The epidemiology of suicide among psychopaths

5 The literature on the epidemiology of psychopathy has primarily focused on antisocial personality disorder (ASPD). A 1999 review by Paul Moran found the prevalence of ASPD in the general population to be between 0.2 and 3.7% [19]. Among the prison population, the figure is between 50 and 80%, but the criteria for ASPD frequently overlap with the characteristics of the incarcerated [14]. Substance abuse is a significant comorbidity [22].

6 Psychopathy is also associated with an increased risk of suicide, with an elevated suicide attempt rate of 3.7 times that of the general population [7]. A 2004 article by Verona et al. found that 10.3% of subjects diagnosed with ASPD had a history of a suicide attempt (SA), with an elevated suicide attempt rate of 2.93 times that of the general population [26]. This was much lower than for major depression, in which 24.3% of subjects had attempted suicide, but ASPD was the personality disorder with the highest SA rate.

7 A 2001 study by Verona et al. assessed male inmates using the Hare Psychopathy Checklist (PCL-R) and the DSM-IIIR [2] and DSM-IV [3] [27]. The authors concluded that there was a significant relationship between the checklist score and a history of SA.

8 Psychopathy thus constitutes a personality organization at risk of suicide, in particular due to its antisocial dimension. Research has mainly focused on SA, with the majority of studies conducted in the prison population. This is due to the challenges presented by follow-up of these patients, who quickly drop out of treatment.

General characteristics of psychopaths

9 One characteristic of psychopathy is that its description combines both social and clinical signs. There is a risk of one of these dimensions overshadowing the other, with an antisocial criminal labeled a psychopath even if their only psychopathic traits are impulsivity and an inability to tolerate frustration. Such shortcuts must be avoided.

10 Hubert Flavigny offers a psychodynamic insight in a 1977 article on new forms of psychopathy in adolescents [15]. As Senon observes [24], Flavigny distinguishes between essential symptoms, secondary symptoms, and background. Essential symptoms consist of acting out, repetitive behaviors, passivity and idleness, and dependence on others, combined with megalomaniacal demands and the pursuit of instant gratification. Secondary symptoms encompass instability, lack of interest, the need for escape, unstable relationships, and somatic complaints. Finally, background is formed by a permanent anxiety hidden behind an aggressive and provocative self-presentation, and affective frustrations linked to family neglect in early childhood.

11 Flavigny observes that these patients are characterized by a history of multiple experiences of abandonment and a “shattering discontinuity in early affective relationships,” with children being moved from their birth mother to an adoptive mother and often ending up in an institution. Their parental images are muddled, with the father absent or non-existent, in symbolic terms, and the mother fluctuating between relationships of fusion and rupture with her child. The histories of psychopaths are littered with early trauma, the death of close relatives, abandonment, assault, and physical and sexual violence. Risky behavior in adolescence or early adulthood thus makes perfect sense: alcoholism, substance abuse, and traffic accidents simply reproduce these life events and further mark the patient’s history.

12 For J. Reid Meloy, psychopathy constitutes “an intrapsychic process that has both structure and function” [21]. He explains that psychopathic personality organization is an extreme and dangerous subtype of narcissistic personality disorder, which represents function and structure at a high developmental level within borderline personality disorder.

13 Borderline personality disorder is characterized by the lack of an integrated identity, the predominance of primitive defense mechanisms, and the maintenance of adequate reality testing. Reid Meloy explains that while borderline patients can differentiate between the self and others, their internal representations are unstable. Primitive defense mechanisms consist of splitting along with primitive idealization, projective identification, projection, introjection, denial, and omnipotence. Psychopathic individuals retain the ability to distinguish between interoceptive and exteroceptive stimuli, and it is the maintenance of this reality testing that separates borderline and psychotic personality organizations.

The concept of acting out

14 Examining the suicidal behavior of psychopaths requires us to consider the concept of acting out that dominates this personality organization. In the view of Étienne Trillat, psychopathic acting out has its own characteristics: “impulsivity, lack of premeditation and clumsy execution, lack of subsequent remorse, and framing the reaction in terms of temperament and behavioral problems” [25].

15 These acting-out behaviors cannot be understood without reference to the ego failure that these patients experience. Criminal acting-out behaviors represent less a relationship to reality than a megalomaniacal self-affirmation apparently intended to compensate for their deficient narcissism.

