1

The Descent Into Suicide.

John T. Maltsberger
International Journal of Psycho-Analysis 85: (3) 653-667. 2004.
Suicidal breakdown requires attention both to attack upon the self (ego) as aggressive forces are unleashed
against it by the superego, but also to the phases of self-breakup (ego regression) that follow. Less attention
has been directed to ego-regression in suicide than to superego-directed assault on the ego in the
psychoanalytic literature; this paper directs attention to the phenomena of ego failure and disarticulation of
the self-representation. Clinical study of suicidal patients shows four aspects of suicidal collapse as ego loosens:
affective flooding, desperate maneuvering to counter the resulting mental emergency, loss of control as the
self begins to disintegrate, and grandiose magical scheming for mental survival as the self-representation splits
up and body jettison becomes plausible. These phenomena are discussed theoretically in terms of failed affect
regulation, ego helplessness, narcissistic surrender, breakdown of the representational world, and loss of
reality testing.
From the beginning, psychoanalytic theory has emphasized the assault of destructive forces against the ego,
moderated through the superego, to explain suicide (Freud, 1915). The self-breakup that follows this attack has
attracted less attention, although Glover (1930) remarked on the importance of ego regression in suicide at the
1927 Innsbruck Congress. Suicidal collapse can be partly understood as arising from overwhelming superego
attack against the self, to be sure, but this alone gives little account of the catastrophic consequences to the
self that ensue, which can be understood as ego regression. The accumulation of empirical data bearing on the
mental experiences of suicidal patients in recent years, especially that which bears on intolerable affect, and
the development of psychoanalytic theory, invite fresh consideration of the matter of self-breakup in suicide.
Attention to overwhelming affective states in empirical psychiatric investigations over the past 20 years has
shown the high association between anxiety and anguish and completed suicide (Fawcett, 2001). The theory
that intense mental distress can have a traumatic, destructive effect on ego organization is a familiar
psychoanalytic theme, and suggests a schema for self-breakdown in such states (Freud, 1926).
I propose a model of suicidal collapse that involves four interlocking aspects, or parts. These aspects are not to
be understood as following one upon the other in strict sequence, though patients may be seen to be moving
back and forth from one to another, so that shifting over time can be observed. Some patients portray one part
more than another, or more than one at a time, but, as suicide nears, patients are more marked by the third
and fourth parts of self-devolution. I propose the following four aspects: the first, which can be compared to
flooding, finds the patient awash in an overwhelming deluge of intolerable painful feeling. This is the aspect of
affect deluge. Aspect 2, efforts to master affective flooding, finds the patient attempting to subjugate and
contain painful feeling, succeeding sometimes, sinking sometimes, and struggling, as it were, to stay afloat.
When he can do this no longer, movement into the third aspect occurs, which can be likened to drowning with
the patient feeling out of control and desperate. Aspect 3 is named loss of control and disintegration. In
Aspect 4, we see the patient, his ego crippled by lost reality testing, mounting grandiose schemes for
self-preservation that may include self-preservation through the jettison of his body. This aspect is labeled
grandiose survival and body jettison.
In 1842, Edgar Allan Poe published his tale The descent into the maelstrm, a metaphor for suicidal collapse.
Poe recounts the experience of a fisherman (whom I take as an emblem of an almost paralyzed ego) whose
boat (standing for the self), caught in catastrophic currents (affects), is whirled downward to its wreck and

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destruction, while the fisherman watches helplessly. Because the story is so evocative, I have interpolated
some excerpts from it into the text.
The phenomenology of self-breakup will be described first, and theoretical discussion will be reserved for the
later portion of this paper.
Aspect 1: Affect deluge
And then down we came with a sweep, a slide, and a plunge, that made me feel sick and dizzy, as I was falling
from some lofty mountain-top in a dream. But while we were up I had thrown a quick glance aroundand that
one glance was all sufficient The Moskoe-strm whirlpool was about a quarter of a mile dead ahead I
involuntarily closed my eyes in horror. The lids clenched themselves together as if in a spasm (Poe, 1842, p.
442).
A number of different terms for the affective distress that besets suicidal patients appear in the literature. We
read of anxiety, psychic anxiety, dysphoria, and psychache (Fawcett et al., 1987; Post et al., 1989; Busch et al.,
1993; Shneidman, 1993). Anguish, an old word that denotes excruciating mental distress, in English use since
1260, is better than any of the newer coinages or German importations (Maltsberger, 1997; Hendin et al.,
2001).
