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Published: 2020-08-28

Le Petit Prince –Teenage Suicide

University of Basel
Translator
Translated from German (Department of social psychological readaptation for ATO (antiterrorist operation) participants and their family members)
adolescents suicidal behavior suicide attempts suicide Psychodynamic approach

Abstract

Suicide and suicidal ideation among adolescents and young adults are some of the most burdensome experiences for families, relatives, and therapists. In the phase of life, which should be characterized by awakening, cheerfulness and vitality, a group of adolescents appears, burdened with serious suicidal thoughts.

This paper will investigate this phenomenon from a clinical point of view, and also show that there are important links between developmental objectives, critical aspects of adolescence and suicidality. A psychodynamic approach is usually used in research on this phenomenon, although there are also several cognitive-behavioral approaches to the phenomenon of suicidality in adolescents.

Definition, epidemiology, and main statements

First of all, the phenomenon of suicidality should be terminologically differentiated by the following forms:

  • acute crisis suicidality (after breaking up with a friend);
  • suicidal communication;
  • suicide against the background of the major depression;
  • parasuicidal behavior (self-injurious behavior);
  • chronic suicidality with narcissism;
  • self-harm due to impulsive or "dependent" behavior.

In particular, parasuicide (i.e., potentially life-threatening or very self-destructive behavior in the absence of intent to kill oneself) should be considered as a prerequisite for suicide in adolescents. The parasuicidal behavior in the past is a reliable predictor of suicide. Comparing different data from psychological "autopsy studies", Marttunen et al. (1993) [57] found that more than 30% of adolescent suicides were characterized by cases of parasuicide at earlier stages of life. In a large nationwide study, Andrews et al. (1992) [2] found that in 41% of adolescents who underwent parasuicide, such episodes recur. After conducting a meta-analysis Shaffer and Piacentini (1994) [80] stated that the risk of recurrence after parasuicide is up to 50%. A WHO multicenter parasuicide study (Schmidtke et al., 1996) [76] also found a 50% recurrence rate after parasuicide, with recurrent parasuicides occurring in 20% of cases six months later.

The high tendency to repeat parasuicides in adolescence also poses a significant threat to inpatient treatment. As shown in a French study (Laurent et al. 1998) [49], 552 adolescents who were hospitalized after parasuicide, have a seven times higher risk of dying from suicide compared with the control group. Pfeffer et al. (1991) [67] with a similar study design found that in children treated in a psychiatric hospital (mean age 10.5 years) after parasuicide, recurrence during the observation period from 6 to 8 years is 30%, with 50% of these cases of parasuicide happened many times. No fatalities were reported.

Classification of parasuicidality

As in the case of suicide, a distinction between forms of parasuidality should be also made:

  • simulation;
  • propensity to accidents as a preliminary stage (unconscious self-destructive behavior);
  • indirect self-harm (addiction, eating disorders);
  • severe manipulation with the face as an intermediate step;
  • open self-damage: mild and severe forms;
  • the hidden task of self-harm: simulation disorder; Munchausen syndrome.

Adolescents with self-destructive behavior often have a catastrophic self-image ("inferior", "crazy"), serious problems with self-perception and relationships with others, and they also suffer from feelings of shame and lack of self-confidence. It is not uncommon in the past to have injuries (Shafii et al. 1985). [82]

Main statements: Adolescence as a vulnerable phase of reorganization

The phase of adolescence and early adulthood is characterized by a special increase in vulnerability to the development of psychological problems and disorders compared to other stages of age development. The cause is the following factors:

  • biological (puberty);
  • neurobiological (for example, lability due to changes in neuroplasticity and completion of brain maturation up to about 23 years);
  • social-age (school and professional requirements);
  • psychodynamic (identity, conflicts, etc.).

It is worth noting that scientists are now inclined to believe that neurobiological and psychodynamic factors can be integrated with each other (Stortelder and Ploegmakers-Burg 2010) [84].

Epidemiology, gender differences, and transcultural factors

In many industrialized countries, suicide is the second leading cause of death for adolescents and young people after the accident (Schmidtke et al. 1996 [76]; Mehlum et al. 1998 [59]). The frequency of parasuicides in the general population for adolescents in various studies is from 2 to 8%. Up to 30% of subjects previously had serious suicidal thoughts (Garrison et al. 1993 [31]; Andrews et al. 1992 [2]; Bronisch und Wunderlich 1998 [11]). Using the "psychological autopsy" approach after the completion of suicide in adolescence, it was found that the incidence of concomitant psychiatric disorders ranges from 79 to 98% (Brent et al. 1993 [9]; Marttunen et al. 1991 [56]). Affective disorders play a significant role in the diagnostic spectrum (Shaffer et al., 1996 [81]). Concomitant morbidity is of great importance: Marttunen et al. (1991) [56] found that more than half of the 53 suicide victims surveyed had more than one psychiatric diagnosis. Since the 1960s, suicide rates among children and adolescents in the United States have increased critically (Brent et al. 1995) [8]. This trend, which can also be traced in some European countries (Diekstra and Garnefski 1995) [19], is especially true for boys aged 15 to 19 (McClure 2001) [58].

Suicides among children under the age of ten are extremely rare, but they also occur. In Germany, from 1990 to 1997, the Federal Statistical Office registered approximately three to four suicides of children under the age of ten per year. In the group aged 10 to 14, 33 children (25 boys, 8 girls) died as a result of suicide in 2000. In the age group from 15 to 19 in the same year, 272 adolescents (206 boys, 66 girls) died as a result of suicide.

Transcultural aspects in epidemiology are also important and difficult to explain. Thus, the suicide rate in Russia for 5-14-year-old boys (3.6 per 100,000) is almost 40 times higher than in Spain or the United Kingdom. But even in 15-24-year-old boys and girls, the ratio can vary four times (low rates are found in Italy or the Netherlands, high, for example, in Russia or New Zealand).

The topic of gender differences (more suicide attempts in women, more completed suicides in men) is also manifested in adolescence (much more suicides in boys, much more parasuicidal actions in girls). Unfortunately, these features cannot be considered in more detail in this paper. In some cases, psychodynamic theories explain the higher frequency of self-injurious behavior (in adolescence), which may be associated with more unstable identity consolidation (Gerisch, 2003) [32].

Causes and risk factors

At this stage, some reasons should be given that are considered specific due to adolescent suicide.

Risk factors

Previous suicide attempts are a special risk factor. After a suicide attempt in 50% of all cases (long-term follow-up), adolescents try to reattempt. 3% of girls and 10% of adolescent boys with a history of suicide will commit suicide later.

As well as in the other age groups, psychiatric diagnoses can also be considered as serious risk factors for suicide in adolescents:

  • personality disorders;
  • affective disorders and emotional disorders in childhood (Paggen 2003) [66];
  • visual hallucinations (Livingston and Bracha 1992) [52] - most often encounters with dead significant people;
  • history of psychosomatic disorders (Paggen 2003) [66] is more common in the group of suicidal adolescents, which in turn also emphasizes the somewhat forgotten importance of autonomic complaints as an early marker of suicide in adolescents;
  • suicide and depression are not always the same; there are genetic studies that show that suicide and depression are not related (Lesch et al., 1995) [50];
  • Acute response to stress/maladaptation - also among mental disorders that increase the risk of suicide in adolescents (and adults). The abuse of psychotropic substances is extremely important (Paggen 2003) [66]; in the United States, the suicide rate of adolescents with alcohol or drug addiction ranges from 30 to 65% (Brent 1995) [8]. In adolescents who have already committed parasuicide, drug addiction significantly increases the risk of dying from suicide (Kotila 1992) [47].

