Tuesday, 18.05.2021

Peter R. Martin: Historical Vocabulary of Addiction




        The noun suicide, according to the current electronic version of the Oxford English Dictionary (OED), is derived from the Latin suīcīdium, a combination of suī  and -cīdium.  The first part of this combination means “of oneself.”  The second part is derived from the             French -cide and Latin -cīdium, meaning “cutting, killing or slaying, murder.”  The Latin words employing these combinations passed frequently via French into English, e.g., homicide (late Middle English), fratricide (16th century).  The meaning of suicide relevant to our discussion is: “The or an act of taking one's own life, self-murder.”  This is an important term to discuss as suicide is highly prevalent among those who suffer from addiction. 

        An example of the first use of the noun suicide in the English language, according to OED, was by Thomas Blount (1618-1679), an English antiquarian and lexicographer, in his work, Glossographia: A dictionary interpreting all such hard words…as are now used in our refined English tongue (1656): “Suicide, the slaying or murdering of himself; self-murder.”  Acceptance of the fact that taking one’s own life is not only theoretical, but actually occurs, led to philosophical, religious and legal deliberation concerning causes, implications and consequences of suicide.  Walter Charleton (1620-1707), a natural philosopher and physician known for introducing Epicurian ideas into England, wrote in Ephesian Matron (1659): “To vindicate ones self from… inevitable Calamity, by Sui-cide is not… a Crime.”  John Erskine of Carnock (1695-1768), a Scottish jurist and professor of Scottish law at the University of Edinburgh, wrote in An Institute of the Law of Scotland (1773): “Suicide, which is a species of murder, ought to be governed by the common rules of murder.”  William Cowper (1731-1800), one of the most popular poets of his time, wrote in his poem Truth, “Charge not... Your wilful suicide on God's decree.”  These quotations together represent accepted perspectives of suicide over time – the notion that suicide is a reasonable exit strategy if the calamity one faces is sufficiently great, that suicide is a crime, pure and simple and that such actions are wrong, a sin that may not be forgiven.

        It is not metaphysics, religion or the law that will be the focus here, but another equally relevant issue: that such an act is most often a consequence of a mental illness, a point that was plainly made in The Anatomy of Suicide by Lyttelton Stewart Forbes Winslow (1844-1913), the British psychiatrist involved in the Jack the Ripper case during the late Victorian era:

        “If we examine attentively the majority of cases of suicide, we shall find that the unfortunate persons have laboured, either for some time previously or at the very moment, under depression of spirits, anxiety of mind, and other symptoms of cerebral derangement. Very few cases of suicide take place in which you cannot trace the existence of previous mental depression, produced either by physical or moral agents. It may be said that lowness of spirits is not insanity; certainly not, according to the legal definition of the term; but we may always be assured, that if mental anxiety or perturbation be more than commensurate with the exciting cause, it may be presumed that the individual is labouring under the incipient indications of insanity.”

        In support of this opinion, whether the person is considered mentally ill or not, such an act seems so unfathomable that it is considered a sin by many religions, subject to legal consequences if failed and may disqualify one’s family from death benefits. 

        There is significant motivation post hoc to deny that a death was, in fact, caused by suicide. Therefore, ascertainment of rates of suicide represents a challenge for epidemiologists and prevalences in populations are of uncertain reliability and can become a subject of polemics.  For example, the early British authority on insanity, a surgeon-apothecary admitted as a Fellow of the Royal College of Physicians late in life, George Man Burrows (1771-1846) believed that “treatment of insanity had an optimistic future” (Tubbs 1947) and hence, viewed an outcome of suicide as a medical failure.  He engaged in an interchange with leaders of French psychiatry by writing A Reply to Messieurs Esquirol's and Falret's Objections to Dr. Burrows' comparative Proportions of Suicides in Paris and London (1822) to dispel the impression overseas that the British were “the most devoted to suicide”:

        “Dr. Esquirol, in the 53d volume of the ‘Dictionnaire des Sciences Médicales,’ article Suicide, has entered into an examination of the grounds on which, in my ‘Inquiry into certain Errors relative to Insanity,’ I have decided that self-destruction is more frequent in Paris than in London… As the contrary has been a favourite axiom with foreign, especially French, writers, it was to be expected that any attempt to controvert it would not long remain unnoticed. Accordingly, not only Dr. Esquirol, but his élève Dr. Falret, in a Work entitled ‘De l'Hypochondrie et Suicide, 1822,’ following his master's example, has attacked both the premises and deductions I have adopted.”  

        Of course, Jean-Étienne Dominique Esquirol (1772-1840) and Jean-Pierre Falret (1794-1870) were fitting adversaries in debate for Burrow.  They were both authorities on insanity, known for efforts to medicalize care in this field, initially inspired to do so at the Salpêtrière Hospital in Paris by Philippe Pinel (1745-1826) and his humane psychological approach to care of psychiatric patients.  All the same, one wonders whether this exchange was not simply continuation of a cross-channel rivalry that began at the Battle of Hastings in 1066, rather than a true analysis of the relationship between suicide and mental illness in the two countries, the rates of which were probably quite unreliable at that time.

