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Archives of Suicide Research

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Ecstatic suicide
John T. Maltsberger

Department of Psychiatry, Harvard Medical School,

Boston, MA; McLean Hospital, Belmont, MA; and
Marsachusetts General Hospital, Boston; Faculty, Boston
Psychoanalytic Institute, MA, U.S.A.
Version of record first published: 27 Sep 2007.

To cite this article: John T. Maltsberger (1997): Ecstatic suicide, Archives of Suicide
Research, 3:4, 283-301
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Archives of Suicide Research 3: 283-301. 1997.

G
J 1997 Kluwer Academic Publishers. Printed in the Netherlands.

Review article

Ecstatic suicide
JOHN T. MALTSBERGER
Department of Psychiatry, Harvard Medical School, Boston, MA; McLean Hospital,
Belmont, MA; and Marsachusetts General Hospital, Boston; Facuhy, Boston Psychoanalytic
Institute, MA, U.S.A.

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Accepted 1 January 1997

Abstract. Suicide is not an epiphenomenon of depression; it occurs in conditions other

than major depressive episodes. Some anguished, excited patients in the grips of ecdysial
or apotheotic fantasies attempt suicide when reality testing fails, feeling it a thrill. When
malignant narcissism colors severe borderline personality disorder such suicides may occur.
Three illustrativecases are presented here and are then placed in the perspective of mass suicides and the ecstatic experiences of third century Christian martyrs. Elated, grandiose suicide
material is to be found in the lives and writings of Yukio Mishima and Sylvia Plath, and in
some perverse sexual fantasies. Some persons kill themselves not feeling depressed in the
melancholic sense; they are delighted. Their suicides are acts of omnipotent, death-defying
magic. Correct suicide risk assessment must take elation of mood and grandiose beliefs about
the nature of death into account, because certain individuals are convinced that suicide is
passage to glory.
Key words: bipolar disorder, grandiosity, hypomania, mental state, metamorphosis, suicide

Introduction
The grandiose phenomena of manic-depressive illness have never been understood to lie exclusively in the temtory of the manic side of the disorder. That
melancholic patients may suffer grandiose delusions of their evil power (I
am the devil and should die before I cause the end of the world) or personal
corruption (I am full of pus and have infected the entire city with syphilis) is
a textbook commonplace. Yet we have come to believe suicide does not take
place in manic temtory, and we do not commonly associate grandiose fantasy
with suicidal behavior. Clinical study of suicidal patients teaches otherwise.
The older literature contains references to suicide in excited or ecstatic states (Tanzi, 1909; Zilboorg, 1936; Friedlander, 1940; Lewin, 1950),
but we search vainly for representative patients in the retrospective suicide
investigations that have appeared in the last forty years (Apter, et al., 1993;
Robins, 1981; Barraclough et a]., 1974; Dorpat & Ripley, 1960; Robins et al.,
1959). Not one of the 63 affective disorder suicides in Robinss (1981) series

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284

had ever had a manic episode. Where today are those patients such as Tanzi,
the eminent Italian psychiatrist of the late nineteenth century, described? He
reported two schizophrenic men, a 30-year-old clerk who twice jumped
from a high window to demonstrate his courage and disarm his enemies,
and an army captain who twice attempted suicide in dangerous ways to confound his enemies and show them he was invulnerable (Tanzi, 1909, pp.
6-41).
Are such suicides so rare that none were captured in the more modem
retrospective series just cited? We lack epidemiological data, but ecstatic
suicides do indeed seem to occur in clinical practice. Three near suicides of
this type will be described here.
Bronisch (1996) suggests that the contemporary tendency to treat suicide
as a strict epiphenomenon of major depression is an error. Are the current
criteria for diagnosing major depressive illness so broad that the diagnosis is
overinclusive? Are they ever underinclusive? Ronningstam and Maltsberger
(in press) have recently reported three cases of deadly suicide attempts in
young men not one of whom was clinically depressed according to the rubrics
of the Diagnostic and statistical manual of mental disorders, 4th Edition
(1 994) (hereinafter, DSM-4).
Here are reports of three women, two of whom are grandiose and ecstatic
in their suicidal moments. The third is also grandiose when suicidal, but not
ecstatic.