Other risk factors and typical characteristics (partly according to Graham 1991) [35]:

  • psychiatric history in the family (primarily depressive disorders and personality disorders; du Bois 2006) [22];
  • loss of parents (identification; desire for reunification; Zilboorg 1936) [92];
  • inconsistent parental behavior (changes from permissive to restrictive attitudes);
  • social isolation of children and adolescents (in the family and among peers);
  • chronic somatic diseases;
  • teenage pregnancy.

However, the importance of specific psychosocial stressors is less clear. Marttunen et al. (1993) [57] compared different studies on adolescent suicide based on "psychological autopsy": the main psychosocial problems were found in most victims, but some psychosocial risk factors could not be identified. Gould et al. (1998) [???] found a link between adolescent suicide and separation or divorce in the family, but after studying parental psychopathology, these claims lost their value.

Characteristics of suicidal adolescents

Suicidal adolescents have the following characteristics (modified according to Eggers and Esch 1988) [23]:

  • Uncertainty of self-esteem (shame).
  • Strict and rigid Superego (pathological organization of the superego, guilt).
  • High Self-Ideal (fear of failure).
  • Ambivalent and unreliable interpersonal relationships.
  • Difficulties in controlling aggression (outbursts of aggression and subdued aggression).
  • The propensity for reverse aggression (self-directed).
  • Fear of total neglect and helplessness.
  • Denial of reality.
  • Pathological idealization (for example, themselves).
  • Fantasies about death (harmony, peace, and security).

Parental psychopathology

The psychiatric illness in parents increases the likelihood of suicide in children. Garber et al. (1998) [29] found an increased "suicide index" in children of depressed mothers.

Brent et al. (1992) [???] found a link between adolescent suicide and major depression, bipolar disorder, personality disorder, and family history of drug abuse.

A long-term study of suicidal adolescents it was found that parental drug abuse, as well as a suicide attempt in the mother's biography, were positively associated with suicide compared with the control group (Pfeffer et al., 1998) [68].

Suicidal fantasies

Suicidal fantasies are extremely common among adolescents. In one study among 15-20-year-old adolescents, it was found that 38% (!) of them at least once more or less seriously thought about committing suicide (42% of girls; 30% of boys). 6% of respondents prepared for this (8% of girls, 3% of boys), and about 2–4% of all adolescents (especially girls) attempted suicide (Faust and Wolf 1983 [???]; Du Bois 2006 [22]).

A large prospective study has also shown that suicidal ideation in adolescence is seen as "a marker of severe suffering and a harbinger of dysfunction, indicating the need for early identification and subsequent intervention" (Reinherz et al. 2006) [71].

Feature of cognitive ideas about death, due to the life stage

Adolescents may be stronger able than children (and this protects them) to understand the existential dimension of death (the question of meaning; self-reflexive distancing from themselves). But at the same time, unlike adults, they, even more, underestimate the reality and finality of death and have a magical illusory idea about it and its reversibility. This hypothesis was developed in 1990 by Habermas and Rosemeier [36].

Existentialism in adolescence

Adolescents often experience a specific form of loneliness (due to the onset of separation from parents and the state between child and adult; that is, feelings of loneliness are also a price to pay for the development of independence). "By suicidal thoughts, they express a desire to actually realize their new freedom in a radical way" (Seiffge-Krenke 2007) [79]. Lewinsky-Aurbach (1980) [51] describes a kind of silence during a therapeutic session before suicide (tunnel vision according to E. Ringel 1961) [74]. Often, as in borderline patients (boderliners), the previous form of chronic suicide is the interest and obsession with death, which manifests itself in immersion in the following topics:

  • dark gothic;
  • satanism;
  • sleeping in coffins, etc. ("Queen of Darkness");
  • narcissistic meaning of death.

Topics of rejection and suicide

Conflicts of autonomy and dependence are especially important in adolescence. In particular, the challenge is the final separation from the mother. Apparently, suicidal adolescents have special problems during this process (Novick 1984) [63], a phenomenon that occurs in adult patients with narcissistic personality disorders, which is often decompensated after the death of one of the parents.

Affective disorders in adolescents are often underestimated

In particular, affective diseases are associated with an increased risk of parasuicide (Paggen 2003) [66]. Garrison et al. (1991) [30] found a significant relationship between the diagnosis of "major depression" and parasuicidal/suicidal thoughts in a large nationwide study of adolescent students. Pfeffer et al. (1991) [67] found in schoolchildren a sevenfold increased risk of developing an affective disorder after parasuicide. Adolescent social behavior disorders are also often accompanied by suicide (Apter et al. 1995 [4]; Brent et al. 1999 [10]).

Structural vulnerability

A crucial precondition for suicide rates, even greater than psychopathological symptoms, is narcissistic vulnerability (Ottino, 1999) [64]. However, in my opinion, both aspects - psychopathology or phenomenology on the one hand and the structure or psychodynamics on the other - should not be opposed to each other. In an empirical study of the structure, about 50 psychiatric patients with and without suicide attempts were examined for self-directed aggression, object loss, self-dysfunction, and pathological object relationships. At the same time, pathological object relations and object loss were discriminatory in regard to suicide (Kaslow et al. 1998) [41].

Simulation aspects ("Werther effect")

Probably the most classic reason for the increase in suicide rates among adolescents is imitation. An illustration of the "infection" with suicide can be considered, for example, the consequences of the broadcast of a very suggestive television series "Death of a Student" in 1980, which shows the suicide of a student. A study by the Central Institute of Mental Health in Mannheim found that immediately after the series was the first broadcast, and after it was repeated the following year, the number of railway suicides among young people increased by 175%. "Death forums" on the Internet are also known and the wave of suicides among teenagers in the small town of Bridge in South Wales (15-27 years, 2007/2008: 24 suicides in two years). The first cases of such epidemics were recorded around 1900 (Neubauer 1992) [62].

Taimenen et al. (1998) [87] were able to identify the effect of imitation, which they interpreted as a small group ritual to reinforce a sense of belonging, in a prospective study of adolescents in inpatient treatment due to both parasuicide and self-harm. Brent et al. (1993) [9] showed that outside the hospital there is a tendency to increase the number of parasuicides and suicidal thoughts in students who have experienced previous suicide of classmates, which in turn confirms the relevance of the so-called "Werther effect".

Simulated, actually caused by the identification of the "Werther effect" (so named due to the increase in the number of suicides immediately after the publication of Goethe's novel "The Sorrow of the Young Werther", which even led to a temporary ban on publication in some parts of Germany) is also described in the Greek myth of Erigone. Erigone was the daughter of the Athenian Icarius. According to the elegy of Eratosthenes of Cyrene (III century BC), the god Dionysus taught Icarius the art of viticulture, and as a token of gratitude for hospitality gave a grape-vine. On behalf of Dionysus, Icarius intended to spread this knowledge. One day he gave wine to the shepherds. And as they did not know what meant to be drunk, they decided that Icarius had poisoned them. They killed him and buried his body in the mountains. Icarius' daughter Erigone searched for her father for a long time, and finally, with the help of her dog Myra, she found his tomb. In desperation, Erigone hung herself on the same tree under which her father's body lay. The dog remained in that place until it died. Then a crazy epidemic of suicides among young girls broke out in Athens. The Athenians received advice from the Delphic oracle to honor Icarius and Erigone with annual sacrifices (see Rosokoki 1995) [75].

