Battling With the Life Instinct: The Paradox of the Self and Suicidal Behavior in Psychosis

Introduction

Suicidal behavior in psychotic disorders, such as schizophrenia, is not uncommon: About 10% of patients diagnosed with schizophrenia are estimated to eventually commit suicide and even more will attempt it.¹ Even Eugen Bleuler, who first coined the term schizophrenia at the beginning of the 20th century, had suggested that “the most serious of all schizophrenic symptoms is the suicidal drive.”² However, despite its prevalence and seriousness, suicidal behavior in psychosis does not seem to be a major research focus and, while biological psychiatry has greatly advanced our understanding of the neurophysiological basis of suicidal behavior in a variety of disorders, there is little research into the actual experience or phenomenology of suicidal ideation and subsequent behavior in psychosis.

Since I wrote my first article, my symptoms have remitted to such an extent that a firm diagnosis of schizophrenia can no longer be held in place, which has brought even more uncertainty to my condition. Nevertheless, certain symptoms—albeit far less florid than many of the positive symptoms I have had before—still linger in my mind. These include a never-ending sense of disintegration and fragmentation of the self and intrusive thoughts—which I think are an attenuated form of the voices I used to hear—urging me to throw my life away because a life without an active self is not worth living. At the same time, I am aware the very fact that I have a living body means I have a self, active or not, so if I killed myself the container for my real self would be lost forever. Still, the thoughts are correct in their own right, too. During this period of remission, I have realized that my whole life is full of contradiction, full of irreconcilable and irresolvable paradoxes which originate from my shattered self, beyond the realm of logic and reason. In this article, I would like to use my own experiences of psychosis in order to propose and analyze some of these paradoxes from a first-person perspective.

Paranoia: The Paradox of the Need to Strike First

When I was last in hospital, I was convinced that a foreign agency was sending people out to get rid of me—I was so convinced because I kept receiving messages from them via a device planted inside my brain which was constantly monitoring me. So I decided to strike first: to kill myself so they wouldn’t have a chance to carry out their plans and kill me. What I did not understand was that the whole idea was self-contradictory: if they really wanted to kill me, the last thing they would want me to know were these plans of killing me. As the treatment continued this “delusion” appeared to have resolved over time but when I finally came to realize the delusional nature of this thought, I found myself deeply trapped in a paradox, a paradox of my very self. Why did I want to kill myself? According to the current theories, hopelessness, helplessness, and a thwarted sense of belongingness are the major precipitating factors to suicidal ideation and behavior.³ I indeed felt hopeless, helpless, and did not belong anywhere, but this had no external basis upon which I could base such feelings. This state of mind was within me, in the form of an external agency. I perceive the paradox of paranoia is that I was no longer able to distinguish between the logical and the inconceivable, yet this illogicality had also become my only logic. The threatening thoughts were real to me, even though they couldn’t possibly be true. The key question is, did I know they could not be true? I was plunged into the unknown world of external thoughts in which there was no way out, so the natural solution appeared to be simple—to eliminate the source of the thoughts. Logically, I would choose to target those who were out there to get me; instead, I chose to end my own life. Does this mean I was aware that these thoughts were my own? I certainly didn’t think it was the case. Everything was a downward spiral, I knew I was being watched by them, I knew sooner or later they would get rid of me, and my decision stayed the same. Fortunately, the hospital had kept me safe throughout my admission and by the time I was discharged I was no longer actively suicidal; but I had this doubt, what if they were really observing me and they deliberately let me know of their intentions just to make me feel even more desperate? I had a clear and certain target; in theory I could have directed all the despair and confusion onto “them,” I could have struck first. Except that I was not able to.

In my last article,⁴ I used a theory of existential permeability—the relationship between one’s self and the external world—to explain mainly the positive symptoms of schizophrenia. Here, I would like to make a link between existential permeability, psychosis, and suicide. To me, paranoia involved a loss of my ego boundary, a dissolved existential permeability where I was observed and persecuted by an external agency. This total dissolution of my ego boundary led to the paradox: the observer and the observed entangle with each other and become unified as a new entity, like the entanglement of particles in quantum physics. Does this create a “better whole,” does this give the observer an omnipotent power and open doors to a more complete perception of the world? The observer was myself and so was the observed. This is what gave the power to the observer. When one’s ego dissolves, it becomes a part of everything surrounding him; but at the same time, this unification entails the annihilation of the self—hence the suicidal ideation. The curious thing is that the main reason for my admission was in fact not the positive symptoms but a suicide attempt. This relates to another aspect of my experience, that I had lost all control of myself.