A general consensus now holds that suicide in the absence of painful emotional perturbation is unusual. States
of intolerable affective commotion appear to drive suicide; those who fall into them must get relief or destroy
themselvesthere are no other alternatives.
At the American Foundation for Suicide Prevention, a continuing study of patients who were in active therapy
at the time they committed suicide is now in progress (Hendin et al., 2001). This work has uncovered a
consistent pattern linking suicide to acute, intense affect states that compound the patients' underlying
depression. Desperation is the acute affective compounder most associated with a suicide. It is defined as a
state of anguish coupled with an urgent need for immediate relief. Intense rage, anxiety, a sense of
abandonment, hopelessness and self-hatred are also commonly observed in patients shortly before suicide.
Often, but not always, a major life event (a precipitating event) can be identified as setting loose an intolerable
flood of mental pain (Hendin et al., 2001; Maltsberger et al., 2003). With or without a clear precipitating event,
intense affects, singly but more commonly in combinations, can drive patients to desperation (Baumeister,
1990).
Intense desperation is a mental emergency. Those patients who can escape it by turning to others for relief are
fortunate. Some patients are lucky enough to receive psychiatric (usually psychopharmacologic) treatment to
relieve their agony. Others may turn to street drugs or alcohol in flight from it. But many unfortunate patients
may quickly take their lives because they cannot wait for relief.
A 42-year-old surgeon, suddenly seized with a state of intense desperation, fell to the floor in a public building
because he could not endure the anguish. Later, he reported that, should such a state recur, he intended to kill
himself immediately, so horrible was the experience.
Though immediate, sudden affect-flight suicides of this kind seem to occur, we have no data regarding the
extent to which self-breakup takes place in these patients (Aspect 4, vide infra), although it may do so. Many
probably die before they can be studied.
One can usually, but not invariably, make correct inferences about the intensity of psychic pain by simple
observation of the patient. Most desperate patients, enraged patients or intensely anxious patients show what

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they feel in face, body movement and demeanor. However, a few desperate patients do not look or seem so to
us; they may be quiet, outwardly calm. Potentially suicidal patients must therefore be questioned about the
intensity of their affective distress, and asked whether it is becoming intolerable. They should be invited to
compare its severity to that felt at other times and places, such as on the occasion of a previously attempted
suicide. Not every patient's capacity to bear mental pain is the same as that of the examiner nor of other
patients, so empathic errors of judgment are common. Those who seem very calm may have dissociated and
may be already embarked on a suicide trajectory. Others, having made up their minds to kill themselves,
experience some sense of restored self-mastery and calmness before they take their lives. Others yet
deliberately conceal their desperation because they do not want their suicidal plans to be interrupted.
Aspect 2: Efforts to master affective flooding (struggling)
It may appear strange, but now, when we were in the very jaws of the gulf, I felt more composed than when
we were only approaching it. Having made up my mind to hope no more, I got rid of a great deal of that terror
which unmanned me at first. I suppose it was despair that strung my nerves.
It may look like boastingbut what I tell you is truthI began to reflect how magnificent a thing it was to die
in such a manner, and how foolish it was in me to think of so paltry a consideration as my own individual life, in
view of so wonderful a manifestation of God's power (Poe, 1842, pp. 442-3).
This sector of suicidal breakdown shows the patient casting about in desperation to avoid spiraling downward
(Heckler, 1994). Behavioral signs of a worsening emotional state are common among patients as they move
toward suicide (Hendin et al., 2001). These may include verbal expressions of suicidal feelings or intent,
escalating self-destructive behavior, declining work and social functioning, and increasing abuse of alcohol or
drugs.
Patients may attempt to save themselves by frantically turning to others, or by telling therapists they can no
longer endure what they feel. Self-mutilation or an outright suicide attempt may occur. In this phase, some
patients split off their feelings from their conscious awareness, that is, they dissociate. Dissociation may be
subtle and not always evident to usthe patient may actually feel quite composed and behave in a deliberate,
organized way.
A 22-year-old law student, who had been in a depressive anguish for some days, decided to kill himself. As
soon as the decision was made, he experienced a sudden calmness of mind, and reported that, for the first
time in weeks, he felt competent and collected. After coolly driving to a high bridge, he jumped off, feeling
detached from himself, observing what was happening with the admiration of an onlooker. As soon as he
began to fall, the dissociation broke, and he began to scream in terror.