Psychodynamics of suicidal relapse

The results of the so-called "Congress of Suicides" of the Vienna Psychoanalytic Association in Wiesbaden in 1919 "On Suicide, in particular, the Suicide of Schoolchildren" contain a number of discussed psychodynamic theories of suicide:

  • Rudolf Reitler: fear of losing an object as a cause of suicide;
  • Isidor Sadger: the motive of unrequited love as a cause of suicide;
  • Wilhelm Stekel: reassessment of affectivity as a cause of suicide;
  • Alfred Adler: feelings of inferiority as a cause of suicide;
  • Karl Molitor: society as a cause of suicide.

Since then, various variants of the psychodynamics of suicide have been described:

  1. Manifestation of the murderous, destructive anger of the perfectionist part, which intends to function and persecutes another, infantile and helpless part.
  2. Manifestation of protection from deeper, threatening (early infantile) disintegration fears.
  3. Expressing a deep identification with the deceased and a desire to be united with them in death.
  4. Manifestation of the unresolved process of separation and individuation (for example, from the mother).
  5. (Quasi) depressive mode as a direction of aggression against oneself in traumatically experienced situations of separation.

The classic description of the psychodynamics of suicide includes:

  • typical triggers: separation, illness, role changes;
  • the so-called "narcissistic economy", described by Henseler mainly from the standpoint of self-psychology;
  • classical phases of suicidal detachment (Ringel 1961) [74];
  • similarities (but also differences) with severe depression (hopelessness, excessive guilt);
  • the link between suicide and aggression (recall the early, instinctive-theoretical views whose proponents spoke of "suicide");
  • suicide and self-regression;
  • specifics of suicides in children and adolescents.

Menninger (1938) [60] in his famous work postulated that in all forms of suicide (chronic, partial and organic) there are three common elements of motives: aggressive, self-punishing, and "perverse and unpleasant" erotic. Applying Freud's theory of death instincts to suicide, Manninger concludes that suicide is thus an expression of three tendencies: the desire to kill, the desire to be killed, and the desire to be dead.

Phases and dynamics of suicide according to Maltsberger

Maltsberger (2004) [54] describes the intrapsychic manifestations of suicidal behavior as follows:

  • splitting of the Self (Self) - self-regression;
  • failure to regulate affect;
  • narcissistic surrender;
  • the collapse of the representative world;
  • partial loss of ability to test reality.

This disorder, which is actually an "I-disorder", develops in four characteristic phases:

  1. The influx of affect.
  2. Desperate maneuvers to avoid a mentally difficult situation.
  3. Loss of control due to increasing disintegration of the self.
  4. The grandiose, magical idea of "mental survival" (splitting the self-image, "dissociation of the body")

Theoretical concepts

Two of the most important modern theoretical psychodynamic approaches to suicide represent object relations theory and self-psychology (see Dammann 2012) [16]. Both directions (especially object psychology) are based on different aspects of the previously dominant driving direction of psychoanalysis.

Kind (1992) [44], who presented a model for the development of suicide in relation to object relationships, postulates that any act of suicide - including completed suicide - means the actualization of the pathological experience of object relations in early childhood and is motivated by conflicting interactions with internal (and external) objects. The object-psychological point of view in this group of patients revealed:

  • insufficient integration of the self-concept (according to Kernberg (1996) [42], the narcissistic patient is identified in suicide with a good part of himself, which punishes the bad part of himself);
  • the dominance of splitting;
  • defusion of self-image ("caring" versus "careless") (e.g., paradoxically contrived hypochondriac concern of drug addicts).

Another view is offered by Self-Psychology, based on a pathologically narcissistic, fixed way of self-regulation. In connection with Kohut's self-psychological concepts, Henseler (1974) [38] suggests that the primary problem of suicide is not a conflict of aggression, but a narcissistic disorder. Because of the necessarily experienced, narcissistically created object relations, the act of suicide is no longer understood as the murder of an object in the subject, but primarily as the salvation of the object and the preservation of an omnipotent sense of self, in the sense of action (genetically even earlier) fantasy of retreat into a harmonious basic (primary) state.

Narcissistic high-risk groups

It is probably no coincidence that all (statistical) groups at increased risk of suicide can also be considered as highly narcissistic groups. Including:

  • adolescents;
  • young men with schizophrenic diseases;
  • elderly men with loss experience.

This relationship was also empirically demonstrated in a qualitative study of 50 adolescents between the ages of 15 and 24 who had previously attempted suicide. Everall et al. (2006) [24] described three central emotional themes of self-perception:

  1. a depressing feeling of hopelessness,
  2. shame and self-loathing,
  3. feelings of otherness and isolation.

At the same time, adolescents found it difficult to cope with negative emotions (coping problems).

Narcissistic economy (Narzisstische Ökonomie)

An individual who is unsure of one’s self-esteem needs idealized individuals in the environment who must have a completely reliable and stabilizing effect to maintain a labile narcissistic balance. If this environment fails, for example, through resentment and frustration, it leads to a "narcissistic catastrophe" from which it is needed to defend oneself. If protection fails, there is a regression to the so-called primary state with fantasies of peace, warmth, and security (merging with a diffusely experienced primary object; Henseler 1974) [38]. The suicider thus renounces through suicide one’s living individuality, however, subjectively gains reliability, security, and peace, even bliss.

Adolescence, as a narcissistically vulnerable phase

Adolescence has been described as a narcissistic transition phase (Blos 1973) [7], an intermediate phase of narcissistic removal (Jacobson 1961) [40], or a phase of narcissistic self-configuration (Streeck-Fischer 2009) [85]. Narcissistic problems are especially common in adolescence. Therefore, stress and maladaptation in adolescence are especially often associated with suicide. Self-esteem problems in adolescents (much stronger than in adults) are associated with suicidal thoughts (Overholser et al. 1995) [65]. Empirically, narcissistic problems became apparent in young soldiers who shortened their lives (King and Apter 1996 [45]; Apter et al. 1993 [3]). Adolescents who cannot or do not want to be open, are distrustful, or share their experiences with anyone are especially at risk (Horesh et al. 2004) [39]. The narcissistic vulnerability is also pointed out, in particular, by the French authors Chabrol (1984) [12] and Caglar (1991) [???].

Narcissistic images that bring this unstable internal balance to a turning point may seem harmless to adolescents, but they have a catastrophic effect from within:

  • teenagers were not invited to the party (a topic of acceptance);
  • they did not pass the exam in the university (the topic of self-esteem and issues of power);
  • there was jest in the sexual sphere (psychosexual identity and shame).

Shame – the myth of Harila

In particular, shame and disgrace on the eve of suicide are very important for adolescents. On the one hand, shame is a trigger of itself, and on the other - as a complex affect is also a symptom of an internal crisis. Greek mythology has a prototype example of public shame even here, the shame of a teenager who later died.

In Greek mythology, Harila is the name of an orphan girl and the name of a holiday celebrated every eight years in Delphi. It was named after her death. As for the origin of the holiday, the ancient historian Plutarch says that at a time when famine reigned, the citizens came to the king to ask him for food. The king distributed bread and vegetables, but only to the best citizens, he knew personally. When a poor orphan girl named Harila persistently asked the king for food, an enraged ruler punched the girl in the face with his sandal. Thereafter Harila, couldn’t endure the shame, she went into the forest and hung herself on her own belt.

