Psychosomatics 44:415-416, October 2003
© 2003 The Academy of Psychosomatic Medicine
Impulsive Suicide Attempts by a Patient With Alcoholic Dementia
Paul B. Rosenberg, M.D., and
Richard Rosse, M.D.
Received Aug. 12, 2002; revision received Dec. 22, 2002; accepted Jan. 22, 2003. From the Mental Health Service Line, Department of Veterans Affairs Medical Center; and the Department of Psychiatry, Georgetown University School of Medicine, Washington, D.C. Address reprint requests to Dr. Rosenberg, Psychiatry and Behavioral Sciences, Division of Geriatric Psychiatry and Neuropsychiatry, Ocler 320, The Johns Hopkins Hospital, Baltimore, MD 21287; wild.rosenbergs{at}verizon.net (e-mail).
Consultation-liaison psychiatrists frequently evaluate suicidal risk in patients with dementia who are on medical and surgical units. These evaluations are particularly challenging because demented patients often cannot accurately recall their mood or intent at the time of an attempted suicide or their thoughts of suicide. We present such a case of a confabulatory patient with alcoholic dementia who made two suicide attempts in the hospital within a 2-hour period
Case Report
Mr. A was a 57-year-old male veteran with history of alcohol dependence, alcoholic dementia, and major depression. He came to an emergency room with an alcohol level of 292 µg/dl stating that he was thinking about hanging himself; he reported this to ambulance attendants but did not recall this 1–2 hours later. He was admitted to the medical service for alcohol detoxification 36 hours after admission and reported no thoughts of hanging himself. He had a subdued and mildly dysphoric affect with no psychotic symptoms. It is of note that he did not recall a psychiatric hospitalization 1 month before. He had an uncomplicated detoxification and was discharged 40 hours after admission but did not leave the hospital. At 1:15 p.m., he was found in the bathroom of the room from which he had been discharged, having attempted to hang himself with a bed sheet. Approximately 30–45 minutes later, he did not recall attempting to hang himself and said, "I must have been in DTs. I've had them a lot before." He was smiling, laughing, engaging, exhibiting a full range of affect and denied any suicidal intent or desire to stay in the hospital. He had intact attention, orientation, speech functions, and did not appear in any way delirious. He was discharged with prescriptions for sertraline, 150 mg every morning, and trazodone, 100 mg/day for 1 month.
Mr. A left the hospital grounds at approximately 3:00 p.m., drank a quart of vodka, took an overdose of trazodone, and was readmitted to the hospital. By the next morning, he was lethargic but arousable and recalled his overdose but not his hanging attempt. After fully regaining consciousness, he was transferred back to the acute psychiatry unit. His score on the Mini Mental State Examination was 24 of 30 the next day; his short-term recall was intact. He restarted sertraline and carbamazepine and was transferred to a residential substance abuse treatment unit.
Mr. A's past psychiatric history included chronic and persistent alcohol dependence, 15 acute psychiatric hospitalizations from 1998 to 2002 that included numerous suicide attempts, and alcoholic dementia. His past medical history included cervical myelopathy, probable alcohol withdrawal seizures, and head injury without loss of consciousness. A computerized tomography scan of his head, performed 3 years earlier, showed bifrontal edema and small bifrontal intraparenchymal hemorrhages with no significant mass effect or midline shift.
Discussion
Psychiatrists usually think of suicidality in terms of a life story that has built up to a crisis. We use our understanding of the pace and process of the crisis to assess the risk of impulsive or violent behavior. The life story is autobiographical and involves autobiographical memory. But what if the patient lacks an autobiographical memory, such as the main character in the movie Memento? Each scene in the protagonist's life is separate and disconnected. He retains higher-order cognitive functions and is aware that he has memory problems (as with Mr. A). He uses strategies to try to work around his memory deficits, writing autobiographical facts that he considers important in indelible ink on his body. Although he awakens autobiographically empty and starting afresh, his mood is consistently paranoid.
Our patient had a similar life experience, although he was much more cognitively impaired. He awakened not recalling that he had made a suicide attempt, only that he had a depressed mood. He could not assess the severity of his crisis because he could not recall his own life story. Note that he could not recall being hospitalized in a distant city a month earlier or that he had attempted a hanging less than an hour before.
Patients with alcoholic dementia exhibit disproportionate deficits in memory of the temporal order of events,1,2 which may be the result of hippocampal damage.3 We hypothesize that these deficits increase the risk of impulsivity in these patients and make their behavior particularly difficult to predict. The patient in this case report complained persistently of a depressed mood during his many psychiatric hospitalizations, while demonstrating relatively few neurovegetative signs or symptoms of mood disorder. This is consistent with a report that complaints of a depressed mood are a relatively specific symptom of depression in patients with Alzheimer's disease and are not a nonspecific finding due to cognitive impairment.4 There are preliminary data suggesting that thiamine treatment may improve memory in patients detoxifying from alcohol.5 A case report of the efficacy of donepezil in alcoholic dementia6 has not been replicated in a controlled crossover study.7 Consultation-liaison psychiatrists need to be especially alert to the potential for impulsive and suicidal behavior in patients with alcoholic dementia.
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