16 In order to further understand these acting-out behaviors, we need to introduce the concept of drives and aggression. In psychopathic patients we observe an impoverished phantasmatic life but a rich instinctual life. “Free aggression” results from the separation of the drives: Freud explains that, when there is union between the drives, aggression acts in the service of Eros, the life drive; but when there is disunion, aggression prevails. Free aggression is characterized by the uncontrollable tendency toward discharge. Psychopathic patients cannot suppress the slightest tension: “the slightest frustration triggers a discharge of anger with aggressive acts toward objects, people, or the self” [6].

17 Acting out occurs when the primary defenses of denial, splitting, projective identification, omnipotence, and idealization are overwhelmed by the separated aggressive drive. In this view, the violent impulsive state is based on a fragile ego, an incomplete ego that is easily overwhelmed by the aggressive drive, which is separate but able to maintain relatively clear inner/outer differentiation through use of the external object, which must remain in its possession, whether through murder or another act in lieu thereof.

18 The psychopathology of hetero-aggressive acting out relates to suicidal acting out when the psychopath is unable to act out on others in a context of frustration or anxiety and/or when the psychopath is in a depressive state.

Addictive behaviors: An equivalent to suicide?

19 Epidemiological data show a high prevalence of ASPD among individuals addicted to illegal substances: the disorder appears to affect 25 to 38% of heroin addicts and has “a significant presence” among cocaine addicts, alongside borderline and narcissistic personality disorders [16]. This personality disorder is typically associated with more severe addiction and poorer responses to treatment [28]. Alain Morel has attempted to identify the links between addictive behavior and psychopathy [20]. As we have seen, identification and narcissism issues play an important role in psychopathy: Jean-Pierre Chartier notes that “the narcissistic foundations are undermined at an early stage” [13], and Jean Bergeret has explored the major identification deficits [8]. The use of psychoactive substances thus forms part of a strategy of protection and reassurance, and it can even act as an identity prosthesis that legitimizes instability and marginality.

20 It is impossible to discuss these behaviors without introducing the notion of risk, for these are certainly risky behaviors. While “the initial period of substance use typically involves a vigilant ‘flirtation’ with danger [. . .] the urgency of cravings and withdrawal, as the addiction develops, then prevails over the controlled ritualization of drug addiction: the drive to ease cravings takes over from the pursuit of pleasure, and toying with risk gives way to taking real risks, overpowering all caution and leaving the heroin addict at permanent risk of overdose, of a suicidal act, and now of HIV infection” [1]. From a psychopathological point of view, Aimé Charles-Nicolas and Marc Valleur refer to these risky behaviors as “ordalic behaviors” [11]. In their view, the modern ordeal involves “the repetition of a trial involving a fatal threat, which the subject undergoes in order to prove, through their survival, their intrinsic value, thus recognized by the transcendent powers of fate. . .” [12]. In this view, repeated drug use thus represents an attempt to master the joy of the high, but also a form of playing with death. Frequent suicides among drug addicts may reflect this ordalic model, as they replace the behavior of repeatedly risking their lives through chasing the high, which “makes them feel alive,” with the more directly suicidal act of playing with death. For Charles-Nicolas, these risky behaviors act as a defense against psychosis and represent attempts to provide structure. As such, the ordalic subject who has a brush with death “draws the permission to live from this experience of risk” [11]. Beyond the sphere of psychosis, the “ordalic project” could be a way to “underpin initially undecided life forces with death” [11].

21 The vulnerability of these patients, their recourse to acting out rather than mentalization, and their addictive behaviors thus make psychopathy fertile ground for suicide.

Analysis of the ANAES guidelines on suicidal crisis

22 The ANAES guidelines [4] focus on the identification of suicidal crisis. This is defined by a mental health crisis whose major risk is suicide: a pathway from feeling negatively about being in a position of failure to believing that it is impossible to escape from this impasse, characterized by the development of increasingly dominant and invasive suicidal ideation, up to the point of the subject ultimately acting on such thoughts. It is unclear, however, whether this model can always be applied to psychopaths, who are characterized by the impulsivity and sudden nature of their acting-out behaviors, without a gradual suicidal process. The concept nevertheless provides a valuable framework for our discussion.

