Kalman J. Kaplan

Suicide risk in schizophrenia: learning from the past to change the future

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5–13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures.This review paper is the results of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophenia patients.

Hopelessness, Temperament, Anger and Interpersonal Relationships in Holocaust (Shoah) Survivors’ Grandchildren

The psychiatric literature is divided with regard to the long-term psychological effects associated with Holocaust (Shoah) experiences because the findings of clinical and empirical studies often contradict each other. Despite case reports of emotional sequelae related to intergenerational transmission of trauma, recent empirical research has suggested that offspring of survivors of the Shoah did not differ from other children and found no evidence that traumatic experiences of survivors of the Shoah affected their children’s and grandchildren’s adjustment. To shed light on some of the differences between the empirical and clinical observations, the present study set out to compare the grandchildren of survivors of the Shoah and persons of the same age whose families had not been through the Shoah experience. This study compared the two groups on some psychological dimensions relevant to traumatic sequelae: hopelessness, temperament, personality, attitudes, and interpersonal expectations. Subjects were 124 equally divided among the Shoah survivors’ grandchildren and comparison groups; we administered to all subjects TEMPS-A Rome, Beck Hopelessness Scale, State-Trait Anger Expression Inventory, and 9AP (9 Attachment Profile). We found no differences between two groups in Hopelessness, Dysthimic/Cyclotimic/Anxious, Hyperthimic temperament, and self-perception; instead the Shoah survivors’ grandchildren have a view of the other as rejecting, hostile, submissive, insecure, unreliable, and competitive in the interpersonal relationships. The Shoah survivors’ grandchildren are similar to controls in affective temperament, hopelessness and self-perception, but they are more irritable and angry than controls, and their perception about others is deeply negative. Attribution theory was used to elucidate these findings.

Disordered verbalizations in schizophrenia: a speech disturbance or thought disorder?

This research provides empirical data relevant to the long-standing theoretical issue of whether disordered speech in schizophrenia should be viewed as a speech disturbance or a thought disorder. The study analyzed whether schizophrenia patients with disordered speech on one test also show strange nonverbal behavior and unrealistic ideas on other assessments. One hundred eighty-four patients, including 55 schizophrenia patients, were assessed at the acute phase and followed up twice, over 4.5 years. Patients were assessed (1) with a standardized measure that can elicit disordered speech, (2) with a different measure that can elicit an atypical sorting of objects and an intermingling of personal ideas, and (3) for delusions (unrealistic thinking). Schizophrenia patients with disordered speech on the Proverbs Test also (1) sorted objects strangely on the Object Sorting Test (P <.05), (2) showed an intermingling of personal ideas into their thinking (P <.01), and (3) had delusional ideas when assessed at two successive follow-ups over a multiyear period (P <.001). The data suggest that most schizophrenia patients and other psychotic patients with disordered speech also show strange nonverbal behavior and unrealistic ideas/beliefs. These data support a theoretical framework in which disordered speech in schizophrenia and other types of psychotic patients is viewed as not just due to a speech disorder, but is often part of a broader constellation that includes gross reality distortions, strange behavior and ideas, and disordered thinking.

Are There Gender‐Specific Risk Factors for Suicidal Activity among Patients with Schizophrenia and Depression?

Are there gender-specific risk factors for suicidal activity among patients with schizophrenia and depression? A total of 74 schizophrenia patients (51 men, 23 women) and 77 unipolar nonpsychotic depressed patients (26 men, 51 women) from the Chicago Follow-up Study were studied prospectively at 2 years posthospitalization and again at 7.5 years. Poor early posthospital global functioning is significantly associated with later suicidal activity only for men in both our schizophrenia and depressive samples. Early display of psychotic symptoms is associated with later suicidal activity among male schizophrenia patients. Early cognitive impairment is not significantly associated with later suicidal activity for any of the four groups of patients. The study results must be seen as exploratory and will hopefully spur future research on this important topic.

Israel: ‘occupier’ or ‘occupied’? The psycho-political projection of Christian and post-Christian supersessionism

Political attitudes towards the modern state of Israel are substantially influenced by underlying theological issues in Pauline Christianity regarding ethnic versus spiritual Israel. The very charge of Israel as occupier can be seen as an inverted perception or even a psychological projection emerging from the supersessionist view that the Pauline Church is the New Israel, displacing the Jewish people as Gods elect. Hard and soft political charges of Israel as ‘occupier’ are discussed as are hard and soft claims of theological supersessionism. Dual covenant Christians tend not to espouse the view of Israel as occupier. Finally, these political and theological realms of thinking are linked in an attempt to bring psychological clarity to the peculiar nature of political projection towards the modern state of Israel, among Christians and even post-Christians in the West.

Why does zeno the stoic hold his breath? "Zenoism" as a new variable for studying suicide.