I.
Mrs. A., a 53-year-old woman who suffers from a bipolar disorder, mixed,
with psychotic features, has been preoccupied with suicide and death since
she started school. As a small child she prayed for a deadly illness, and in
the fifth grade, offended by a mean teacher, she plotted to jump in front
of a fast car and later did so, narrowly escaping injury when the temfied
driver slammed on the brakes.
Though she has usually worked effectively as a business executive, there
have been four occasions when her chronic hypomania worsened and she
required hospital care. These episodes were marked by emotional lability, loquacity, distractibility, psychomotor agitation, sleeplessness, overactivity, profound suicidal preoccupation, and severe emotional anguish
(psychache; see Shneidman, 1993).She is subject to outbursts of weeping, shrieking, and beating herself. The patients anguish can be so intense
that she drives about recklessly in her car for hours, screaming with pain
and remorse for past misdeeds. It causes her to take risks in traffic. She
can only bring this experience under control by injuring herself; she has
repeatedly burned herself to attenuate the mental pain.

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During attacks the patient has heard different hallucinatory voices which
she says represent self-fragments. Some of the voices seem protective,
but others are murderously hostile. The voices sometimes shout at each
other all at once. Two of the voices propel the patient to kill herself;
the one she calls Tormentor is associated with experiences of intense
anguish. The other killing voice she calls Hangman. He pours out his
hate for everything about the patient (including the other hallucinatory
presences) except himself and believes he will survive her death. She says
she is closest to suicide when the Tormentor and the Hangman get going
together; they can seize all her energy and paralyze the other presences.
In her states of torment the patient likes to play erotic, thrilling death
games. As an adolescent she took terrible risks with motorcycles. As an
adult she likes to drive up behind large trucks on the superhighway, close
her eyes, and accelerate her car as fast as she can, not looking until the
last possible moment. She says these dangerous games restore her sense
of control and arouse her to a state of near orgasm; she is driven to play
them when she feels helpless and flooded with anguish. Such an episode
gets the adrenaline going, she says; she becomes ecstatic. She laughed
excitedly in describing her highway thrills, and then suddenly began to
cry.
She takes pleasure in torturing her therapist with suicidal threats to show
him who is in charge. In the hospital she was ecstatic on one occasion
when she succeeded in getting out on a window ledge and temfied the
staff.

She has attempted suicide twice by whipping her speeding car off interstate highways into ravines. She has had a suicide scheme for years and
intends to die in style. She plans to leave taped messages and funeral
instructions, to dress in her best clothes, and to have her car specially
washed and polished for the great day. Planned death means having
total control of her life; it is the opposite of helplessness, which she
greatly fears. Her favorite film is Thelma and Louise, a portrayal of the
double suicide of two women who speed over a cliff together in an open
convertible.
Mrs. As father was an outright sadist. He liked to hurt her physically
and emotionally, and liked to kill and torment animals. He encouraged
the patient to be physically merciless with herself, to endure pain silently,
and never to cry. From childhood he liked to talk to her about death and
suicide. To please him she killed small vermin. She was sexually abused
by a visiting adolescent boy (repeated vaginal rape resulting in bleeding)
when she was eight, but never dared tell anybody.

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11.

