Psychiatry & Psychotherapy Podcast - How Does Mental Pain, Meaning in Life & Locus of Control Influence Suicidality?

Episode Date: May 22, 2020

On this episode of the Psychiatry and Psychotherapy Podcast, we talk about meaning, and how it relates to suicide.  This is part 3 of a series of podcasts on suicide. If you haven't listened to the first two episodes, they are here:  Suicide Epidemiology, Risk Factors, and Treatments Genetics and Environmental Factors in Suicide By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.  

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. So welcome back to the podcast. I am here with Stephen Casparick. He is finishing up his master's,

and we have been working for about two years on this episode. So we have gone back and forth. We've been exploring the meaning of life in the midst of looking at suicide. He's helped me prepare for a couple lectures I've given, so we've done a lot of digging into articles together and looking at things. And this is really like part-third.

of the suicide series, it's going to stand alone. And we're going to look really at meaning and how meaning is related with suicide. So just as a way of introduction, I'm going to introduce kind of go over what the highlights of episode one and two are. You can go back and listen to those if you haven't already in the future, but I think you could listen to this one straight through as well. So in episode one, we talked about suicide being the 10th most common cause of death for adults, the second leading cause of death for people age 15 to 24. There are around 45,000 suicides per year in the U.S. And the rate of suicide is 11 to 14 per 100,000. It's been increasing a little bit recently. And if you look at some of the other countries, we're not the highest in central

eastern European countries like Scandinavia and Hungary. The rate is 27 per 100,000. And it's lower in some Latin American countries, Middle East, 6.5 per 100,000. So about two-thirds of suicide completers are male, and about 80% of those who complete had prior attempts. We know that ethanol abuse is common in those that commit suicide. There's a high rate of alcohol in the blood and a lot of suicide completions. We know that social support is really important and the loss of social support is really hard. And I'm thinking about that, especially in this season where we're sort of taken away from our families, our friends because of COVID-19. and sometimes being in close confinement, being in close quarters with an already dysfunctional relationship

just kind of brings out the dysfunction even more. So social support loss is linked to suicide and 90% of suicide completers had a major psychiatric disorder at the time of suicide, greater than one half were clinically depressed. We know that in the VA population, there's a high rate of suicide in those that use substances, alcohol, marijuana, opiates, cocaine, that kind of substances, the rate is as high as 75.6 per 100,000. I remember it's around 14 in the U.S. And for those who do not use substances, it's double what the normal rate in the U.S. is. It's 34.7.

So in part two, we really looked at the average rate of suicide being around 10 per 100,000. Now, if you think about that in terms of the amount of zeros and the amount of years that people live, it's around 1% of the population dies by suicide, maybe a little bit less. if monozygotic twins committed suicide in the largest study there was only an absolute increase in 4% compared to diezegotic twins so there is some genetic component but it's not deterministic by any means if you think about an absolute increase of 4% if your genetic twin that was raised in a very similar early environment a similar womb which accounts for some aspects of it similar environment early on, it's only a 4% chance that the other mono-zagotic twin will commit suicide

above what it would be in a dysa-zegotic twin. So if you have a lot of environmental factors early on, you know, really difficult upbringing, trauma, stuff like that, that increases the risk of committing suicide about four times. So we're talking about from 10 per 100,000, you know, thousand people years to about 40 per 100,000 people years. So once again, it's not deterministic by any means. Even if you look at the genetic and the environmental, although both of them are important to look at, there seems to be this kind of,

this kind of trajectory as well with like, is treatment received? And specifically, we're going to be looking at meaning and how meaning changes. Now, we know that the suicide brain is a sick brain. And so there are changes in the brain, and probably in a future episode I'll go over the changes that occur in the brain. But there are multiple studies on autopsies of these brains, and they don't look like a healthy human brain. So there is pathology that has gone on, sometimes for years, untreated mood issues, untreated psychiatric issues.

issues. And we know that most suicides do not have ongoing treatment. They're not currently seeing, you know, a psychiatrist or a therapist. Upwards around two-third in one study were not in any treatment for the past big chunk of time. Okay. So that kind of left us off where we're going to start here in this episode, and we're going to be talking about meaning, and we're going to be talking about how choice plays into this. And one of the things I mentioned in a previous episode that'll highlight here is that people who are convinced that they do not have free will, that they do not have choice, are more likely to cheat. They're more likely to conform to social norms. they have reduced helping behavior, increased aggression.