Passivity: The Paradox of the Unwilling Executor

I remember standing on the top of an 8-storey car park, thinking I would appreciate this beautiful view for one last time before I took the final step. It was not me who was engaging in such behaviors. I was unaware of my actions, observing myself in the third person with the voices saying that I had lost myself and to jump was the only way to reconnect with my real self. I had no other choice yet I did not jump immediately. This gave the police chance to come upstairs and rescue me. Three months later, I tried again by taking a large overdose of my antipsychotic drug, which led to my last admission. Still, I did not admit that it was my real self behind such behaviors. In order to explain the strangeness and alienation of my own thoughts and behavior, the delusion of the foreign agency developed and I believed it was them who controlled my movement by sending me the messages and would eventually kill me, maybe even using my own hands. In my last article, I attributed passivity phenomena to a disembodied self, yet this is another paradox: who is experiencing the disembodied self if the self is no longer there? Whose behavior is being controlled externally if there is nothing to control in the first place? Surely, it is a case of “esse est percipi,” to exist is to be perceived. To me, the converse stands true as well: the perceiver has to exist in order to perceive. Therefore, the self who experiences the disembodiment must exist, and killing this experiencing self will almost certainly remove the perceived—a no-win situation. Why was I so determined to try again and again only because I was following the instructions of a disembodied self? The consequence of suicide is clear: a complete cessation of consciousness, there will be no perceiver and there will be nothing to perceive. Yet still, it seemed to be a both tempting and tormenting option, when there was no option at all.

The paradox in passivity phenomena is that the external control cannot exist without an internal self, and simultaneously, the internal self has absolutely no control over the external. As long as the delusion of control persisted, my real self would never come back to me. My self—or someone else’s self—was already out there, controlling my every move without my conscious awareness. I was trapped in the nothingness between the internal and the external, hiding behind the veil of my own perceptions, which I didn’t perceive to be my own. Even the psychiatrist found my statements self-contradictory and lacking common sense, which served as another piece of evidence that I had a thought disorder. I tried to explain that my thoughts were not in my control, but it simply made the situation worse. The constant doubt and the psychological pain, or psychache as Edwin Shneidman suggested,⁵ of uncertainty alone were destroying me from the inside—until there was nothing left. I believed that I did not exist at all, which is in itself a vicious cycle: the “fact” I did not exist pushed me to self-destruct, and the unrecognizable nature of the self-destructive behavior was further explained in a delusional context, which was that I was under alien control because my real self did not exist and thus had no free will.

Nihilism: The Paradox of the Loss of the Self

I think this is the trickiest paradox in everything I have experienced: the belief that I do not exist. It was thought to be another delusion by the psychiatrists, namely nihilistic delusions such as Cotard’s syndrome. Indeed, the very concept of nihilistic delusions is self-defeating. A dead person cannot think or express his thoughts by any means, thus the act of thinking or saying “I am dead” is logically implausible. It is not simply explained by the observation that delusions lie beyond logic and reason; it is about the nature of the self and the interpretation of reality. When I believed I did not exist, nothing else mattered to me. Even suicide meant nothing to me—I am not real, I do not exist, so it does not matter if this nonexistent self dies. The question is, how can something unreal die? Is unreality an entity equally valuable as reality? The vast majority of people would argue that only external reality is valid, so let me assume that reality is objective and universal. In my delusion, I cannot die because my true self has already died; in the universal reality, I cannot die because I do not reside in the objective reality. A delusion is the deception from the so-called “reality” to which we entrust our perception. In other words, reality lied to me—which made it no longer objective. I did not only lose my own self, I also lost my reality. There was nothing for me to believe except my nonexistence, over which I had no control. I knew there had been something, which turned into nothing. It was like combining matter with antimatter—you create a state of total annihilation but also a state of unity and stasis. I found such unity seductively attractive to me.