The problem of shame also includes non-hallucinatory forms of dysmorphophobic fears (du Bois 1990) [21] in adolescence. Suicide could also be seen as an attack on the disgrace, shame, intolerable, sexually altered body (Laufer and Laufer 1984) [48]. Thus, suicide will be an expression of a form of "hatred of the body" and thus an attempt to get rid of this unbearable body and the associated stress.

Typical dynamics and trigger

Failure of the first love relationship, conflict with parents or partners, as well as disciplinary problems, and conflicts with the law (for example, shoplifting) are typical of adolescent suicides. It is precisely the difficulty of adapting to social arrangements as a trigger for parasuicide among adolescents that was found by Fergusson and Lynskey (1995) [26] in a large long-term study: criminal activity, police contact, and school dropout were significantly more common among adolescents after parasuicide than in the rest of the sample.

The vast majority of suicide attempts are made by adolescents in the parental home (68%; Remschmidt and Schwab 1978) [72]. On the one hand, it shows the dynamics of the conflict, but probably also the desire to be saved (the probability of rescue and intentional mortality are strongly correlated).

Adolescent crisis and structural disorders as a trigger of suicide should, in my opinion, be distinguished, i.e., both suicidal actions, which are a manifestation of the crisis of adolescence (specific adaptation disorder), and structural disorders in adolescence should be evaluated. The latter group is characterized by major problems in various spheres of life, while during the adolescent crisis the problem is more specific (and, for example, does not affect school performance). However, both groups can be considered fundamentally suicidal. Adolescent crisis can be dramatic but quickly subsides. (Schwald and Dammann 2009) [77].

Spontaneous, sudden suicides (especially in male adolescents) occur and can also occur unpredictably, for example, immediately after a therapy session.

Suicide as a seal that protects against identity fragmentation

Both from the standpoint of self-psychology (internal narcissistic regulation) and from the object-psychological point of view, suicide is understood as a stabilizing "seal" that protects against fragmentation. Thus, in the understanding of Morgenthaler (1984) [61] (the concept of perversion), suicide could be understood as a kind of "seal" that aims to avoid mental disorganization. The instability of this phase of development in connection with the consolidation of identity is of particular importance.

  • Both individualization and the need for dependence are equally unbearable (even more than usual in adolescents).
  • Suicide (-fantasy) simultaneously satisfies both the fantasies of individualization and escape and, on the other hand, the desire to merge (Sztulman und Chabrol 1997) [13].
  • Whether the condition shortly before suicide should be understood more as a split (Friedman et al. 1972) [27] or as a traumatic return of the rejected (the collapse of the split; Sztulman und Chabrol 1997) [13] is meta-psychologically contradictory.

Identity problems in adolescence are quite common, but in normal development, they are tolerable and regulated. Crises of self-esteem should be considered not only as a problem of intrapsychic development, but also to check whether deeper neurotic or structural disorders are added, and differentiation is not always easy. Deep disturbances in family dynamics are also very important in this context. It is probably not uncommon for these aspects to be closely linked: developmental problems or pathological problems of self-regulation and lack of family support. In this regard, it seems plausible that homosexual adolescents are exposed to a special burden (stamps) of identity and have higher rates of fear, depression, psychopathology, somatization, and suicide (Biernbaum und Ruscio 2004) [6].

Conscious and unconscious motives and fantasies

First of all, the motives during suicidal communication may be different:

  1. the interlocutor must worry or care;
  2. the interlocutor should see how bad you feel;
  3. the interlocutor must be punished;
  4. the interlocutor should be intimidated;
  5. The interlocutor should be forced to take coercive measures.

However, a number of conscious, subconscious, or unconscious motives and fantasies that may accompany suicidal tendencies among adolescents are more decisive:

  • desire to escape and pause (King and Apter 1996) [45];
  • desire for control and power;
  • desire to kill and punish;
  • desire to die;
  • auto-aggression;
  • uncontrolled discharge of aggressive intenseness (catharsis);
  • revenge and retribution (not so rare, for example, suicides of children of psychotherapists or even child and adolescent psychiatrists);
  • tendency to self-punishment due to unconscious guilt (punishment and redemption, retribution) (Kilpatrick 1948) [43];
  • fantasies of omnipotence, the desire to be "master of the situation";
  • anniversaries of death or birthdays - so it is important to record the days of the death of reference persons; a quarter of young people commit suicide within two weeks of their own birthday (Shaffer und Piacentini 1994) [80];
  • the murder of an internalized object;
  • reunion (Ernest Jones) with a dead or loved one;
  • the desire for rebirth (C.G. Jung), salvation, and a new beginning;
  • the actual realization of an emotional state that has already arisen, namely - the desire to be mentally "dead";
  • desire to return to childhood;
  • masochistic subordination.

Suicide and maternal object

Suicide and other aggressive attacks on one's own body are also seen as an attack on an internalized maternal object (Davies 1993) [18]. In this context, narcissistic desires for merging may prevail in the splitting and denial of all aggressive instinctual impulses (i.e., in the so-called "segregation of instincts"). Maternal connection and thoughts of death often coincide, as Stork (1993) [83] showed. Maternal (highly ambivalent) love as almost the only true love is often found in farewell letters (Seiffge-Krenke 2007) [79] ("Death is a woman you love only once, but forever"; "Death is the only woman you can trust").

Dissociation of physical and mental Self

Gerisch (2003) [32] describes the characteristic "Dissociation of the physical and mental self." The "mental self" is saved, the "body ego" seems to be sacrificed for the sake of it. A person with a narcissistic disorder, turning this hidden fantasy into action (suicide, suicide attempt, open threat of suicide), paradoxically (as something that is self-destructive, gets a self-protective effect), actively anticipates intrapsychic, threatening narcissistic catastrophes, and thus for the last time stabilizes the unstable "narcissistic economy". Here, dissociation must be understood descriptively rather than in a protective mode, which could be more of a denial or a split.

Narcissistic anger and rage (madness, shooting) of schoolchildren

Suicide after school shootings (Faust 2010) [25] should, in my opinion, also be understood as a special form of extended suicide associated with mass narcissistic anger (homicide-suicide). Similar actions have occurred in some cases before, for example, during the tragedy in Bremen in 1913, the school massacre in Bata in 1927, or the murder in Folkhoven in 1964. Recently, such acts occur more often, and criminals are often current or recently expelled students. The decision to commit a crime matures over a long period of time and is probably caused by a non-specific event, which ultimately makes targeted lethal violence the only solution for the offender. In the literature, resentments, and losses that are perceived by the offender as serious are regularly mentioned to be the trigger. Adler (2000) [1] presented three psychological and psychiatric typologies of criminals, distinguishing among (delusional) schizophrenic, (shy) depressive, and (narcissistic) personality disorder. The author considers the latter as the most dangerous, whose actions lead to the largest number of victims. Young teachers or students were attacked by young people in a state of amok, depending on the nature of the previous insult.

Chronic suicide

While in most cases the occurrence of suicide fits into the picture of crisis exacerbation, there are severe forms of personality disorder in which chronic suicide is not part of the crisis, but on the contrary, suicide failure can lead to a crisis shock (Dammann und Gerisch 2005) [17]. Suicide can be seen as a last-ditch attempt to establish personal independence and thus triumph over an object that is so desperately needed. Attempted suicide in such cases (also in therapy) is sometimes an attempt to punish the object for its imperfection. Suicide in this group of patients is an expression of a desperate situation of dependence on others and because of this - a tendency to expose themselves more and more to internal psychological dangers (fear of merging, paranoid feelings, guilt, shame, etc.).