Miss B. is a 30-year-old former athlete who at the beginning of her treatment satisfied the DSM 4 criteria for narcissistic personality disorder, borderline personality disorder and a major depressive episode. After extensive psychotherapy and exhaustive drug trials she became less impulsive,
her relationships with others stabilized, and she gave up cutting herself
on her forearms and inner thighs, her almost daily practice for several
years. Her depression never completely remitted, however, it cyclically
worsened and improved every few weeks. Not a typical patient, Miss B.
suffered no psychiatric symptoms apart from mild depression and mild
adolescent anorexia until her twenty-seventh year. Rejected by a young
man, it was then she then began to cut herself, to binge-eat, and to purge.
Taking a tricyclic compound for her depression, in the course of a bicycle
race the patient collapsed in ventricular fibrillation and narrowly escaped
death. In the course of the subsequent hospital treatment her depression
deepened.
A psychiatric hospitalization of many months followed throughout which
the patient was believed dangerously at risk to kill herself. Over the next
three years she attempted suicide on four or five occasions by ingesting
large amounts of aspirin (as many as forty tablets).2 On one occasion she
swallowed an overdose of tricyclic antidepressants. She likes to practice
suicide by stretching ropes and scarves over a doorknob and choking
herself with them until she begins to see black and flashing lights and
stars. From time to time she has come to her treatment session with rope
bums on her neck. She kept a suicide rope in a secret place and refused
to surrender it to her psychiatrist. The cutting and choking are the best
means she can devise for relieving intense feelings of depersonalization
and depressive anguish. These practices also bring great pleasure; she begs
her psychiatrist for permission to injure herself. A secondary benefit
from her morbid behavior is the obvious glee she enjoys in frightening
those responsible for her care. She makes gory suicide threats and asks
psychiatrists and nurses if they will be coming to her funeral.
Though never frankly manic, the patient sometimes reports racing
thoughts and feels speeded up. Early in her psychiatric treatment she
was given fluoxetine briefly. This aroused intense anxiety and the prospect
of self-injury and death began to seem thrilling and erotically arousing.
She formerly imagined herself to be intensely radioactive, so destructive
and evil that all who came in contact with her would be destroyed. Though
she has never hallucinated and has remained free of delusions, she still
cherishes a grandiose fantasy of suicide that is sometimes almost delu-

sional in force. Suicide promises escape from suffering, and is for that
reason much longed for.

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But further, Miss B. imagines suicide to be a path to magical transformation into Apollonian manhood. She longs to cast off her female corpse
as an emerging butterfly its chrysalis. To die of suicide would result in a
phaenix-like metamorphosis. By death the patient plainly means a kind
of passage to masculine apotheosis; it does not mean the end of her self,
but the end of her body only. She once ecstatically described a wish that
as she died her head might be quickly filleted out of her body, lifted away
by a crane, and transplanted into that of a powerful, beautiful young man.
Miss B showed great talent as a swimmer in early adolescence, and set her
heart on winning an Olympic gold medal. With the eager encouragement
of her family she trained to the point of exhaustion and entered numerous
competitions, but never swam well enough to qualify for the Olympic
team. She blames this on her womanhood. She remains convinced that
had she been born male she would have had a perfect body and the
necessary muscles to win an Olympic gold. She imagines the cheering
crowds and the publicity she would have enjoyed in winning the medal.
To die of suicide would be just like that, she says; she compares her
imaginary Olympic glory to the flashing stars and lights she sees when
she chokes herself almost unconscious.
Not every victim of ecdysial suicide is ecstatic or elated, though some are.
Though the third patient reported no ecstatic experience, she nevertheless
denied that her bizarre behavior would kill her, and acted on a grandiose
delusion of ecdysial purification.
111.

Miss C., a 57-year-old spinster veterinarians assistant with a history of

bipolar disorder, had been sexually and physically abused as a child. At
the time of the present admission she satisfied the criteria for a diagnosis
of major depressive episode and borderline personality disorder. Over the
course of her unhappy life the patient reported she had overdosed heavily
on several occasions, fully intending and expecting to die. About a year
after the death of a beloved sister whom Miss C. nursed through her
terminal illness (melanoma - there was continuous bloody oozing and
great pain at the end) the patient developed a severe major depressive
episode with psychotic features. She suffered precordial pain, a sense
of tremulousness inside the abdomen, and breathlessness so painful she
wanted to jump in front of oncoming traffic. She hallucinated her sisters
voice summoning her, and other voices commanding her to phlebotomize
herself.

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In the course of her veterinary work Miss C. had learned the technique for
phlebotomy. She developed the delusion that all the evil which suffused
her body as a consequence of the sexual abuse was concentrated in her
blood. She sought to purify herself by phlebotomy. Over the course of a
week she drained off 2.6 litres of blood; the most she ever took at one
sitting was 1.5 litres. Her hematocrit fell to 1 1.3
She denied this behavior was suicidal and stoutly claimed she would not
die even if she rid herself of the evil blood to the last millilitre. She insisted
she would, once purified, become reunited with her sister. With reluctant
disinterest she agreed that her behavior might lead to physical death, but
averred the loss of her body, a meaningless husk, would be a matter of no
great consequence, and would not constitute death. She therefore denied
that the ex-sanguination she was carrying out was suicidal in character.