23 According to ANAES, non-professionals can recognize suicidal crisis by the expression of suicidal ideas and intentions, mental health crisis, and a background of psychological vulnerability (depression, impulsivity, and pre-existing psychiatric disorders). Its guidelines advise care providers to establish a bond and a relationship of trust by adopting a caring attitude characterized by listening, dialogue, and alliance that will encourage the patient to draw on their support and care networks. Psychopaths, however, are cut off from their friends and family and are characterized by impulsivity. Recommendations regarding close friends and family are therefore of little relevance to these patients.

24 In its guidelines for assessment in a healthcare setting, ANAES introduces the concept of risk factors. The primary factors consist of psychiatric disorders, personal and family history of suicide, the communication of suicidal intentions, and impulsivity. These are factors that may be influenced by treatment, and they act as valuable red flags at the individual level. The secondary factors encompass early parental loss, social isolation, unemployment, financial and professional difficulties, and negative life events. These are difficult to influence through treatment and have low predictive value in the absence of primary factors. The tertiary factors of male sex and age (old and young age) cannot be modified and only have a predictive value if primary and secondary factors are present. Impulsivity also facilitates acting on suicidal thoughts, especially in combination with anxiety or depression. Psychopaths clearly have a combination of primary risk factors (personality disorder and impulsivity), secondary risk factors (family breakdown, isolation, and negative life events), and tertiary risk factors (as they are most often male). They have often experienced predisposing life events such as early parental losses and in some cases child abuse, and precipitating life events through conflicts of various kinds.

25 In broad terms, suicidal crisis is recognized on the basis of a suicidal context, psychological vulnerability, and impulsivity. The difficulty in relation to psychopaths is that impulsivity and vulnerability are fixed elements and that the suicidal context will not always be present given their tendency toward acting out.

26 The assessment of urgency and dangerousness is a fundamental stage in the evaluation of a suicidal crisis. It involves considering the level of suffering, degree of intentionality, elements of impulsivity, any precipitating events, access to lethal means, and the nature of support from close friends and family. Here again, the situation of psychopaths can soon become a highly urgent one, given their access to lethal means and frequent isolation, and thus require hospitalization.

27 ANAES recommends adapting interventions to the patient’s context: close family and friends are not very present in the lives of these subjects, and prison can provide a place for intervention. Social workers may be a source of support and can direct patients to an appropriate organization. If the psychopath is under the care of a psychiatrist, they will of course be a key contact. But the primary option would appear to be the emergency services, who can assess the patient and make a decision on whether hospitalization is required in the case of an emergency. ANAES recommends the use of scales by the emergency services, mainly Beck Scales, and in particular the suicide ideation scale to assess the risk of short-term recurrence of SA [5]. Some questions appear to be of little relevance to psychopaths, including those about the level of premeditation and preparation for the act; since psychopaths act impulsively, such a dynamic does not apply. Getting subjects to verbalize the purpose of their actions and any regrets they may have can however provide useful information if this is solicited by way of a structured interview without necessarily sticking rigidly to the scale.

28 Psychopaths thus appear to be at a particularly high risk of suicide, and while their place in psychiatry may be disputed, this should not be the case for patients who are considering or have attempted suicide. They are by nature impulsive, they express themselves through acting out rather than words, their lives are a series of ruptures and failures, they have little family support as a result of frequent family breakdown, and they often have access to lethal means (various psychotropic drugs and potentially a firearm). All of these elements facilitate suicidal acting out that will require hospitalization under specific arrangements.

29 Management of the suicidal crisis (secondary prevention) is followed by prevention of repeat attempts, or tertiary prevention. The statistics show that there is a major risk of a repeat attempt in the year following an SA: 10 to 20% of patients in the cohorts studied, with a suicide rate of 1% at one year, and an increased risk of death from all causes [4]. These general data also apply to psychopaths, since we know that, in the psychopathology of patients who make repeat attempts, psychosocial crises play less of a role than long-term psychiatric disorders, including personality disorders and addictive behaviors. The guidelines issued by the Consensus Conference of the French Federation of Psychiatry further add that the risk of a repeat attempt is increased for patients with primary risk factors [4], a group that includes psychopathic patients. Adherence to the follow-up offered by care teams appears to be low, with 10 to 50% of individuals following the recommended treatment, but it appears to be improved by the use of routine reminder phone calls or letters or home follow-up care [4]. For patients with primary risk factors or multiple risk factors, ANAES recommends “specialist follow-up, either through hospitalization or outpatient follow-up. After the crisis period, the goal is to introduce, modify, continue, or resume treatment for the underlying disorder. If this is the patient’s first contact with the psychiatry service, the practitioner or team that intervened at the time of the suicidal crisis has an essential role to play in promoting the long-term therapeutic alliance, informing patients and their friends and family about treatment options, and preparing the handover to future care providers to ensure continuity of care” [4].