The concept of disobjectification of the French psychoanalyst Andre Green can be useful for a better understanding of the so-called "terminally ill" patients (Dammann 2010) [15].

The little prince

It is probably no coincidence that in the farewell letters of adolescents who shortened their lives, they found quotes from the famous and often incomprehensible to children work of Antoine de Saint-Exupery "The Little Prince" (Klagsbrun 1976 [46]; Diekstra 1987 [20]). This work describes many "narcissistic" themes of adolescence (existential loneliness, grandeur, etc.), and the meeting of the little prince with the personification of death - a snake that tries to seduce him - is also convincing. The temptation is not presented here in a sexual context (as in the case of Adam and Eve) but in a narcissistic one.

Suicide is affective and in these cases is not always associated with depression and hopelessness. All possible forms of other affective states are described and reach "ecstatic forms" (Maltsberger 1997) [53].

Therapy

The therapy of suicidal adolescents places high demands on therapists and other staff, especially when it comes to understanding countertransference, such as when a patient initially appears very unavailable, unwilling to cooperate, or prone to rejection.

Empirical data are striking (for example, in a large Danish epidemiological study of 72,765 children and adolescents, which found that adolescents treated by psychiatrists or in contact with psychiatry had an increased tendency to commit suicide (Christiansen und Larsen 2011) [14]). However, the probable causes of this phenomenon are insufficiently studied (possible factors of influence could be a low economic status, the presence of personality or addiction disorders, drug addiction, or pharmacological polypragmatism).

Modification of dialectical behavioral therapy (DBT) primarily for adolescents with borderline problems was studied by Rathus and Miller (2002) [69] in a therapeutic study.

Grounds

After a suicide attempt, narcissistic conflict is often not given enough attention. Suicide can only be "directed" (somatic help, referral to outpatient therapists). Sometimes there is a so-called "exchange of blows" between a group of doctors and a patient. Often there is a prejudice against the patient: "he is to blame", seeks to end the relationship, etc. There is a risk of a lack of understanding and coordination between therapists. On the one hand, there are "protective" therapists, who, however, seem unconsciously "infantilized", on the other hand, and in contrast to them - therapists who confront reality, pretending to be cruel and indifferent. Both should be rejected. Suicidal patients meet therapists with rejection or hostility that actually affects other people (substitution) (Reimer und Henseler 1981) [70].

Comments on countertransference

A special problem during treatment is the lack of countertransference analysis. In fact, these patients should be discussed more often in supervision and Balint groups. Counter- Countertransference feelings (and negative ones as well) are always the key to the patient's inner psychic world if they understand them and do not act them out. Typical countertransference reactions can be (partly according to Giernalczyk und Kind 2008) [34]:

  • countertransference hatred (feelings of disgust, Maltsberger und Buie 1974) [55];
  • therapists want to unconsciously distance themselves from patients who are in detestation (Tabachnik 1961) [86];
  • appropriation of omnipotence and common achievements, "high flight" (difficulties are denied, resources are overestimated on the one hand);
  • the therapist tries to single out again the trauma of separation or adoption in prehistory through the patient's close family ties, but does not notice that it also exacerbates the suffering experienced in childhood;
  • regressive vortex and blackmail due to suicide (long-term tolerated by the therapist, increased desire for care instead of objective analysis);
  • attempts to heal an injured patient with a real relation to the injury caused by the action of transference or countertransference, eventually lead to recurrence (incest) of the trauma and its boundless dynamics;
  • Particularly inattentive or particularly controlling behaviors recorded during suicide may have been associated with parental error (Chabrol 1984) [12].

Various defense mechanisms of therapists increase the risk of suicide of their patients. The suicidal patient begins first with a "transference attack" consisting of a variable system of provocation and projection. It may occur a projection on the therapist, for example, the patient's hatred of the object, which disappoints or offends them. Provocation can take the form of verbal insults, devaluation, contempt for the therapist, or manifest itself indirectly through silence, constant repetition, or hypochondriac recitation of complaints. The danger may be that the therapists either suppress their anger, restrain their own feelings of hatred and thus make those feelings inaccessible in the relationship, or express them by insulting and humiliating the patient.

Considering the problem of suicide’s self-esteem, a doctor's narcissism is often a specific target of an attack of transference (for example, if the therapists suggest a plane of influence (attack) due to their own shortcoming). Interestingly, from a psychodynamic point of view, there is evidence that therapists who believe they will save their patients from suicide tend to achieve the opposite result (Searles 1967 [78]; Zee 1972 [91]; Richman und Eyman 1990 [73]). In these cases, the therapist in the context of the action of countertransference adopts the patient's unconscious desire for an unconditional, infinitely loving mother (for example, constantly available to the patient by phone, etc.). They take responsibility for the fact that they "stay alive" in collusion with their unconscious imagination. However, it is clear that the therapist will not be able to maintain this requirement indefinitely, which in the future may lead to the next catastrophe.

Verbalization and mentalization

In particular, confrontational interpretations should not be used too quickly among young people, as suicidal adolescents are particularly quick to respond to criticism and rejection, and therefore explanations may be perceived as an attack if they do not fit into the existing therapeutic relationship. In many cases, an initial, more supportive phase is required, in which the verbalization of affects and methods of mentalization (refinement and reflection) come to the fore. In this group of patients, even in an inpatient setting, a longer therapeutic relationship is often required (Thompson et al. 2005) [88], which in the future may lead to a narrative reconstruction of the suicide attempt.

Significance

In the further process of treatment, there can be strengthened meaningful interpretations on the basis of psychodynamics (see above) which will be allowed by the patient. For example, showing the conflict between the libidinal (and why the suicide attempt failed) and the destructive aspects, when at the same time the patient denies the existence of the conflict and insists that they want to kill themselves, or that the danger is gone. The libido component should in this case be only named (and not proven), otherwise, there is a risk of the so-called power struggle, which in turn prevents dialogue with the needy parts of the patient and brings aggression to the fore. The purpose of this phase is to make suicidal behavior "ego-dystonic."

Further fields of interpretation appear if the adolescent seeks to live only for their pet or another person. In this case, the manifestation of libidinal aspects and their dangers are shown (projection of libidinal aspects of one's own "self" into another in order to protect them from destructive influence). The danger is that this can lead to decompensation when "the other does not live up to expectations" because self-regulation is closely linked to the other object.

A different dynamic, which Fairbairn object-psychologically described in the 1940s, occurs when a person takes on all the excessive guilt and attacks oneself, even though from the beginning it is the person who was injured or the one who was attacked. Dynamically, it is about maintaining a good appearance (physical impression) and (obvious) control by taking all the blame. It may also show the paradox that a person attacks oneself even more if they feel humiliated or attacked.

Generalization

Adolescent suicide is common, often spontaneous, and sometimes latent.

Suicide and self-injurious behavior are phenomena that are difficult to distinguish.

Psychopathological and psychodynamic phenomena are interrelated.

Specific conflicts and tasks of adolescence development, as well as the narcissistically vulnerable phase, prepare the ground for suicide.

The body, feelings of shame, and the formation of identity play a special role.

However, pre-existing structural vulnerabilities are crucial.

Imitation or better identification aspects are of particular importance.

There are different types of adolescent suicides that need to be distinguished.

Conscious and unconscious motives matter.

Self-destructive and "self-protective" aspects have an intrapsychic effect, so suicide appears as a kind of "solution".