A single misfortune may be seen as just that, or may be interpreted as Zeno the Stoic did, as a “sign” of cosmic proportion (zenoizing), which paradoxically provides a missing meaning structure. This article presents two studies testing out this new variable (zenoism): in Study One (n = 233), we explore the moderating effects of religiosity and gender on zenoism, depression, demoralization, and suicidality. In Study Two (n = 137), we explore these same moderating effects on zenoism, fear of dependency, value of life, and favorability toward physician-assisted suicide (PAS). Results indicate: 1) men and non-religious respondents (especially men) zenoize more than women and religious respondents; 2) non-religious respondents, (especially men) are more generally favorable to PAS and more suicidal; 3) Zenoism is negatively related to depression, demoralization, and value of life for non-religious respondents, and for men; 4) Zenoism is positively related to favorability toward PAS toward ones self and overall suicidality; and finally 5) general and self-specific favorability toward PAS are distinct, but both relate to overall suicidality.

Towards a biblical psychology for modern Israel: 10 guides for healthy living

Abstract This article examines the dependence of modern psychology and psychiatry on Greek thought, and specifically call for a Biblical reformulation of mental health with regard to 10 areas: (1) God, nature and creation; (2) men and women; (3) obedience versus disobedience; (4) fathers and sons; (5) mothers and daughters; (6) sibling rivalry and its resolution; (7) self and other: cycle versus development; (8) body and soul; (9) freedom, life and suicide; and finally (10) a hopeful versus a tragic outlook on life.

Recovering biblical narratives for positive psychology and suicide prevention in modern Israel

Abstract Suicide is the ultimate outcome of a tragic and pessimistic view of life, so prevalent in ancient Greek writings. Indeed, over 16 suicides and self-mutilations can be found in the 26 surviving tragedies of Sophocles and Euripides. In contrast, only six suicides can be found in the Hebrew Scriptures. This article examines evidence regarding seven risk factors for suicide. It contrasts biblical and Greek narratives regarding each of these factors respectively: (1) Elijah against Ajax; (2) Job against Zeno; (3) David against Coriolanus; (4) Jonah against Narcissus; (5) Moses against Oedipus; (6) Rebecca against Phaedra; and finally (7) Ruth against Antigone. All these Greek narratives lead to self-destructive behaviours while biblical narratives provide a hopeful positive psychology, and a safe way out these dilemmas. It is high time to develop a biblical psychology and psychotherapy commensurate with the restored land of Israel and a Hebrew civilisation.

Social Status and Suicidal Activity Among Psychiatric Patients: Moderating Effects of Gender, Race and Psychiatric Diagnosis

The relationship between suicide and social class has proved to be complex. Durkheim predicted suicide rates would increase with social status, while others thought the opposite. Results have been mixed. In some studies, suicidality has increased with increasing social status, and in other studies, the two variables have had an inverse relationship. These studies have been primarily conducted on general non-psychiatric populations The present study, in contrast, examines this relationship on a 20-year prospective longitudinal sample of 400 psychiatric patients (differentiated by psychiatric diagnosis) after index hospitalization. Of these, 160 patients show some sign of suicide risk (87 cases of suicidal ideation, 41 of suicide attempts, and 32 suicide completions). A complicated pattern emerges across psychiatric diagnosis, gender, and race. The great majority of patients show no statistically significant relationship between social status and suicide risk. At the maximally different extremes, however, a dramatic difference does emerge. White women diagnosed with nonpsychotic depression show a positive relationship between social status and suicide risk (p < .01) while black men diagnosed with schizophrenia show a negative relationship between these 2 variables (p < .02). The relationship between social status and suicidality among psychiatric patients varies across race, gender, and psychiatric diagnosis. More research needs to be done on this complex and important topic, especially with regard to samples of psychiatric patients. The role of anomie should be studied.

“To Life”: Biblical Narratives, Positive Psychology, and Suicide-Prevention

Some 16 suicides and self-mutilations can be found in the 26 surviving tragedies of Sophocles and Euripides. In contrast, only 6 suicides can be found in the Hebrew Scriptures, and 1 suicide in the Christian New Testament. In addition, the Hebrew Scriptures present a number of suicide-prevention narratives largely absent in Greek legends underlying much of mental health. In other words, the Hebrew Scriptures seem to provide a psychological stopper for people in despair which seems unavailable to figures in the writings of the great Greek tragedians. This chapter examines evidence regarding seven risk factors for suicide: (1) feeling isolated and ignored; (2) feeling one’s life is without meaning; (3) feeling exiled from one’s home or homeland (feeling as a refugee or an outcast); (4) feeling unable to be oneself with others; (5) being raised in a foster home and later feeling alone in one’s life mission; (6) feeling abandoned by one’s child leaving the family nest and building his/her own life; and (7) feeling doomed by a dysfunctional (even incestuous) family of origin. We contrast biblical and Greek narratives regarding each of these factors, respectively: (1) Elijah against Ajax, (2) Job against Zeno, (3) David against Coriolanus, (4) Jonah against Narcissus, (5) Moses against Oedipus, (6) Rebecca against Phaedra, and finally, (7) Ruth against Antigone. All these contrasts should demonstrate to psychotherapists, counsellors, and clergy alike as to how Greek narratives lead to self-destructive behaviours while biblical narratives provide a hopeful positive psychology, and a safe way out of these dilemmas. It is high time to develop a Biblical Psychology.