30 Promoting the therapeutic alliance would appear to represent a challenge with psychopathic patients. While home visits from a specialist psychosis nurse are recommended, this can be dangerous with psychopathic patients. They may become overinvested in an individual assigned nurse, who risks disappointing them and becoming a bad object. The guiding principles of avoiding a repeat SA appear to consist of offering appointments with a psychiatrist and support from a medical and psychiatric center, where different nurses can administer long-acting antipsychotic medication. Welfare assistance also has an important role to play in reducing the frequency of precipitating events for suicidal acting out. Missed appointments and non-adherence to medication are however to be expected, and time is likely to be a major ally in helping these patients.

Management in the hospital setting

31 Psychopathy is associated with a number of comorbidities. Addictive disorders (alcoholism, drug addiction, and psychotropic abuse) are the most frequently reported [22], but depression [23], anxiety disorders, and schizophrenia [9] may also be present. Psychopathy can also be complicated by brief psychotic episodes. Depression is of particular interest here since it is a risk factor for suicide, regardless of the patient’s underlying personality organization.

32 Psychopaths may be admitted to the emergency room for a wide range of reasons, including suicide attempts, depression, causing a public disturbance, self-harm, substance abuse, and delusional state.

33 The initial assessment takes place in the emergency room and consists of identifying the risk of self-injury, injury to others, and manipulative behaviors. For suicidal psychopathic patients who may cause harm to others, sedation with injectable antipsychotics may be required, potentially combined with the use of restraint if necessary. Involuntary commitment may be required: at the request of a third party, if the patient is judged to require urgent care and their consent cannot be obtained; or by the public authorities, if their condition presents a threat to public order. Involuntary commitment generally lasts only a few days, enabling the patient to recover from the suicidal crisis and avoid the emergence of psychopathic functioning, which is not easily compatible with hospitalization. Closed wards appear to be the most suitable for this type of patient, given the containing framework they provide.

34 Pierre Lamothe explains that many psychiatrists feel that psychopaths belong in prison and are outside the scope of their work [17]. Indeed, psychopathic personalities are not recognized as a mental illness in any country. Lamothe presents the psychopath as a subject suffering from a psychic economy that is generally unsuccessful and costly to the self and to the psychopath’s interlocutors. He advises employing affective neutrality with these patients, in order to avoid provoking sadomasochistic abandonment mechanisms and to promote appropriate narcissistic gratifications that rebuild identity and self-esteem.

35 Suicidal psychopaths, who may be depressed, can be manipulative and may express their pain through self-harm or hypochondriac complaints. In response to this depression, they draw on their characteristic defense mechanisms of megalomania, pathological lying, and inability to tolerate frustration. They may also attempt to seduce some staff members and be dismissive of others, struggling with the anxiety of abandonment. Care providers find themselves in a challenging position faced with the confounding behavior of such patients, wondering how they can possibly help someone who, while exhibiting genuine distress, meets their endeavors with unbearable aggression. In general terms, a relationship of trust must be established. This is achieved through somatic care that demonstrates the importance of the patient, by providing them with support and restoring their self-worth with accessible tasks that do not set them up for failure. Therapy contracts are valuable, as they establish a framework and maintain consistency in care, with limits made clear to the patient. Psychiatrists must however be wary of overly restrictive contracts that will no doubt be seen as a provocation and increase the risk of rejection, reawakening the patient’s memories of very early childhood experiences of tyranny by the archaic maternal law [17]. Finally, assigning the patient a single point of contact should be avoided, as this tends to encourage potentially harmful over-investment in another person. Éric Marcel sums up the challenges of treating psychopaths in the hospital setting as follows: “We know these patients [psychopaths] well—we see them all the time: they are frequently admitted to hospital, they disrupt the wards, they are unstable, constantly testing the structure in place, only feeling at ease when this is solid enough to respond to them. Hence the importance of work, consistency, the care team, and the institution in relation to these patients. Given time, they are open to a discourse of care and ultimately present little violence on the ward. Admission is often challenging, but most of the time we manage to contain them” [18].