Malignant narcissism, personality disorders, and affective disorders

All three of these patients manifest borderline, narcissistic, and probably bipolar features (Miss B. suffers from racing thoughts and feels speeded up from
time to time). Ronningstam and Gunderson (1 99 1) have found that grandiosity is much more characteristic of patients with narcissistic personality disorders than of those with borderline personality disorders. The grandiosity of
the narcissistic personality disorder patient is global; they believe they are
unique, superior; they exaggerate their talents; in their self-centeredness they
boast and strut, expect special treatment, and exploit others. Mrs. A., Miss
B., and Miss C. are all assuredly grandiose, but their grandiosity applies to
their suicidal fantasy only. Each suffers from low self-esteem and most of
the time feels profoundly inferior. Kemberg (1 990) would deny the narcissistic personality disorder diagnosis to these patients because they are from
time to time psychotic, or at least functionally so. He has stated that when
reality testing is compromised, as in psychotic cases, the diagnosis does not
apply. Others, however, including the approach of the DSM-4, do not treat
occasional psychosis as exclusionary.
The first two cases, both of whom merit a DSM-4 narcissistic personality
disorder diagnosis, plainly meet the criteria for Kembergs malignanfnarcissism. Both Mrs. A. and Miss B. are crippled with a pathological grandiose
self highly infiltrated with aggression. Each experiences confirmation of her
grandiosity and a rise in self-esteem when she can injure herself or torment
others. They take pleasure in self-mutilation and cruelty to others. Kemberg
writes:

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The sense these patients convey of being capable of calmly damaging

themselves, in contrast to the fear and despair and the pleadingefforts of
their relatives and staff to keep them alive and to maintain their human contacts, illustrates a dramatic distortion of the gratification of self-esteem.
The patients grandiosity is fulfilled by the feeling of triumph over the
fear of pain and death and, at an unconscious level, by their sense ofbeing
in control over death. (Kemberg, 1984, p. 257; italics added)
Kembergs emphasis on morbid character or personality organization in
these patients distracts attention from the fact that many such borderline
patients also suffer from subtle (or not so subtle) bipolar disorder, or else
function psychologically at the dynamic level of mania, even though they
may not manifest enough of the index phenomena to qualify for a full
hypomanic-manic diagnosis. Many such patients are nevertheless unquestionably grandiose.
That atypical bipolar or mixed bipolar cases sometimes masquerade as
patients with borderline personality disorder is well recognized (Akiskal,
1981). Akiskal and colleagues (1983) have suggested that underlying temperament may influence the clinical expression of affective disorders and
influence their prognosis. Gunderson and Elliott (1985) further address the
diagnostic overlap between borderline personality disorders and affective disorders, acknowledging that while the diagnoses appear to be discrete, some
patients are heterogeneous and possess symptom clusters fitting both syndromes.
Just as borderline personality disorder patients sometimes satisfy the criteria for bipolar disorder, so do patients with narcissistic personality disorder.
Akhtar (1 989) has commented on this overlap, pointing out that both hypomanic and narcissistic personality disorder patients may be grandiose, selfabsorbed, and feel both bored and inferior. Ronningstam (1996) has reviewed
the literature that treats pathological narcissism and narcissistic personality
disorders as they occur in Axis I DSM-4 diagnoses, finding that narcissistic personality disorder is present in 4 4 7 % of bipolar patients. The rate of
comorbidity rises as the severity of manic symptoms increases.
Zanarinis (1994) emphasis on the importance of intolerable affect as
a major morbid influence throughout childhood and adolescent personality
development deserves special notice and further study. She shines a light
on the relationship between atypical bipolar disorder and borderline personality disorder, remarking that many borderline patients can do no more
than maintain tenuous life adaptations because they have constantly been
flooded by intense emotional pain through most of their lives. Chronic dysphoria throughout childhood and adolescence must interfere with normal
developmental progress; the necessary identifications and structuralizations

290
for healthy adult living cannot be laid down. Zanarinis observations are of
importance inasmuch as much so-called borderline behavior has the impulsive, irritable, and passionate character familiar in hypomania and in mixed
states. Zanarini and DeLuca have developed an important research instrument, the Dysphoric Affect Scale, which promises to be very useful in
studying suicidal behavior in borderline and dyspshoric cases particularly (in
press).