Others may be able to master their subjective agony by some combinations of denial, projection or even
obsessional affect isolation. In this phase, patients begin to withdraw their emotional investment in others, to
give up on their attachments to work and other valued pursuits, including psychotherapist and psychotherapy.
Reality testing softens, and distorted views of others supervene, wherein others seem hostile, uncaring or
unavailable.
Still others, making the decision to commit suicide, seem to experience a refreshed sense of self-mastery
without dissociating, and quiet down as they go forward with their deadly plans.

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Aspect 3: Loss of control and disintegration
We careered round and round for perhaps an hour, flying rather than floating, getting gradually more and
more into the middle of the surge, and then nearer and nearer to its horrible inner edge Round and round
we sweptnot with any uniform movementbut in dizzying swings and jerks (Poe, 1842, pp. 443-5).
The sense of loss of control experienced by the patient, a sense of falling apart, is accompanied by intense
horror and fear. In this phase, the patient feels completely overwhelmed, unable to help himself, and begins to
give way to despair.
Some suicidal patients' dreams portray disorganization and fragmentation of the self, specifically in the way
their bodies appear in the manifest content (Maltsberger, 1993a). Such dreams can be understood as
metaphors for loosening of the self as a mental structure, and as alarm signals that self-integrity is beginning to
fail (Greenberg, 1989; Goldberg, 2000). Suicidal patients may dream of a landscape littered with body parts, or
parts of dead animals. Some dream of being shaken to pieces, as a dog might shake a rat. Others dream their
bodies are literally going to pieces, disarticulating (Alvarez, 1970). In other dreams, death and killing are more
elaborately symbolized (Grotjahn, 1960).
I dreamed I was standing on the edge of the cliff and parts of my body were coming off and dropping over the
edge. You were standing nearby with your hands in your pockets, doing nothing to help me, and laughing
(Litman, 1980, p. 285).
Some suicidal patients report dreams in which they see their doubles, and treat their doubles as though they
were other persons (Lukianowicz, 1958):
In my dream there were two of me sitting in my jeep parked at Lookout Point. I was in the driver's seat holding
a gold-plated gun to my head. Then the passenger pulled the trigger spattering stuff all over. The one in the
driver's seat said, Oh no! (Litman, 1980, p. 290).
Aspect 4: Grandiose survival and body jettison
Trapped in a flood of unmanageable pain and experiencing disintegration of the self, all reality solutions failing,
urgent to do something, patients may act on magical fantasies to save themselves from impending psychic
annihilation.
There are many reports in the literature of grandiose dreams and fantasies associated with suicide. Desperate
for relief, the patient may adopt omnipotent schemes to achieve control over life and death. In this phase,
patients commonly imagine they can split their mental and physical selves, and, by killing their bodies, survive
in mind in another sphere. Some patients dream of death as a rebirth in which they rise again as Christ. Others
dream they are in powerful positions, rejecting others who have in fact rejected them. Death is not pictured as
a defeat or an end but as a triumph or beginning (Maltsberger and Buie, 1980; Hendin, 1991, 1992).
Some patients identify their bodies as the source of emotional anguish and believe that by getting rid of the
body, now experienced as an enemy, they will escape an intolerable situation and somehow go on to life
somewhere elsesuicide is imagined as an escape, and the suicidal act is seen not as self-annihilatory, but as
the killing of an enemy in self-defense.
As reality testing fails, some patients experience narcissistic overinflation in which certain schemes of action,
some plans of problem solving, appear to them brilliant. Exaggerating his own talent for escape, convinced of
his extraordinary power, and that he is an exception, such a patient may launch out on a mad suicidal scheme

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absolutely convinced he can escape his intolerable state (Maltsberger, 1997). Patients with narcissistic
personality disorders must be particularly vulnerable to such developments when shaming precipitative events
crush them, or when they fall into severe depressions (Ronningstam, 1998).
Discussion
Clinical experience shows that threatened self-breakup, and actual self-breakup in various aspects, is common
among suicidal patients. To date, no empirical studies have appeared to compare self-breakup in acute suicidal
states to self-breakup in non-suicidal disturbances. There is good reason to believe, however, that many
patients experience a particular kind of dissociation before killing themselves wherein mental and body selves
are experienced subjectively as separated (Laufer and Laufer, 1984, 1989; Laufer, 1995). Self-breakup can be
scrutinized from a variety of positions in psychoanalysis.
