Intentional self-harm

DR. AJAY RISAL

“….Let me die! Doctor. Let me die. I am of no use in this world. I don’t want to live anymore. So, leave me alone and let me die in peace…….”

These words keep on echoing in my ears these days. I don’t know why? It has already been over a week that I interviewed her, and this was not the first time I spoke to those who had attempted suicide. In fact, it is my routine to perform detailed psychiatric evaluation of any patient referred to my department. No one with a history of attempted suicide (Intentional self harm) is spared in our hospital. Anybody with such a history admitted in any other department visit the psychiatry OPD at least once before they get discharged. Cases of “attempted suicide” abound in our hospital. Referring to our own study published in a medical journal last year, we had 73 patients in a six months period who had tried ISH (roughly 12 per month) which is not insignificant. Though the modes may vary, “suicide attempt” is one of the important causes of morbidity in our hospital, and all over the world and is considered the most common reason for psychiatric emergency. But also, interview with her keeps on awakening me in my dreams…….though she has survived the incident and was discharged after a five-day stay in hospital.

She is a 66-year-old widow staying alone in a small hut at a nearby village. Her husband who was suffering from asthma expired two years ago at the age of 68 due to exacerbation of respiratory problems. She has two sons, both working abroad and their family are staying separately for the last five-six years. Her daughter is married and staying with her husband who works in some terai region. Both her daughters-in-law quarrel with her day-in and day-out. They have unresolved economic issues and land disputes. After the death of her husband, she has been alone dealing with them and is being treated for depression. Around 10 days back, her daughters-in-law started quarrelling with her while she was working in her field.. She was accused of being a witch and the sole reason for their child’s poor health. Her sons kept silent even though they were around. No villager came to her rescue even when she was being physically abused by the in-laws. Later, she had to run away for her life. She remained locked up inside her home. The next day, her neighbors found her unconscious inside and a bottle of Novan was found near her. Later, she was brought to the hospital. A 66 year old lady who has two sons and a daughter ought to have been a respectable member in a family. But she has come down to this fate, seeking “death” and begging for her life to end…….what a tragedy? Whose fault is this ultimately?

Being a psychiatrist, I am always troubled by the term “suicide”. Should I consider it merely a phenomenology in a psychiatric spectrum or is it within a domain of human right? Is it a social or a legal problem? Can it be only a spiritual/ moral consideration or has to be dealt holistically?Biologically, we find genetics and heredity deeply underpinned in suicidal tendency. Hence, some researchers even say, suicide is contagious. Some studies have gone deep to the molecular level. Neurotransmitters like serotonin have been shown to be a possible culprit. Mental illnesses like depression and schizophrenia, personality disorders and drug abuse have their own shares in this emergency condition but percentages may vary.

Considering psychological dimensions, childhood emotional trauma, absence or death of parental figures in childhood, temperamental issues all come into play while making any adult personality. Freud’s concepts on “Anger turned inwards” and Menninger’s thesis on “Wish to die- Wish to kill” all explain psychological contributions towards this disastrous behavior.

Social issues cannot be forgotten in this regard. The case explained earlier shows how social and family issues drag an individual towards fatality. Sociologist Durkheim has contributed in the study of social factors leading to suicide. An individual may be anomie or egoistic, he may hold altruistic and fatalistic ideas ultimately showing him the ways forward to end his own life. Hara-kiri in Japan and sati in our own country are the prime examples of altruistic modes of suicide. Human right activists in different parts of the world including our neighboring country India are moving even further raising their voices for and against euthanasia (i.e., mercy killing).

Keeping the issues of altruistic form of suicide and euthanasia out of the scope in this article, this writer wants to bring the concern of all towards the significance of mental health parameters in this genuine public matter.

Keeping these facts and figures in mind, suicide can no longer be neglected just as a news-item or a social problem. It has to be dealt with holistically, utilizing all the possible resources- medical, social, spiritual, legal, political and much more.

Realizing the sensitivity of this issue which compels a fellow citizen to flee from his own life, I want to repeat, “Let them live a life to the fullest.”

Dr. Risal is a Psychiatrist at Dhulikhel Hospital