The psychodynamic view of adolescent suicide complements sociological, biological, and psychiatric (phenomenological and nosological) approaches.

Knowledge of psychodynamics helps to distinguish which adolescent patients, regardless of diagnosis, should be classified as more or less prone to suicide (Hendin 1991).

During therapy, special attention should be paid to countertransference and the "struggle for power", which should be avoided using a purely supportive strategy.

References

  1. Adler L. Amok, Eine Studie. München: Belleville; 2000.
  2. Andrews JA, Lewinsohn PM. Suicidal attempts among older adolescents: Prevalence and co-occurrence with psychiatric disorders. J Am Acad Child Adolesc Psychiatry. 1992;31(4):655–62. DOI: https://doi.org/10.1097/00004583-199207000-00012 PMID: https://pubmed.ncbi.nlm.nih.gov/1644728/
  3. Apter A, Bleich A, King RA, et al. Death without warning, A clinical postmortem study of suicide in 43 Israeli adolescent males. Arch Gen Psychiatry. 1993;50(2):138–42. DOI: https://doi.org/10.1001/archpsyc.1993.01820140064007 PMID: https://pubmed.ncbi.nlm.nih.gov/8427554/
  4. Apter A, Gothelf D, Orbach I, et al. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry. 1995;34(7):912–8. DOI: https://doi.org/10.1097/00004583-199507000-00015 PMID: https://pubmed.ncbi.nlm.nih.gov/7649962/
  5. Apter A, Gothelf D, Offer R, et al. Suicidal adolescents and ego defense mechanisms. J Am Acad Child Adolesc Psychiatry. 1997;36(11):1520–7. DOI: https://doi.org/10.1016/s0890-8567(09)66560-6 PMID: https://pubmed.ncbi.nlm.nih.gov/9394936/
  6. Biernbaum MA, Ruscio M. Differences between matched heterosexual and non-heterosexual college students on defense mechanisms and psychopathological symptoms. J Homosex 2004;48(1):125–41. DOI: https://doi.org/10.1300/J082v48n01_06
  7. Blos P. Adoleszenz. Stuttgart: Klett-Cotta; 1973.
  8. Brent DA. Risk factors for adolescent suicide and suicidal behavior: mental and substance abuse disorders, family environmental factors, and life stress. Suicide Life Threat Behav. 1995;25:52–63. PMID: https://pubmed.ncbi.nlm.nih.gov/8553429/
  9. Brent DA, Perper JA, Moritz G, et al. Psychiatric Risk Factors for Adolescent Suicide: A Case-Control Study. J Am Acad Child Adolesc Psychiatry. 1993;32(3):521–9. DOI: https://doi.org/10.1097/00004583-199305000-00006 PMID: https://pubmed.ncbi.nlm.nih.gov/8496115/
  10. Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L. Age- and sex-related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry. 1999;38(12):1497–505. DOI: https://doi.org/10.1097/00004583-199912000-00010 PMID: https://pubmed.ncbi.nlm.nih.gov/10596249/
  11. Bronisch T, Wunderlich U. Psychische Störungen und Komorbidität bei Jugendlichen und jungen Erwachsenen mit Suizidversuch. Suizidprophylaxe. 1998;3:92–9.
  12. Chabrol H.Les comportements suicidaires de l’adolescent. Paris: PUF; 1984.
  13. Chabrol H, Sztulman H. Splitting And The Psychodynamics Of Adolescent And Young Adult Suicide Attempts. Int J Psycho-Anal. 1997;78:1199–208.
  14. Christiansen E, Larsen KJ.Young people’s risk of suicide attempts after contact with a psychiatric department – a nested case-control design using Danish register data. J Child Psychol Psychiatry. 2011;53(1):16-25 DOI: https://doi.org/10.1111/j.1469-7610.2011.02405.x PMID: https://pubmed.ncbi.nlm.nih.gov/21564096/
  15. Dammann G. Vom Tode bewohnte Patienten. Zeitschrift psychoanal Theorie Technik. 2011;25:461–73.
  16. Dammann G, Grimmer B, Sammet I. Narzissmus: Theorie, Diagnostik, Therapie. Stuttgart: Kohlhammer; 2012. URL: https://download.e-bookshelf.de/download/0002/7595/14/L-G-0002759514-0014126318.pdf
  17. Dammann G, Gerisch B. Narzisstische Persönlichkeitsstörungen und Suizidalität: Behandlungsschwierigkeiten aus psychodynamischer Perspektive. Schweiz Arch Neurol Psychiatrie. 2005;156:299–309.
  18. Davies M. Heroic deeds, manic defense, and intrusive identification: some reflections on psychotherapy with a 16-year old boy. J Child Psychother. 1993;19(1):79–94. DOI: https://doi.org/10.1080/00754179308259382
  19. Diekstra RF, Garnefski N. On the nature, magnitude, and causality of suicidal behaviors: an international perspective. Suicide Life Threat Behav. 1995;25(1):36–57. PMID: https://pubmed.ncbi.nlm.nih.gov/7631374/
  20. Diekstra RFW, Hawton K. Suicide in Adolescence. Dordrecht: Martinus Nijhoff; 1987:25–78.
  21. Du Bois R. Körpererleben und psychische Entwicklung. Göttingen: Hogrefe; 1990.
  22. Du Bois R (2006) Emotionale Entbehrung und narzisstische Regulation – Zur Entstehung und Behandlung depressiver Krisen bei Kindern und Jugendlichen. Prax Kinderpsychol Kinderpsychiatr. 2007;56(3):206–23. URL: https://www.pedocs.de/volltexte/2011/3049/pdf/Du_Bois_Emotionale_Entbehrung_und_narzisstische_Regulation_2007_Heft_56_03_W_D_A.pdf
  23. Eggers C, Esch A. Krisen und Neurosen in der Adoleszenz, In Kinder- und Jugendpsychiatrie. Berlin: Springer; 1988:324–329.
  24. Everall RD, Bostik KE, Paulson BL. Being in the Safety Zone: Emotional experiences of suicidal adolescents and emerging adults. J Adolescent Res. 2006;21:370–92.
  25. Faust B. School-Shooting. Jugendliche Amokläufer zwischen Anpassung und Exklusion. Giessen: Psychosozial; 2010.
  26. Fergusson DM, Lynskey MT. Childhood circumstances, adolescent adjustment, and suicide attempts in a New Zealand birth cohort. J Am Acad Child Adolesc Psychiatry. 1995;34(5):612–22. DOI: https://doi.org/10.1097/00004583-199505000-00013 PMID: https://pubmed.ncbi.nlm.nih.gov/7775356/
  27. Friedman M, Glasser M, Laufer E, Laufer M, Wohl M. Attempted suicide and self-mutilation in adolescence: Some observations from a psychoanalytic research project. Int J PsychoAnal. 1972;53(2):179–83. PMID: https://pubmed.ncbi.nlm.nih.gov/5057061/
  28. Gabbard GO. Miscarriages of psychoanalytic treatment with suicidal patients. Int J Psychoanal.2003;84(2):249–61. DOI: https://doi.org/10.1516/002075703321632720 PMID: https://pubmed.ncbi.nlm.nih.gov/12856351/