1. Failure in affect regulation
Freud implied two forms of injury to the self-representation (ego) in Mourning and melancholia (1915) and in
The ego and the id (1923). In the earlier paper, he describes how the ego (using the term as synonymous with
the self) can come under aggressive attack when it is identified with a hated object. In the second, he refers to
withdrawal of positive narcissistic investment in the ego (the self) when it is adjudged weak and ineffectual, so
that it is abandoned and left to die.
Bibring (1953) described some depressions in terms of Freud's 1923 formulation, suggesting they occur when
the ego lacks the force and capacity either to achieve unrealistic demands set by the ego ideal, or to meet the
reality challenges of the exterior world. The patient who tries and fails again and again experiences a drop in
self-esteem, and may give up on himself. Bibring defines depression as the emotional correlate of collapse of
self-esteem of the ego. Finding itself unable to live up to its aspirations, it is overwhelmed by feelings of
helplessness.
The foremost narcissistic demand of the self must be the protection of its own integrity (Stolorow, 1975).
Entering into the early phases of self-breakdown, the self observes that it is unable to hold togetherunable to
master powerful affect, unable to control impulses and actions. Patients in the American Foundation for
Suicide Prevention series found themselves flooded with painful affects they could not control; they
experienced rage, turmoil, anguishthat is, the beginning of ego failure. Some of these patients in turn could
not control themselves; they became passive, horrified witnesses to the further failure of their egos. One of the
patients, an attorney, lost control of herself and made a scene in the courtroom. Another, a Vietnam veteran,
behaved so aggressively to his wife that she left him. Another, a nurse, slapped a troublesome child in the
hospital in spite of herself. The patients, to their horror, saw themselves behaving badly, making their lives
worse, but were unable to check themselves. In spite of themselves, they were destructive, frightening to
others, getting out of control. To experience oneself as breaking down in this way is itself a profound
narcissistic blow.
Bibring's formulation holds that the helplessness of the ego in the face of overwhelming forces, from within or
without, is the root of depression. When helplessness lasts long enough, hopelessness supervenes.
Hopelessness is, of course, a well-known marker of suicidal states (Fawcett et al., 1990; Beck et al., 1993).
While giving up on the self as described by Freud would seem insufficient to explain the violent
psychodynamics of self-attack, withdrawal of positive regard (narcissistic libido) from the self-representation
would play a part in loosening its cohesion, rendering it vulnerable, leaving it unprotected from the hostile
forces arising from morbid, destructive introjects.

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Bibring offers the view that the turning of aggression against the self is secondary to a breakdown of
self-esteem. He believes that it is ultimately due to the feeling of powerlessness and helplessness that the ego
surrenders itself to the superego to be punished. His theory of depression suggests that the puzzling states of
calm which appear to supervene just before some patients kill themselves might arise from ego emergency
operations called into play to ward off overwhelming states of helplessness. There appear to be at least two
kinds of pre-suicidal calm.
The first type of pre-suicidal calmness is dissociative; the depersonalized law student described above who
jumped off a high bridge entered a state of calm detachment once he decided on a plan, his anguished turmoil
quieting down. Depersonalization can be understood as a defense whereby overwhelming tensions are blocked
off when the integrity of the self is endangered. Depersonalization of this kind is well known not only in acute
suicidal crises, but also in situations of acute danger. States of cold alertness and clarity of mind can occur in
life-threatening circumstances, when the person endangered feels he acts as an automaton. Once the danger
passes, delayed reactions may occur in forms of tremors, crying spells, sweating and other varieties of
autonomic, anxious discharge. The ego protects itself against the danger of being further overwhelmed by
intolerable tension by temporarily blocking further affective experience.
Calming before suicide can probably occur without dissociation in the usual senses of descriptive
psychopathology. It may be that formulating a suicide plan in itself is sometimes sufficient to master the sense
of intolerable helplessness, so that a sense of total control is substituted. The patient escapes the intolerable
position of passive helplessness by turning passivity into activity.
Laufer and Laufer (1984, 1989) and Laufer (1995) take the position that, at least in adolescents who attempt to
commit suicide, the alteration of consciousness that accompanies the act represents such a failure of reality
testing that the attempt should be understood as a transient psychotic episode. Calming occurs as the
intolerable passive suffering of the patient is turned into the activity of attack on the patient's body, which is
experienced as alien to the core self, and, as the seat of intolerable sexual and other painful feelings, an enemy
which must be destroyed in self-defense.