They don't slow down after making errors to reevaluate. So there's a lot of frontal lobe function that seems to be lessened if the person believes that they do not have a choice, that they believe they do not have free will. And so these studies, there's a group of studies, and I'm going to be doing an episode on free will soon. I have that prepared as well. It's in the pipeline. So I won't be labor this point, but the point is that there seems to be this aspect of choice, which we don't want to take away from people. We don't want to make them believe that they're purely deterministic.

So in the prior episode looking at the mono-zegotic twins compared to die-zegotic twins, if one commits suicide, there's only an absolute increase in 4% that the other one will commit suicide. So it's not completely genetic. it's not completely that early environment. And further in the studies on trauma, early life trauma, an increase of the rate of suicide four times. But it's not deterministic. Four times is like, once again, it's going,

it's a couple percentiles of absolute increase in suicides. So that all being said, we come to this episode on meaning. And Stephen, what got you? you kind of excited about this as you were reading through the literature before we get into the details let me just pick your brain on that sure absolutely so i first learned about locus of control and meaning in life while doing a lit search for key factors in suicidality this was during the spring semester last year and i'd come across several papers focused on these concepts the research just made intuitive sense to me. In fact, I felt locustin meaning were personally relevant.

I realized these were the same things that have allowed me to appreciate the opportunity I've been given to be a student here at Auburn. Furthermore, they've been the same things that have given me perspective and kept me focused on my goal of becoming a physician. Really, overall, just appreciating the moment. Yeah, and there, you know, when we go through life, we find that there's meaning that pulls us through things. And I go back to some of what Victor Frankel talked about. Victor Frankl is one of my favorite things to talk about. Did a whole episode on Logotherapy, part of the Therapeutic Alliance series.

But he said the way in which a man accepts his fate and all the suffering and intent. The way in which he takes up his cross gives him ample opportunity, even under the most difficult circumstances, to add a deeper meaning to his life. It may remain brave, dignified, and unselfish. Or in the bitter fight for self-preservation, he may forget his human dignity and become no more than an animal. He's talking about in the concentration camps, how he would see people serving their brothers, serving their sisters, in the midst of all the suffering.

they were not purely thinking about their own survival and how that meaning that they had actually allowed them to survive, that meaning of the brotherhood, of the sisterhood, of sacrificing together, of looking out for each other. So that's helped you in your journey. Absolutely, absolutely. So certainly, although I'm fortunate in not being able to relate to, a lot of those specific circumstances you had mentioned. I think in the manner in which anybody's life unfolds, there are a number of twists and turns.

And really just kind of speaking about my life specifically, I find myself as a student here at Auburn University in a pre-medicine master's program. and really just consider myself very fortunate for a lot of the opportunities, including this one that I've been given over the past couple of years. So from those opportunities, I've derived a substantial amount of meaning. And that's really what I would say initiated my interest in this topic. Yeah.

So maybe let's get into the meaning. a little bit. So Stephen, with with it in mind that it's been helpful for you in your journey, like as we kind of look at the data of suicide, and we started looking at like that the suicide rate has been increasing, what did you find about how it's been increasing? Right. So as far as suicide's rate of increase over the past 10 years, from 1999 to 2018, that rate, increased 35%. In 1999, the suicide rate per 100,000 individuals was 10.5. And in 2018, that had risen 35% to 14.2. And as you had mentioned, Dr. Puter, in the introduction, so suicide, it's now the second leading cause of death for ages.

10 to 34. And then it's the fourth leading cause of death for the age groups 35 to 54. And I mean, when you really kind of think at what parts of our community is represented by those age groups, really what's being robbed of our communities is that exuberance, that optimism for the future, of the youth, but then it's also suicides robbing our communities of that steady foundation and a strong sense of productivity from those members of our community that are in a little bit older of an age group. Yeah. I think about, you know, just the daily, or the frequent discussion I have with patients who lose someone that they love to suicide, had one of those patients today and sitting with her lament of this close friend of hers and thinking about

just all of the people in this person's family that are going to be touched by that. It's a lot. It's a lot. So it's an important topic to discuss and to sort of think about like what can be done. And I'm hoping that we can draw out some aspects that maybe people haven't talked about that much. I don't think I ever read this in the textbooks when I was going through psychiatry, residency, or medical school. So let's talk about this 2009, Avid Wilczek article.