  29. Garber J, Little S, Hilsman R, Weaver KR. Family predictors of suicidal symp- toms in young adolescents. Journal of Adolescence. 1998;21(4):445–57. DOI: https://doi.org/10.1006/jado.1998.0161 PMID: https://pubmed.ncbi.nlm.nih.gov/9757409/
  30. Garrison CZ, Jackson KL, Addy CL, McKeown RE, Waller JL. Suicidal behavi- ors in young adolescents. Am J Epidemiol. 1991;133(10):1005–14. DOI: https://doi.org/10.1093/oxfordjournals.aje.a115809 PMID: https://pubmed.ncbi.nlm.nih.gov/2035501/
  31. Garrison CZ, McKeown RE, Valois RF, Vincent ML. Aggression, substance use, and suicidal behavior in high school students. Am J Pub Health. 1993;83(2):179–84. DOI: https://dx.doi.org/10.2105%2Fajph.83.2.179 PMID: https://pubmed.ncbi.nlm.nih.gov/8427319/
  32. Gerisch B. Die suizidale Frau. Psychoanalytische Hypothesen zur Genese. Göttingen: Vandenhoeck & Ruprecht; 2003.
  33. Gerisch B, Fiedler G, Gans I, Götze P, Lindner R, Richter M. Ich sehe dieses Elendes kein Ende als das Grab: Zur psychoanalytischen Konzeption von Suizidalität und der Behandlung Suizidgefährdeter. Tübingen: Edition discord; 2000:9–64.
  34. Giernalczyk T, Kind J. Psychoanalytisch-tiefenpsychologische Konzepte von Suizidalität. Regensburg: Roderer; 2008:197–218.
  35. Graham P. Child Psychiatry: A developmental approach. Oxford: Oxford University Press; 1998.
  36. Habermas T, Rosemeier HP. Kognitive Entwicklung des Todesbegriffes. Heidelberg: Springer; 1990:263–79.
  37. Hendin H. Psychodynamics of Suicide, with particular reference to the young. Am J Psychiatry 1991;148(9):1150–8. DOI: https://doi.org/10.1176/ajp.148.9.1150 PMID: https://pubmed.ncbi.nlm.nih.gov/1882991/
  38. Henseler H. Narzißtische Krisen, Zur Psychodynamik des Selbstmords. Opladen: Westdeutscher Verlag; 1974. DOI: https://doi.org/10.1007/978-3-322-97123-4
  39. Horesh N, Zalsman G, Apter A. Suicidal behavior and self-disclosure in adolescent psychiatric inpatients. J Nerv Ment Dis. 2004;192(12):837–42. DOI: https://doi.org/10.1097/01.nmd.0000146738.78222.e5 PMID: https://pubmed.ncbi.nlm.nih.gov/15583505/
  40. Jacobson E. Adolescent moods and the remodeling of psychic structures in adolescence. Psychoanalytic Study Child. 1961;16:164–83.
  41. Kaslow NJ, Reviere SL, Chance SE, et al. An Empirical Study of the Psychodynamics of Suicide. J Amer Psychoanal Assn. 1998;46(3):777–96. DOI: https://doi.org/10.1177/00030651980460030701 PMID: https://pubmed.ncbi.nlm.nih.gov/9795891/
  42. Kernberg OF. Narzissmus, Aggression und Selbstzerstörung. Fortschritte in der Diagnose und Behandlung schwerer Persönlichkeitsstörungen. Stuttgart: Klett-Cot- ta; 1996.
  43. Kilpatrick E. A psychoanalytic understanding of suicide. Am J Psychoanal. 1948;8:13– 23.
  44. Kind J. Suizidal, Psychoökonomie einer Suche. Göttingen: Vandenhoeck and Ru- precht; 1992.
  45. King RA, Apter A. Psychoanalytic perspectives on adolescent suicide. Psychoanal Study Child. 1996;51:491-511. DOI: https://doi.org/10.1080/00797308.1996.11822443 PMID: https://pubmed.ncbi.nlm.nih.gov/9029973/
  46. Klagsbrun F. Too young to die. Boston: Houghton; 1976.
  47. Kotila L. The outcome of attempted suicide in Adolescence. Soc Adolesc Med. 1992;13(5):415–7. DOI: https://doi.org/10.1016/1054-139X(92)90043-B
  48. Laufer M, Laufer ME. Adoleszenz und Entwicklungskrise. Stuttgart: Klett- Cotta; 1984.
  49. Laurent A, Foussard N, David M, Boucharlat J, Bost M. A 5-year follow-up study of suicide attemts among french adolescents. Journal of Adolescent Health. 1998;22(5):424–30. DOI: https://doi.org/10.1016/s1054-139x(97)00262-0 PMID: https://pubmed.ncbi.nlm.nih.gov/9589345/
  50. Lesch KP, Gross J, Franzek E, et al. Primary structure of the serotonin transporter in unipolar depression and bipolar disorder. Biol Psychiatry. 1995;37(4):215–23. DOI: https://doi.org/10.1016/0006-3223(94)00147-U
  51. Lewinsky-Aurbach B. Suizidale Jugendliche, Grenzen und Möglichkeiten psychodynamischen Verstehens. Stuttgart: Enke; 1980.
  52. Livingston R, Bracha HR. Psychotic symptoms and suicidal behavior in hospitalized children. Am J Psychiatry. 1992;149(11):1585–6. DOI: https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.1176%2Fajp.149.11.1585 PMID: https://pubmed.ncbi.nlm.nih.gov/1415829/
  53. Maltsberger JT. Ecstatic suicide. Arch Suicide Research. 1997;3:283–301. DOI: https://doi.org/10.1080/13811119708258280
  54. Maltsberger JT. The descent into suicide. Int J Psychoanal. 2004;85:653-67. DOI: https://doi.org/10.1516/3C96-URET-TLWX-6LWU
  55. Maltsberger JT, Buie DH. Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry. 1974;30(5):625–33. DOI: https://doi.org/10.1001/archpsyc.1974.01760110049005 PMID: https://pubmed.ncbi.nlm.nih.gov/4824197/
  56. Marttunen MJ, Aro HM, Henriksson MM, Lönnqvist JK. Mental disorders in adolescent suicide, DSM-III-R axes I and II diagnoses in suicides among 13- to 19-year-olds in Finland. Arch Gen Psychiatry. 1991;48(9):834–9. DOI: https://doi.org/10.1001/archpsyc.1991.01810330058009 PMID: https://pubmed.ncbi.nlm.nih.gov/1929774/
  57. Marttunen MJ, Aro HM, Lönnqvist JK. Adolescence and suicide: A review of psychological autopsy studies. Europ Child Adolesc Psychiatry. 1993;2(1):10–8. DOI: https://doi.org/10.1007/bf02098826 PMID: https://pubmed.ncbi.nlm.nih.gov/21590525/
  58. McClure GMG. Suicide in children and adolescents in England and Wales 1970–1998. Br J Psychiatry. 2001;178:469–74. DOI: https://doi.org/10.1192/bjp.178.5.469 PMID: https://pubmed.ncbi.nlm.nih.gov/11331565/
  59. Mehlum L, Hytten K, Gjertsen F. Epidemiological trends of youth suicide in Norway. Arch Suicide Research. 1999;5(3):193–205. DOI: https://www.researchgate.net/deref/http%3A%2F%2Fdx.doi.org%2F10.1080%2F13811119908258329
  60. Menninger K. Man Against Himself. New York: Harcourt; 1938.
  61. Morgenthaler F. Homosexualität, Heterosexualität, Perversion. Frankfurt am Main: Qumran; 1984.