        Whenever the prevalence of suicide has formally been examined, alcoholism is closely linked with the associated psychopathology (Whitehead 1972; Miles 1977).  This had been suspected since Magnus Huss (1849) declared in his classic on alcoholism, “…that the suicidal impulse is a more frequent accompaniment of the melancholia of drunkards than of melancholia from other causes; and further, that among the uneducated classes suicide frequently follows on the disordered emotional tone, which, sooner or later, results from the abuse of alcoholic liquors.”  After weighing various potential mechanisms whereby alcohol use might be implicated in suicidality, the author of the editorial The Relation of Alcoholism to Suicide concluded (Anonymous 1902):

        “…the chronic intoxication by alcohol, as we observe it clinically, produces generalised disorders of visceral function throughout the economy, whence there results an alteration and disturbance of those organic stimuli which form the groundwork of our personality; those, stimuli whose activity, as Maudsley [Henry Maudsley (1835-1918) was a pioneering English psychiatrist, commemorated in the Maudsley Hospital in London and in the annual Maudsley Lecture of the Royal College of Psychiatrists] puts it, is ‘even of more consequence in determining the tone of our feeling or of our disposition and the character of our impulses than that activity which follows impressions received from the external world.’ The depressed emotional tone thereby induced prepares the suicidal impulse, which issues in action when a supervening increase of intoxication has still further lowered the level of function in the brain.”

        The association between alcoholism and suicide has been extensively documented since these early reports, including implicative drinking among persons who commit suicide, documented occurrence of suicidal thoughts and attempted suicide and completed suicide among persons who are alcoholics (Whitehead 1972).  Even if an actual suicidal act cannot be identified, alcoholism may be considered a form of slow suicide based on destruction of one’s health and personality through drinking (Menninger 1938).  Associations with suicide are not restricted to alcoholism, but have subsequently been reported for all drugs of abuse, e.g.,  sedative hypnotics (Allgulander, Ljungberg and Fisher 1987), opioids (Vaillant 1966) and stimulants (Kalant and Kalant 1975), suggesting that suicide may not relate absolutely to the pharmacological actions of the agent as much as clinical characteristics of the user, the motivation for use, response to the drug and its life consequences (Robins, Gassner, Kayes et al. 1959; Miles 1977; Mann, Waternaux, Haas and Malone 1999).    

        Most studies demonstrate a greater likelihood of death by suicide in those who have alcoholism/drug use disorder co-occurring with other psychiatric disorders, especially depressed mood and hoplessness (Weissman, Slobetz, Prusoff et al. 1976).  Also, since in early epidemiologic studies, mood disorders and addictive disorders each accounted for the highest rates of suicidality among all psychiatric diagnoses (Miles 1977), the important question that remains is whether the primary driver of suicide is a mood disorder, an addictive disorder, or their combined effects.  In fact, co-occurring mood disorders and alcohol/drug use disorders are very common (Regier, Farmer, Rae et al. 1990) and such individuals may be particularly at risk for suicide.  Among the various psychiatric diagnoses associated with suicide, common wisdom has pointed to the significant preponderance of depressive features.  However,  this viewpoint has evolved to recognizing the important role of mood instability, as manifested in patients with bipolar disorders in depressed phase or mixed state and unipolar depression with mixed features, as well as the state precipitated by selective serotonin receptor uptake inhibitors in these individuals (Bunney, Murphy, Goodwin and Borge 1970; Jamison 2000; Akiskal, Benazzi, Perugi and Rihmer 2005).  Recent research has suggested that the mood disorders most associated with alcohol/drug use disorders may not be unipolar depressive disorders at all, as was previously thought, but rather hyperthymic mood disorders which may play a mechanistic role in development of addiction (Rich and Martin 2014).  Finally, Mann, Waternaux, Haas and Malone (1999) have proposed that a more useful approach to determining risk for suicidal behavior may be the concept of a predisposing stress diathesis, which makes room for other psychiatric disorders and traumatic experiences in the formulation.

        Investigations of the inheritance of suicidality have proceeded down a similar path as have epidemiologic studies of the associations of suicidal behavior with psychiatric diagnoses – the initial  focus was linking suicidal behaviors to the genetics of depression (Roy 1993).  Although this approach yielded advances, Chistiakov, Kekelidze and Chekhonin (2012) have described a strategy for linking suicidal behaviors with endophenotypes, namely separation of behavioral symptoms into more stable phenotypes with a clear genetic connection (John and Lewis 1966). Proposed endophenotypes included impulsive/aggressive traits as mediated by low serotonergic function, neurocognitive impairment resulting in disinhibition of impulses and decision making, particularly severe (early onset) major depression, profound stress as manifested by hyperactivity of hypothalamic–pituitary–adrenal axis, functional neuroimaging measures of brain responses as emotions and impulse inhibition, lowered skin conductance, personality disorders characterized by interpersonal hyperreactivity and lithium treatment response.  It is important to note that many of these endophenotypes are closely inter-related and the presence of alcohol/drug use disorders alone is a powerful predictor of risk for subsequent suicides in historical attempters (Oquendo, Galfalvy, Russo et al. 2004).  So, regardless of whether a psychiatric diagnostic or endophenotypic strategy is selected to identify risk for suicidal behaviors, alcohol/drug use disorders emerge as highly predictive.

        This discussion naturally leads to the current “opioid epidemic” in the U.S.  Deaths due to overdose from opioids and accompanying other central nervous system depressants have increased substantially over the last decade (Tori, Larochelle and Naimi 2020).  This time frame parallels the observation of a decreased life expectancy in the U.S. during this same period, for the first time since World War II (Woolf and Schoomaker 2019).  A major contributing factor to this change in life expectancy has been an increase in mortality from specific causes, especially drug overdoses and suicides among young and middle-aged adults of all racial groups.  How to distinguish suicide and accidental death from overdose?  Menninger (1938) recognized that chronic alcoholism often progresses to death over years of hazardous use and coined the term “slow suicide,” even though an actual suicidal act could not be documented with precision.  Addiction to drugs that can be deadly due to their pharmacological potencies may not allow a person to survive intoxication if an impulsively chosen combination results in respiratory arrest and death. The result of this is the same as might have occurred if the drug was taken to voluntary to end one’s life.  Not knowing if one might die from self-adminstration of drugs to which one is addicted, or not caring, are not at all the same thing.



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December 31,  2020