36 For patients who are aggressive, particularly those who threaten self-harm, isolation can be used, combined with sedation and ultimately restraint if necessary. This must not be used for punitive purposes, but rather for protection. It is also essential to ensure that such measures are not implemented by a single care provider.

37 Agitation, triggered by frustration, and psychotic episodes, triggered by toxic substances, must always be monitored. Management of these symptoms is based on verbalization and reframing while emphasizing respect and trust.

38 Teamwork is fundamental with these patients in analyzing acting-out behaviors and taking a collective step back in order to avoid negative, non-therapeutic counter-attitudes.

39 Medication can be useful, particularly antipsychotics for agitation or delusional episodes, and antidepressants in patients with confirmed depression.

Care providers’ attitudes toward psychopaths

40 Care providers often find it difficult to position themselves in relation to psychopathic patients, and the view that “they should be in prison instead; they scare other patients and scare us” may be apparent on the wards. Those who try to maintain a framework are a target for the psychopath’s aggression and must manage this. There is a temptation to reflect such aggression back on the patient, who is then stripped of their status as an individual in pain. It then becomes impossible to imagine that they might act out against themselves, and if they do, to offer even the slightest empathy.

41 How, then, can we help these patients when it is difficult to place ourselves in a caring position?

42 Cyrille Canetti discusses the issue by explaining that it is difficult to feel concern for individuals who seem to take pleasure in manipulating their interlocutors, as the anxious desire to avoid being manipulated then obscures the patient’s suffering [10]. But the suffering denied by the patient is projected externally in order to maintain the integrity of their identity. While psychopaths are incapable of caring about the suffering of others, they are also incapable of caring about their own. Deceptive behavior appears to be part of a will for psychic survival. Making sense of the attitudes of psychopaths could help avoid non-therapeutic reactions.

43 Auto-aggression comes as a surprise in such patients, and surprise or fear risk paralyzing the care provider or provoking a negative or even sadistic counter-attitude. This is observed by Claude Balier [6], for whom the patient’s possibility of change is dependent on their past and their psychic organization, but also on the countertransference investment made by the care team. The responsibility of this team and its work therefore consists in supporting these patients, particularly in times of suicidal crisis.

44 Therein lies the heart of the problem of treating the psychopathic patient—to quote J. Reid Meloy, “the response of most clinicians to the psychopathic patient is to question the possibility of psychotherapeutic change, which may be either a countertransference reaction to psychopathic devaluation or a realistic decision based upon sound clinical judgment” [21]. Reid Meloy considers psychopathy to be a deviant developmental process that manifests in a disturbance of personality function. He argues that in order to avoid the countertransference reaction, it should be considered as a disorder situated on a hypothetical continuum, ranging from mild to severe. Otherwise, the clinician risks falling prey to “his own disidentifying and dehumanizing impulse” [21]. Psychopathic patients can thus trap us in their acting-out behaviors, provoking counter-attitudes that are uncaring because they are hasty and unconsidered, and this risk persists when they act out against themselves.

45 The concept of countertransference appears to be fundamental in the management of psychopathic patients, and it represents a guide for psychiatrists and their teams regarding the action to take and the analysis that guides their decisions. In cases of suicidal crisis, the intrinsic characteristics of psychopaths, such as manipulation and deceit, are no longer to the fore but are overshadowed by the suicidal crisis. When assessing these patients in the emergency room, it is essential to forestall attempts to manipulate the physician and institution, to assess the risk of harm to others, the potential secondary benefits for the patient, and the potential difficulties of managing the patient in a hospital ward—all elements that would make hospital admission useless and harmful for the unit. Management of psychopathic patients who are considering or have attempted suicide works best when it involves a short hospital stay, involuntary if necessary, in a containing framework such as a closed ward.