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Metamorphosis (ecdysis) or apotheosis in suicide

Mrs. A. is psychotic from time to time. Though Miss B. has not met DSM 4
criteria for a psychosis on a purely descriptive basis, her intermittent loss of
reality testing when in the grips of grandiose fantasies of suicidal metamorphosis occasionally make her functionally psychotic. Both patients experience
distinct sexual arousal when giving themselves over to cherished suicide daydreams, and both experience pleasurable, ecstatic excitement at the pitch of
suicidal-parasuicidal action. Miss C . was driven by a purification delusion in
draining away her tainted blood.
Baechler (1975, p. 168) refers to transfiguration suicides, remarking that
some people kill themselves to anive at an infinitely desirable condition.
He described a 20 year old student, solitary and religiously preoccupied, who
became very excited and delirious, wanting to convert everyone to her
ideas. She caused an uproar in a cafe; the police were summoned and took her
home. Feeling called by God and wishing to suffer in order to be purified,
she jumped out the window.
All but the religious examples Baechler adduces seem to puzzle him; he
does not consider that such persons are functionally psychotic at the time
they die. He is careful to separate transfigurational suicides from suicides of
flight (escape), the purpose of which is to put an end to an intolerable state
of affairs - escape suicide is a negative matter. Transfigurational suicide, he
observes, aims at a more positive goal.
Many suicidal patients are canied along by metamorphic death fantasies.
Their aim in dying is self transformation, to escape from an insupportable
present into a better future beyond death. To shed ones body as a molting
insect breaks out of its shell, or cocoon, after maturing into an adult, is the
core wish (Maltsberger & Buie, 1980; Ronningstam & Maltsberger, in press).
The suicide fantasy is one of e c d y ~ i s . ~
In their fantasies of post-mortem survival these patients repudiate parts
of themselves (those parts destined to die) but do not repudiate other parts
which they expect will continue to live. Ecdysial suicides reflect the mental,

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29 1
or thinking self, acting on the body-self as object; the body-self is to die, the
mental-self is not (Maltsberger, 1993).
A subtype of ecdysial suicide is apotheotic inasmuch as deaths purpose
is to elevate and transform the self into godlike perfection. Miss B. was
obsessed with the idea she could through death metamorphose herself into
a perfect young man who would take his place as an Olympic champion suicide, she believed, would turn her into an Apollo. At the moment of her
apotheosis in death she imagined the cheers of the crowd celebrating her glory
(rapturous, orgasmic, absolute) as she grasped the gold medal. For Mrs. A.
suicide promised much the same ecstasy. Miss C. expected to rise immaculate
from the husk of hercorpse, but her description of this transfiguration was
without rapture.

Ecstatic suicide beyond the clinic

Ecstatic suicidal themes have been ubiquitous through history. I shall draw on
certain perversions, ritual suicides, religious suicides, group suicides, and the
writing of a suicidal poet, Sylvia Plath, to show that they are very generally
met, are well known in history and literature, and should not be overlooked
in clinical settings where they not only occur also, but may indicate danger.
Litman and Swearingen (1972) have published two cases of ecstatic
fetishistic death, one of which the coroner classified as an accident, the other,
as a suicide. They described twelve other death-preoccupied sadomasochistic fetishists as well. Of their nine male patients six reported histories of
serious suicide attempts and depression; most had experimented with nooses
and self-hanging. The authors agree with Weisman (1967) that such patients
aim to master lonely, depressive circumstances through ritual sexual activity
accompanied by fantasies of victory, pleasure, and dominance. Masturbatory
or shared sadomasochistic activity provided these men transitory, ecstatic
relief from depression. Mostly these patients were thrilled by hanging, but
feared they would go too far and die. Several reported they were saving
hanging for the ultimate scene or eventual suicide.
Suicides for honor such as hara-kiri do not appear to arise from depression.
Euphoria, heightened self-esteem,and sexual arousal may be associated with
the ritual preparations. Yukio Mishima, the Japanese writer, incorporated such
themes in his writings before he himself died in this way. Hara-kiri suicides
would appear to have a manic coloration, at least in some cases (Asch, 1980).
Ecstatic, transformational themes are familiar enough in Eastern religious
suicides which did not become unusual until the end of the nineteenth century.
In India it was widely believed that to drown oneself in certain parts of the
Ganges promised advantageous transformation in the next transmigration