  62. Neubauer J. The Fin-de-Siecle Culture of Adolescence. New Haven: Yale University Press; 1992.
  63. Novick J. Attempted suicide in adolescence: the suicide sequence. Bosten: John Wright; 1984:115–137.
  64. Ottino J. Suicide attempts during adolescence: Systematic hospitalization and crisis treatment. Crisis. 1999;20(1):41–8. DOI: https://doi.org/10.1027//0227-5910.20.1.41 PMID: https://pubmed.ncbi.nlm.nih.gov/10365506/
  65. Overholser JC, Adams DM, Lehnert KL, Brinkman DC. Self-esteem deficits and suicidal tendencies among adolescents. J Am Acad Child Adolesc Psychiatry. 1995;34(7):919– 28. DOI: https://doi.org/10.1097/00004583-199507000-00016 PMID: https://pubmed.ncbi.nlm.nih.gov/7649963/
  66. Paggen U. Suizidalität und Automutilationen während der stationären Behandlung jugendpsychiatrischer Patienten. München: Ludwig-Maximilians-Universität; 2003. URL: https://edoc.ub.uni-muenchen.de/1464/1/Paggen_Ulrich.pdf
  67. Pfeffer CR, Klerman GL, Hurt SW, et al. Suicidal children grow up: demographic and clinical risk factors for adolescent suicide attempts. J Am Acad Child Adolesc Psychiatry. 1991;30(4):609–16. DOI: https://doi.org/10.1097/00004583-199107000-00013 PMID: https://pubmed.ncbi.nlm.nih.gov/1890095/
  68. Pfeffer CR, Normandin L, Kakuma T. Suicidal children grow up: relations between family psychopathology and adolescents’ lifetime suicidal behavior. J Nerv Ment Dis. 1998;186(5):269–75. DOI: https://doi.org/10.1097/00005053-199805000-00002 PMID: https://pubmed.ncbi.nlm.nih.gov/9612443/
  69. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002;32(2):146–57. DOI: https://doi.org/10.1521/suli.32.2.146.24399 PMID: https://pubmed.ncbi.nlm.nih.gov/12079031/
  70. Reimer C, Henseler H. Missglückte Interventionen bei Suizidanten. Stuttgart: Frommann-Holzboog; 1981:171–87.
  71. Reinherz HZ, Tanner JL, Berger SR, Beardslee WR, Fitzmaurice GM. Adolescent suicidal ideation as predictive of psychopathology, suicidal behavior, and compro- mised functioning at age 30. Am J Psychiatry. 2006;163(7):1226–32. DOI: https://doi.org/10.1176/appi.ajp.163.7.1226 PMID: https://pubmed.ncbi.nlm.nih.gov/16816228/
  72. Remschmidt H, Schwab T. Suizidversuche im Kindes- und Jugendalter. Acta Paedopsychiatrica. 1978;43(5):197–208. PMID: https://pubmed.ncbi.nlm.nih.gov/360767/
  73. Richman J, Eyman JR. Psychotherapy of suicide: individual, group, and family approaches. Philadelphia: Charles C Thomas; 1990:139–158.
  74. Ringel E. Neue Untersuchungen zum Selbstmordproblem, unter besonderer Berücksichtigung prophylaktischer Gesichtspunkte. Wien: Verlag Brüder Hollinek; 1961.
  75. Rosokoki A. Die Erigone des Eratosthenes eine kommentierte Ausgabe der Fragmente. Heidelberg: Winter; 1995.
  76. Schmidtke A, Bille-Brahe U, DeLeo D, et al. Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempers during the period 1989–1992, results of the WHO/EURO multicentre study on parasuicide. Acta Psychiatr Scand. 1996;93(5):327–38. DOI: https://doi.org/10.1111/j.1600-0447.1996.tb10656.x PMID: https://pubmed.ncbi.nlm.nih.gov/8792901/
  77. Schwald O, Dammann G. Krisenintervention bei narzisstischen Persönlichkeitsstörungen. München: CIP-Medien; 2009:87–100. URL: https://sbt-in-berlin.de/cip-medien/2007-2-11.-Schwald-Damman.pdf
  78. Searles H. The dedicated physician. Philadelphia: Lippincott; 1967:128–43.
  79. Seiffge-Krenke I. Psychoanalytische und tiefenpsychologisch fundierte Therapie mit Jugendichen. Stuttgart: Klett-Cotta; 2007.
  80. Shaffer D, Piacentini J. Suicide and attempted suicide. Oxford: Blackwell; 1994:407–24.
  81. Shaffer D, Gould MS, Fisher P, et al. Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 1996;53(4):339–48. DOI: https://doi.org/10.1001/archpsyc.1996.01830040075012 PMID: https://pubmed.ncbi.nlm.nih.gov/8634012/
  82. Shafii M, Carrigan S, Whittinghill JR, Derrick A. Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry. 1985;142(9):1061–4. DOI: https://doi.org/10.1176/ajp.142.9.1061 PMID: https://pubmed.ncbi.nlm.nih.gov/4025622/
  83. Stork J. Suizid und Inzestwunsch bei Adoleszenten. Kinderanalyse. 1993;1:13–23.
  84. Stortelder F, Ploegmakers-Burg M. Adolescence and the reorganization of infant development: a neuro-psychoanalytic model. J Am Acad Psychoanal Dyn Psychiatry. 2010;38(3):503–31. DOI: https://doi.org/10.1521/jaap.2010.38.3.503 PMID: https://pubmed.ncbi.nlm.nih.gov/20849240/
  85. Streeck-Fischer A. Adoleszenz und Narzissmus. Stuttgart: Schattauer; 2009:154–64.
  86. Tabachnik N. Countertransference crisis in suicidal attempts. Arch Gen Psychiatry. 1961;4:572–8. DOI: https://doi.org/10.1001/archpsyc.1961.01710120042005 PMID: https://pubmed.ncbi.nlm.nih.gov/13774724/
  87. Taimenen TJ, Kallio-Soukainen K, Nokso-Koivisto H, Kaljonen A, Helenius H. Contagion of deliberate self-harm among adolescent inpatients. J Am Acad Child Adolesc Psychiatry. 1998;37(2):211–7. DOI: https://doi.org/10.1097/00004583-199802000-00014 PMID: https://pubmed.ncbi.nlm.nih.gov/9473918/
  88. Thompsen C, Mazet P, Cohen D. Treatment of a Suicide Attempt through Psychodynamic Therapy in a 17-year-old boy with Depression: A Case report. Isr J Psychiatry Relat Sci. 2005;42(4):281–5. PMID: https://pubmed.ncbi.nlm.nih.gov/16618063/
  89. Wiener Psychoanalytischer Verein. Über den Selbstmord, insbesondere den Schüler-Selbstmord. Wiesbaden: Bergmann; 1910.
  90. Wunderlich U. Suizidales Verhalten im Jugendalter. Göttingen: Hogrefe; 2004.
  91. Zee HJ. Blindspots in recognizing serious suicidal intentions. Bull Menninger Clin. 1972;36(5):551–5. PMID: https://pubmed.ncbi.nlm.nih.gov/5077128/
  92. Zilboorg G. Consideration on suicide with particular reference to the young. Am J Orthopsychiatry. 1936;7(1):15–31. DOI: https://doi.org/10.1111/j.1939-0025.1937.tb05556.x

How to Cite

1.
Dammann † G, Polishchuk В. Le Petit Prince –Teenage Suicide. PMGP [Internet]. 2020 Aug. 28 [cited 2024 Mar. 28];5(2). Available from: https://ojsdemo.e-medjournal.com/index.php/psp/article/view/240