Then, I watched my own self diminish and disintegrate. Christian Scharfetter⁶ described ego fragmentation in psychosis as something different from that in dissociation: a dissociative mind is like quicksilver and a psychotic mind is like glass. If you drop quicksilver, the little parts will eventually reform, but if you shatter a piece of glass, the shards will never come back together. Even if you try to glue the pieces together you will not be able to get rid of the marks. Or you can completely destroy the glass and create a new piece. This was exactly my logic: although I didn’t know if it would create a new self, I could certainly destroy the present one. Is it not the case that I just said I had no self? Then who was doing the thinking, who decided I would end my own life? The psychache of knowing yet oblivious, being conscious yet unaware, is more than enough to make anyone contemplate suicide in my opinion. Even the idea of “cogito ergo sum” cannot rescue a shattered self. When everything has failed, including one’s own thinking processes, how can anyone expect him to trust the external world? It is not a case of “I am thinking therefore I exist” any more, it is “someone else is thinking my thoughts therefore I do not exist.” The possessive word “my” has lost all the meaning and validity because there is no “me.” Even the false reality is nothing but a distant dream, let alone the “real” one. Perhaps it is not about losing my self and my own reality, it is about realizing that my own reality never existed. The paradox is, how could something unreal become a reality in the first place? How could I lose something that had never been real? Most importantly, who decides? When I came to the realization that what I was convinced to be true and real for so long was everything but true and real, I found myself no longer able to be convinced of anything. I had insight at long last, but at what price?

Insight: The Paradox of Introspection

After I was discharged from hospital I couldn’t help but wonder what if things had happened differently. What if I had succeeded? What if I had remained in my delusional state and would I have engaged in the same behavior had the voices not been there? It felt as if I had been taken away from another world, a world of dangerous certainty and comfort where I could easily dissolve and be absorbed into the surroundings. Even though I have now come back to the “real world” with the realization that it was nothing but my mind “playing tricks on me” which enables me to write articles like this, I still continue to question my own experiences. There is a constant sense of doubt, a fear that this reality is a fake, too. Moreover, what about my self? How do I know my mind is not still playing tricks on me if I am the only one who can make the judgment? The apparent fact that reality is shared by others does not necessarily guarantee that my share, once it becomes my own interpretation, is still the same as their reality. I was convinced without the slightest trace of doubt that my beliefs were true but now I am not completely sure of anything any more. However unhealthy the beliefs might be, they did provide a protective “bubble” for me, to contain my own reality. Now, my insight has exposed me to the external world where I am no longer protected, the initial sense of helplessness can almost rival that from the persecutory delusions. Here lies the paradox of insight: The reason for which a pathological mental state occurs has changed or disappeared but the mental state itself does not always change or disappear with it. In this situation, the sufferer may even regress to the original reason even if he knows it is untrue. Who are we to deprive him of his right to seek comfort and certainty? In extreme cases, the consequence of “coming back to reality” can be very negative, if the sufferer is not willing or ready to accept it. Some might argue that this is why I still need ongoing maintenance treatment to prevent relapse, and I agree with them; perhaps introspectiveness is a major trait of my personality, and there is indeed little research evidence to support the correlation between insight and postpsychotic depression, eg, but this trait is not unique to me. Every now and then the thoughts of suicide still invade my mind, thoughts that are not mine, thoughts without explanations—have I accepted this new reality? Maybe I have, maybe I have not. What I do know and understand is that every time I think of my past symptoms there is a tiny sense of nostalgia, no matter how much insight I have.

The Suicidal Drive: The Ultimate Paradox?

I think I can fully understand why Bleuler considered the suicidal drive is the most serious of all schizophrenic symptoms even though this drive is not a psychotic symptom in its own right. Rather, the suicidal drive is a result of intense psychache, and it once again has a paradoxical nature because it can be a consequence of both the psychosis and the insight into psychosis. Whatever the mind is trying to end, whatever the self is trying to escape from, there is no easy resolution for such a paradox as this is the constant battle with the life instinct, the most basic and essential of all instincts. Suicide is no longer an open option for me because I am aware that the very self who commits suicide will never be able to know or experience the peace it has finally sought as there will be no consciousness. In a way, however self-contradictory this may sound, the suicidal drive could actually be life preserving: Whether it is the psychosis or the insight, one’s mind has to be alive and existent in order to perceive it. The attractiveness of the suicidal drive means that one has to live to maintain such a drive. Perhaps this is the most valuable realization. The suicidal drive is there to facilitate neither psychosis nor insight; it is there as a thought, a reminder that something—whether it is one’s own or not—still exists there even though it is only a thought. Yet at the same time, I believe that thought is behavior in rehearsal. The possibility of carrying out the thought is still an imminent risk for many sufferers of psychosis but everything should be on a fine balance where the paradoxes of the self can coexist. When nothing seems to be real, when the suicidal drive seems overwhelmingly persuasive, I shall remember to hold on to such unreality because even this unreality contains the possibility that my real self will come back to me that I will be able to find unity in this paradoxical and fragmented world.