Well, absolutely. So in her study, Aviod Wilczak, she really wanted to elucidate factors pursuant to suicide that can be used in what's referred to as a salutogenic model. And so essentially this is a model that emphasizes cultivating wellness and resilience to stress. This is something that's really substantially different than traditional models of suicide. And so traditional models have a tendency to really focus on avoiding certain risk factors and really just preventing pathology. So Aviad Wilczak, in her 2019 study, had certain goals as far as elucidating these factors for use in her model. And in particular, she studied the relationship between locus of control and suicidal tendency.

Her goal was to discern whether meaning in life acts as the connection between, the covariance in locus of control and suicidality. I think just why this article jumped out to me was because the decreased meaning in life correlated with risk of suicide and the strength of that correlation was negative 0.82. Really strong. Point 82 is so strong. That is such a strong correlation. I mean, I don't, like usually when I read studies, if the correlation is like 0.3 or 0.4, it's like, okay, yeah, yeah.

If it's like 0.1, it's like, I don't know. It's pretty low. But this is 0.8. That's so large. And then with locus of control, it's 0.49, just like, as locus of control decreased, it was like 0.5, basically. and as meaning of life decreased, it was 0.8 correlated with suicidality. Those are really strong correlations. I think it's, at least in my point of view, I think it's really encouraging to see these really strong correlations consistently demonstrated in the literature just because they make intuitive sense as far as what the definition of locus of control is, what it represents. So you have an internal locus of control whereby an individual believes

that the outcomes in their life and the circumstances in which they live are the results of that person's actions. And then on the other side of the spectrum is an external locus. that person essentially believes things happen to them. They believe whatever outcomes exist or occur in that person's life has nothing to do with that person's effort. And so when you see the really strong correlations between something like Locus of Control, where we're essentially looking at how much a person believes they're in control of their environment

and that strong correlation with suicide it just makes intuitive sense. Yeah, yeah. And I like how you defined internal locus of control. And a lot of people who I talk to are very suicidal, they don't believe that they can make their situation better. They don't believe that they can do anything,

make any changes, make any choices that would get them out of the situation that they're in. And, you know, I think we talk so much in psychiatry about this is genetic or this is your environment. And that, I think that's an important contributor to different mental illnesses and to, you know, suicide to some degree. But there is this huge gap where, like, this is the message for someone who's struggling with suicide. It's like, hey, you can make some time. choices you can find meaning you don't have to stay stuck you know i i almost hear this episode if like a family member lost someone to suicide and they listened to it it might be hard to

listen to like like it's almost like when the family has someone who commits suicide it's like sometimes my the most soothing thing is to talk about the sick brain and how some people you know autopsy studies show that the brain does have have some damage that's happened over the course of, you know, their mental illness that's led to this, this behavior. But for someone who's struggling in the midst of suicide, talking about the importance of not conceding to their environment, that their environment will shape them, you know, and finding meaning, right? Finding meaning in the midst of life and their struggles. I think it's really important.

Let's talk just to kind of deepen what this actually means because sometimes when I see these strong correlations, I'm like, okay, what does this really mean? Like, what are we talking about the risk of suicide? So they measure the risk of suicide using the clinical index of potential suicide. And I want to read some of those questions just because I feel like it'll give you an idea

for like what we're talking about here. Okay, so they're rating this on a lycard scale, zero to four, where four is severe, zero is none. And the questions are like, do you ever feel sad or depressed? If there's any part of your day when you feel worse, best, do you have crying spells or feel like it?

How have you been sleeping? You know, is there a sleep distress? Is there decreased appetite? Is there decreased libido? Is there weight loss? Is there like bodily symptoms like constipation? Is there is your heart beating fast like tachycardia? Fatigue? You know, how tired are you? Confusion. You know, which is kind of looking at maybe dissociation or just disconnection. And then psychomotor retardation have you slow down the way that you usually do things. So those are some of the questions that they ask to sort of gauge how suicidal someone is.

Do you have anything you want to add to that? Well, so I would just say from that 2019 study that the main finding Aviad Wilczek came across

from her study of two groups of individuals, one of which being patients in an inpatient psychiatric ward and then the other group being a normative control, I think the most significant finding Aviod Wilczek came to was that meaning in life indeed does act as a mediator for this really strong negative correlation between locus of control

and suicidal tendency as measured according to that clinical scale you just mentioned. And so, specific. Typically, a higher locus of control, basically a locus of control that is more internally oriented, correlated with higher meaning in life. And then higher meaning in life, then correlated with lower potential suicide. And I think in a lot of what you were discussing, Dr. Puter, as far as locus of control and the relationship, it has. has with meaning in life, I mean, it sounds like in your clinical experience, you've seen that firsthand. Yeah, absolutely.