The expression transient psychotic episode as used here does not necessarily denote any of the specific
diagnoses listed in such standard nomenclatures as the American Psychiatric Association's Diagnostic and
Statistical Manual, though episodes of this kind may occur in the indexed diagnoses, such as major depressive
episodes. By psychotic I refer to a mental state in which the thoughts, affective response, ability to recognize
reality, and ability to communicate and relate to others are sufficiently impaired to interfere grossly with the
capacity to deal with reality (Sadock, 2000, p. 680). No hallucinations are ordinarily found in these states, and,
to the extent that the patients are deluded, the false convictions under which they labor are not likely to be
long in duration. They are typically affect-driven. Such states are often accompanied by depersonalization and
other dissociative phenomena, in the sense that suicidal mental and behavioral processes are separated from
the rest of the person's psychic activity. Suicidal ideas and plans are apt to be separated from the emotional
tone (anguish and anxiety), which expectably might accompany them (pp. 681-2).
2. Structural instability of the self-representation
Sandler and Rosenblatt (1962), in describing the representational world of the mind, ushered us into a
metaphorical theater of the patient's inner world, the great proscenium of mental life, wherein living portraits
of the self are seen to move, to feel, to remember, to interact and to have their being, along with similar
portraits of objects. Not only does conscious imagination play itself out there; the inner world theater is also

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the stage whereon our dreams are enacted. These living portraits of self and others, the actors on that stage,
they called self- and object-representations.
The self-representation is built up over a lifetime, but it remains fluid as experience and learning alter its
organization. Withdrawal of self-regard, or flooding with aggression directed from a critical superego, can lead
to disorganization of the self-representation. Self-breakdown in suicidal crises can be reflected in the events of
the inner world.
Suicidal patients in breaking apart their mental and their body selves objectify their bodies, thereby enabling
self attack (Maltsberger, 1993b). When the self-representation disarticulates and the portion of it that
represents the body takes on the characteristics of an object representation, the way is open for attacking the
body as though it were something or someone else, not the self. The body, in the language of Klein (1951),
takes on a not-me quality. When this happens, the patient can adopt a paranoid attitude toward his own
disowned flesh, and may attempt to rid himself of it, experiencing his body as a persecutory enemy. This is the
device to which Freud (1915) referred when he described the ego's falling under the shadow of an internalized
object, rendering it vulnerable to the attack of the superego. Structural cohesion of the self-representation is
lost, and the positive narcissistic coloring of the body-representation is abandoned (Orgel, 1974).
Theoretically, the integrity of the representational world, the self-representation and the body image, as well
as the integrity of the superordinate ego-superego system, depends on the neutralization of aggression over
the course of development. Too much unneutralized aggression in the ego-superego system invites ego
regression and self-breakup.
Introjects excessively charged with unneutralized aggression (sometimes called hostile or sadistic introjects
when they take on representational qualities) are discussed in the psychoanalytic literature as playing a part in
suicidal phenomena (Maltsberger and Buie, 1980). These introjects tend to operate in a fluid way, sometimes
loosely attaching themselves to the superego system, sometimes becoming affiliated with the body portion of
the self-representation, and sometimes seeming to have an independent position in the mind. When attached
to the superego, such introjects promote self-directed cruelty, criticism and self-destructive attitudes. When
influencing the body self, they invite feelings of self-alienation and self-revulsion, including a disposition to
self-attack. When affiliated with neither superego nor self-representation, they tend to take up a life of their
own as hostile inner presences. We see them at work among the personae of multiple personality disorder.
They may be projected out on to othersthat is, when they affiliate themselves to object-representations,
they give rise to fears of persecution from without (Asch, 1980).
Instability between the self- and object-representations invites dissociative experiences. In fact, phenomena
such as derealization and depersonalization can be understood as evidence that the integrity of the
representational world is loosening. Orbach (1994, 1996, 1997), Orbach et al. (1995a, 1995b) and Links (1990)
have studied suicidal dissociation, employing empirical methods, and have shown that obj ectification and
attacks upon the body-self not only occur very commonly in states of dissociation, but that physical and sexual
abuse in childhood predisposes patients to dissociate and self-attack.
