fire hydrant and jumped. He was adamant that this act had not been planned for more than a few seconds.
As soon as he left the bridge he regretted his action, reflecting on people and things that mattered to him. Accordingly, he assumed the ‘pin-drop position’ in the hope of saving his life. The pin-drop position is when the legs are held straight and together and the toes are pointed; the arms with fingers straight are held firmly to the sides; the body is held straight. The aim is to enter the water feet first and avoid injury. The patient had learned this technique as a boy when jumping off cliffs with his friends.
The patient survived and was able to climb onto a ledge around a pylon. He sustained a bruised right shoulder on impact and some scrapes on his arms and legs while climbing onto the ledge. He was rescued the next morning when he was noticed on the ledge and the police were called. The patient was brought to the hospital by ambulance and admitted for assessment.
On mental status examination the patient was a good-looking man of stated age and average build, with blonde, mid-length hair. He was cooperative during the interview and rapport was good. He exhibited normal psychomotor activity. His affect was reactive, congruent and appropriate with normal range. His mood was euthymic. There was no evidence of formal thought disorder. He denied delusions, hallucinations, and suicidal or homicidal ideation. He was cognitively intact. He was very glad to be alive but also expressed feelings of guilt regarding the misappropriation of money. He showed good insight and judgment. He described the event as being an impulsive response to stress and denied any psychiatric symptoms.
Discussion
We assessed the survivor of a suicidal act in which a highly lethal means was used, and were able to exclude mental disorder.
In the 2007 Parliament of Tasmania Joint Standing Committee on Community Development Report on Strategies for Prevention of Suicide, the coroner's office stated that 32 people had died by jumping off the Tasmania Bridge between 1982 and 2005 (a distance of 49 m). Local psychiatrists believe that up to three people have jumped and survived (albeit with injuries). This is consistent with the 85% mortality associated with jumping from the Sydney Harbour Bridge (a distance of 59 m) [5]. But public opinion in Tasmania is that jumping from the Tasman Bridge is a means of certain death. Thus, for at least some seconds the patient wanted to die and took steps to that end.
This man reported an important stressor; he was about to be disclosed as a thief who had stolen from his workmates. We speculate that this threat was amplified in the present case because the patient lived in a small rural town where he, his parents and sisters were known to everyone in the community. The patient and his parents requested that no information about the event and the admission be relayed to the local general practitioner, due to potential leaking of information by the local surgery clerical staff.
The patient and his parents were interviewed together on a number of occasions. They enjoyed a supportive and emotionally warm relationship. The patient still had friends from his early school days and was employed. There was little to indicate personality problems.
The patient stated that he acted on impulse, and that the impulse lasted only seconds. This is consistent with the literature that links suicide with impulsivity [4]. Although not detected at interview, impulsivity was probably a feature of the patient's personality, given that he had gambled the stolen money. Impulsivity is the central feature of one subtype of pathological gambling [6]. As might be expected, the literature indicates a high prevalence of suicidal behaviour among pathological gamblers [7], [8].
The patient had stolen money from his workmates. He had been suspected of stealing money from his employer on one earlier occasion. Thus, dishonesty may be a personality feature. While impulsivity and stealing are present, there was insufficient to form a diagnosis of personality disorder.
Suicide is a major public health concern and is often associated with mental disorder. The literature on the suicide of people who do not have a mental disorder is scarce. This may be, at least in part, because those who complete suicide are not available to provide necessary information. Because the present patient acted impulsively and chose a highly lethal means, but changed his mind and took action to survive, this is a rare case in which a person intended to die but was subsequently able to provide information. In summary, this is an example of a person under the stress of inevitable disgrace and perhaps legal action, who chose and executed a highly lethal means of suicide, and in whom no Axis I or Axis II mental disorder could be diagnosed.