I mean, fortunately, I've not seen a lot of people right before they commit suicide. I think that's very limited in my experience because I think most people who actually complete suicide are usually not in treatment. And I think when people get into treatment and get through like, a partial program. It's like they feel so much better. But what I've seen is that the people who struggle the most with suicide, you know, they have a very sort of external locus of control mindset. And they also have just a lack of meaning and purpose. It's, it's, I think this is why residents have a lower suicide rate than the average population. It's about a third.

third in one study. And I think it's because in medical residency, although it's incredibly hard, like the hours are extensive, 80 plus hours a week. I know it's supposed to be 80, but sometimes it goes above. And the stress of people dying around you and the interpersonal conflicts, it's just a very stressful time, especially the first three months. The first three months do have a higher suicide rate than the rest of the residency. But what I think is that there's a mission, there's a purpose in what they're doing. And so although the stress is high, the rates are lower of suicide. It changes as physicians get older in life.

When they get into their 50s and 60s, the rate goes up especially. And I think some of that is because of the difficulty of providing care and sometimes the busyness of things. the meaning sort of fades within burnout, and meaning and burnout kind of go together as well. So, yeah, I've seen it both in my clinical practice, and I've been seeing in my deep dive into medical education and what that's like.

But let's keep going. I want to get through some of these other studies, some of these other things that you found. Let's talk briefly about this 2014 study of Israeli adolescents. they looked at the ones that were immigrants and not immigrants. And they found that decreased meaning in life was negatively correlated with suicidal tendency in the male Israeli adolescence.

Really a large number, negative 0.80 and less in the immigrants, negative 0.52. How do you understand that? it's like it's a weaker connection it's a weaker connection um and there may be a lot of other factors leading to someone who is of Ethiopian origin like they may be worrying about other factors you know and the the correlation is still high though boys, point two, adolescence, 0.6 in general. And, you know, is there, if you were to do a test of looking at, is there significance between those two numbers, maybe there wouldn't be that big of a significance.

Maybe the range, you know, it would be similar. But the point from this study is that the correlation is still there. It's another study. The correlation is high between meaning of life and suicidality. Okay, so let's quickly go through some of these other, studies you found. There was a study where they looked at the relationship between meaning and life and aggressive antisocial behavior.

Brassali, 2012. So the correlations here are a little bit, they're weaker correlations, but I think they're still important to talk about a little bit. Because hopelessness was correlated negatively with meaning in life. So as someone had less meaning in life, they became more hopeless. And the correlation was 0.35 for the presence of meaning, the search of meaning about the same. And meaning was negatively correlated with aggressive and antisocial behavior.

So 0.24. And irresponsibility of academic work and behavior. Negative 0.21. So it seems like meaning in life, this is not as strong as the prior studies are suicideality of 0.8. But there's still a correlation between doing aggressive, antisocial acts, you know, irresponsibility in school with like meaning.

And it's around 0.2, 0.25. And they also found that as meaning increased, healthy eating increased, physical activity increased. That was interesting to me. That was correlated. But these are smaller, correlations of 0.17 and 0.18.

So these are not like the huge correlations we were seen before. I would expect locus of control to have a much stronger correlation than presence of meaning with healthy eating and physical activity, wouldn't you? As far as you can control essentially your health, so you go and do that? Yeah. Yeah. And sometimes you have a measure like meaning, and they're picking up on positive things as well. And so, like, positive things tend to run together.

So you're going to see these low correlations. That doesn't mean it's a causal relationship. Like, you have to have meaning to have physical activity. But if you are full of more meaning, you may do things that are better for you in general, right? Okay. So the borderline symptom, list correlation with meaning. I think that's worth discussing. So this was a study Marco and colleagues where they studied the meaning in life in the context of borderline personality disorder.

And, you know, we know that clinical features borderline personality disorder are unstable emotions, self-image issues, huge amounts of emotion around relationships. You know, when relationships break up, there's often destabilization of their of their mood, affect, life, and we know that people with borderline personality sort of have a higher risk of trying to commit suicide. There's a higher risk that they will actually complete the suicide as well. So in this study, they found that the correlation between the borderline's symptom list with purpose of life was correlated 0.73, negative correlation. and with the borderline list with meaning in life. 0.76.

Life goals and purpose, 0.57. Does that surprise me? No, it doesn't surprise me at all, actually, because we know that people with borderline for size disorder, I've seen a number of people who find a deep sense of meaning and purpose, and they do a whole lot better. It, like, stabilizes them. How does a person with borderline personality disorder find meaning and purpose?