Normal adult narcissistic functioning presumes a reasonably stable superego system in which self-criticism is
kind while realistic. The normal adult ego-ideal does not demand perfect or omnipotent achievement and
mastery. When development is undisturbed, introjection and identification operate to transform the child's
relationships with the parents into stable ego-ideal structures. Traumatized children, however, do not establish
reliable superego systems. Dissociation accompanies sexual and physical trauma in childhood and adolescence,
and invites introjection of unempathic, neglectful or brutal parental experiences. Unusual aggressive and

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self-punitive self-attitudes are likely to result as maturation takes place, and the self-kindliness of the normal
superego does not develop (Schafer, 1960; Furman, 1984).
Highly dramatic illustrations of breakup of the self-representation are found in cases of major depressive
disorder with psychotic features. Delusions of infestation by alien enemies, for example, reflect invasion of the
self-representation by a hostile introject, experienced as hurtful object-representations which establish
themselves within the representation of the patient's body-self. The patient tells us his body is infested by
worms, animals that rip and tear at his insides, or by evil spirits and aliens from space. By killing his body he
imagines killing and escaping from them.
Feelings of body-splitting are well known in depression. Among 200 consecutive patients admitted to a
psychiatric unit with depression or anxiety, 15 complained of bizarre bodily experiences. A depressed woman
said her body felt as though it had been split in two like a tree-trunk struck by lightning. She said that the two
parts felt a few inches apart, but that there was nothing between them except a black, empty, dead hole
(Lishman, 1998, p. 75). A schizophrenic man, having developed a delusional head growing out of his shoulder,
shot it, that is, shot himself, and nearly died as a result (Ames, 1984). Borderline patients often speak of
feeling empty inside. Therapists generally understand such statements metaphorically, but, on a number of
occasions, I have encountered suicidal patients who quite concretely believed there were anatomically empty
spaces in the thorax or abdomen.
Self-attack is well known among borderline patients, who frequently describe their bodies as not real. One
suicidal borderline patient felt that someone from the outside had foisted her body on her, that it was a
sinister counterfeit of her true body. From such observations as these, we have ample evidence that patients
objectify their body-selves and confuse them with representations of hostile others. We also may recall that
borderline patients often develop confusions in the transference, so that they are unable to tell where they
leave off and where their therapists begin. These patients often disavow their own feelings, especially hateful
ones, attributing them to their therapists, and cannot distinguish affective boundaries (McGlashan, 1983).
Rorschach testing can reflect loss of self-integration and failing capacity to discriminate between self and
object. Inferences of such failure appear in the modes of space organization in patients' reports of Rorschach
responses, as well as in fantasies and dreams. Experiences of seeing through transparent or translucent
three-dimensional spaces suggest this kind of breakdown, which has been tentatively empirically associated
with suicide (Blatt and Ritzler, 1974; Roth and Blatt, 1974), although efforts at replication have raised some
questions about this finding (Hansell etal., 1988).
Fowler et al. (2001) developed a suicide index comprising four psychoanalytic Rorschach signs that predicted
with considerable accuracy which patients would later make lethal suicide attempts. They found that
unconscious processes signaling penetrating affective overstimulation, disturbance in capacity to maintain ego
boundaries, and affect states characterized by morbid preoccupation with death and inner decay were strong
predictors of dangerous attempts. Rydin et al. (1990) reported that violent suicide attempters were more
paranoid, less able to cope with conflict situations, less able to endure dysphoric affect and poor in
differentiating between reality and imagination. These findings are consistent with what has been described
here as self-breakup.
Thomas and Duszynski (1985) have published a prospective study in which the records of Rorschach
examinations administered to 1,154 medical students, 20 to 35 years previously, were analyzed for the
frequency of occurrence for the word whirling and similar words (they call these whirlall words). When the
subjects were followed up, it was found that 16 had died of suicide. Seven of these 16 suicides (43.8%) had
given whirlall responses at the time of the examination, in contrast to 9.62% of the group as a whole. What this

9
finding means is uncertain, but whirlall responses in the Rorschach may signal potential instability of the
self-representation. (Oddly, whirlall responses in the original protocols also predicted premature death from
causes other than suicide. Of the 48 subjects dead from causes other than suicide, a third had given whirlall
responses on the Rorschach.)
Although a scheme of self-breakdown has been delineated here, one that can be encountered across a variety
of diagnoses and mental disturbances, it is not possible to say whether such a breakdown process is empirically
(statistically) more characteristic of those who commit suicide or make grave attempts than it is of other
mentally anguished persons who do not. That states of anguish as outlined above are very typical of those who
commit suicide can be asserted with some confidence. Nevertheless, other patients, with better capacity to
bear anxiety and depression, may endure some of the experience of the suicidal maelstrm without being
swept down into the lower depths of the aspect 4 (Zetzel, 1949, 1965). To date, we lack the necessary
empirical knowledge to differentiate between those who suffer without breaking down into suicide and those
who are swept away into lethal disintegration.
From the clinical point of view, patients in a state of severe anguish who have moved into a suicidal crisis and
who further demonstrate evidence of self-breakup as outlined here, should be assumed to be at great risk of
committing suicide and managed accordingly (Hendin et al., 2001).
Conclusion
As self-breakdown (following on from ego failure and ego regression) takes place, the anxiety experiences of
patients are far more intense than those belonging to ordinary life. The anxiety is so intense that mental
functioning is paralyzed, and, to the extent that the patient can think at all, he recognizes that he is helpless
and feels that he is in terrible danger. Sometimes called annihilation anxiety, Freud's term for it was primary
anxiety or traumatic anxiety. Because terrific anxiety onslaughts of this kind are so paralyzing, they are usually
experienced as pouring in from outside the self, and must be endured, to the extent that they can be endured
at all, passively. In the face of such anxiety, the self is rendered helpless. Freud (1923) regarded such anxiety
experiences as psychically very dangerous and injurious to the ego.
Kohut took the view that disintegration anxiety was the deepest anxiety of all, and believed that none of the
forms of anxiety Freud described were equivalent to it. Potentially he felt that it could be greater even than the
fear of death. If this is so, it is congruent with the view that, in order to escape disintegration anxiety, a patient
might elect to kill himself, as the disintegrative anxiety would be more intolerable than the horror of dying
(Kohut, 1984, p. 16, p. 213, fn; Kluft, 1995).
Freud's (1923) view that anxiety can be so intense as to be psychically injurious is theoretically attractive,
because it lends itself to one formulation of a suicidal state: that the failing ego is abandoned by the superego
system as incompetent and worthless.
To defend itself against anguish of this order, whether one describes it as annihilation, disintegration, primary
or traumatic anxiety, the ego will go to any lengths. Freud's famous analogy of the horse and the rider applies
to the suicidal moment. The compromised ego is compared to the rider on a runaway horse:
The horse supplies the locomotive energy, while the rider has the privilege of deciding on the goal and of
guiding the powerful animal's movement. But only too often there arises between the ego and the id the not
precisely ideal situation of the rider being obliged to guide the horse along the path by which it itself wants to
go (1933, p. 77).

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In many suicidal cases, the overwhelmed ego, deprived of its reality-testing function, and with its capacity for
self and object differentiation failing, proves an ineffective rider. The terrified, anguished horse, out of control,
seems to run itself and the rider over the cliff into the suicidal precipice.
The psychoanalytic theory of suicidal breakdown presented here implies massive failure of the ego in terms of
affect modulation and the preservation of the integrity of and distinction between self- and
object-representations. Reality testing and self-object differentiation fail. The surviving mental self, turning
against the body self as an enemy, may then turn to body-killing in self-defense.
Many patients survive suicide attempts that expectably should have diedsome are rescued by sheer chance,
others survive hangings or leaps or gunshots that by all odds should have been lethal. Other patients, as we
have seen, commit suicide while in intensive treatment. These sorts of patients might be more extensively
studied, with matched controlled groups of depressed patients who had made no suicide attempt, with a view
to seeing how often they show evidence of self-fragmentation before the attempt. Of particular interest would
be the comparison of attempters with the controls with respect to dissociation experiences at times of
maximum affective distress.
The vernacular expression nervous breakdown anticipates a number of the phenomena belonging to suicidal
states, very notably, a deluge of painful affect that cannot be regulated or moderated. The German word for it,
Zusammengebruch, is even better. Important mental functions including self-object differentiation fail; fears of
self-disintegration become primary; self- and object-representations blur; grandiose and magical behavior
supervenes. Suicide reflects profound narcissistic collapse, loss of reality testing, self-fragmentation and ego
failure.
Acknowledgements: Dr Ann Pollinger Haas, Dr Herbert Hendin and Dr Igor Weinberg have made valuable
suggestions for the preparation of this manuscript.
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