It just, I don't know anybody with it that I know of. And just from what I understand, just at a basic level, it's defined by instability. In so many just key aspects of a person's life, how does that person actually go about finding meaning and purpose? I've seen a couple join religious organizations, and that's very stabilizing for them, as long as the religious leader is warm and loving and caring and not toxic. I've seen them find causes that for them make all the world of a difference. And if they find the cause and they feel like they're making a difference in the world, that can make a big difference.

I remember one of my attendings sat a family down of a pretty brutal borderline and it was like, you guys got to get this person to some mission field in Africa or something like that. It's a very kind of odd recommendation, but the family did. The family took this person and got them doing some humanitarian stuff and, you know, at an orphanage in Africa and the person improved quite a bit. So sometimes it's like when the monolithic focus is on the self, it's actually detrimental to this type of cluster of symptoms. But when they feel like they can be a part of something, making other people's lives improve

better, it gives a lot of meaning and purpose. And it kind of begs the different, it begs the question, should we only have an individualistic approach in the way that we do psychotherapy? Like, you need to do more stuff. for yourself type of thing. Well, maybe the question is better, like, where have you found meaning? Where have you found purpose in the past? What have you found meaning in? I know a lot of people with borderline personality who go on to be therapists, go on to be doctors. And, you know, although getting through the process of the education is tough, once they find a place where they're

giving, where they're, you know, contributing to society, if they can find a stable relationship, it does really stabilize them to find those good things. A lot of it, a lot of it honestly has to do with good mentors. Like if they can find good mentors, if they can find good people to be around. I mean, I think that's where psychotherapy has a lot of value. And then, you know, sometimes in the midst of like a dialectal behavioral therapy track, at least the way that our partial is run towards the end,

they're finding ways to volunteer, they're finding ways to get out in the community to give back. Like that's part of the treatment is moving from a place into a place of generativity. That makes sense. You're generating connection. You're generating meaning. Absolutely. Okay. Well, I think we should kind of wrap things up because I think borderline personality disorder was a good one to end with because there is such a higher rate of suicide.

The incidence of completing suicide is around 10%. They're about 50 times higher than the general population to. to be struggling with suicidal thoughts. So we've discussed a couple articles. She's written more. She's written one on how second generation Holocaust survivors who had higher trait anxiety, depression, how that was correlated with meaning in life

around a 0.5.6 correlation. State and trait anxiety seems to be correlated as well in around 0.7, 0.8 association. So we're going to include this in the blog, in the article, in the resource library, all this data, all the links. And, you know, gosh, I really want to interview her. We should reach out as well, get her on the podcast at some point. You know, I think in summary, like what I'm hoping people to take away from this episode, I'm hoping that people take away this idea of like a target of something that you can target when you're,

approaching someone who's feeling suicidal. What is their meaning? What do they find meaningful? What is their locus of control? Do they feel like they can make a difference in their trajectory? For locus of control, I always say, if you can't change something, change your environment. So, for example, getting stuck, doing exercise, doing some lifestyle stuff, I got some coaches. I'm like, okay, I'm going to pay for coaches.

I'm going to find the best. and it's been really helpful for me. So in the same way, if you're struggling with mood issues, you know, you've got to find a coach. You can change your environment. I think that's why the daytruent programs, partial programs are so powerful, because they really do go into depth and density really quickly

with other people who are struggling with similar things that you are, if you're struggling with suicide, if you're struggling with depression. So changing your environment, changing the way that you look for what is meaningful, looking for how do I become someone who can make an impact in the world, make the world just a little bit better? These are questions that keep me going too.

Honestly, like in this time, seeing patience, doing stuff on the side like these podcasts, it's like, okay, can I help people just a little bit? I can train a therapist, a psychiatrist, and educate them in a way that gives them a little bit of value, that helps them interact with patients a little bit better, that helps their patients develop a little bit more meaning, a little bit more purpose, maybe a little bit more internal locus of control. You know, that's going to make a difference. And so how can we have a ripple effect?

So I really appreciate you, Stephen, for coming on. Thank you very much for the opportunity. Yeah, it's good. I appreciate your own internal locus of control for reaching out to me and your own meaning for keeping going. At one point, we had about 70 pages of document and we cut it down and we kept kind of looking for what was the most interesting thing we could find for some of these links.

So I'll leave it there for today. I wish you all well. and have a great day.