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292
(Gait, 1908). Those widows who threw themselves into the flames of their
husbands funeral pyres (sari suicides) did so in the belief they would be
bettered in the afterlife (Crawley, 1908).
Ecstatic, metamorphic suicide is psychologically akin to the deaths of
certain third century Christian martyrs who provoked the imperial authorities
to put them to death. Some of these martyrs died in groups, others, alone.
Many were obviously suicides in effect; the would-be martyr deliberately
provoked someone else, often a Roman official, to kill him. Suicide of this
sort is sometimes called victim-precipitated homicide (Wolfgang, 1968).
Convinced by their culture and by teachings of some Church Fathers (Tertullian, Ignatius of Antioch, Cyprian, and Origen, for example) that to die for
the faith expiated every sin, repaired every spiritual defect, and delivered the
sufferer into immediate eternal bliss, some passionate Christians
exasperated the fury of the lions, pressed the executioner to hasten his
office, cheerfully leaped into the fires which were kindled to consume
them, and discovered a sensation of joy and pleasure in the midst of the
most exquisite tortures. . . .The Christians sometimes . . . rudely disturbed
the public service of paganism, and rushing in crowds round the tribunal of
the magistrates, called upon them to pronounce and to inflict the sentence
of the law (Gibbon, 1993, Vol. 2, pp. 39-41).
Later, during the time of the Diocletian persecution (284-3 13 A.D.), the
excesses of those who sought to provoke martyrdom and achieve an ecstatic
metamorphosis worsened. The Donatist (Circumcellion) heretics were infected with a suicidal frenzy never matched since.
Many of these fanatics were possessed with the horror of life, and the
desire of martyrdom; and they deemed it of little moment by what means,
or by what hands, they perished, if their conduct was sanctified by the
intention of devoting themselves to the glory of the true faith, and the
hope of eternal happiness. Sometimes they rudely disturbed the festivals,
and profaned the temples of Paganism, with the design of exciting the
most zealous of the idolaters to revenge the insulted honor of their gods.
They sometimes forced their way into the courts of justice, and compelled
the affrighted judge to give orders for their immediate execution. They
frequently stopped travellers on the public highways, and obliged them
to inflict the stroke of martyrdom, by the promise of a reward if they
consented, and by the threat of instant death if they refused to grant
so very singular a favour. When they were disappointed of every other
resource, they announced the day on which, in the presence of their friends
and brethren, they should cast themselves headlong from some lofty rock;
and many precipices were shown which had acquired fame by the number
of religious suicides. (Gibbon, 1993, Vol. 2, p. 361)

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293
Eusebius (1932) records that when the Roman authorities burned the
Church in Nicomedia and butchered and burned Christians there, men and
women leaped upon the pyre with a divine and unspeakable eagerness (p.
267).
On the night before she was taken to the arena St. Perpetua, martyred in
203 A.D., experienced a vision that resembles the ecdysial fantasy of Miss B.
Perpetua foresaw herself led out before the crowd, where, when stripped, she
was miraculously transformed into a man. Thereupon she enjoyed unarmed
single combat with an Egyptian (the devil personified) whom she overthrew
and then trod on his head.
The next day when in fact she was led into the amphitheater and gored by
a mad heifer, so absorbed was she in ecstasy that she appeared unaware of
what had happened. In her rapture she finally guided the executioners dagger
to her throat (Farmer, 1992).
Ecstatic, metamorphic mass suicides are recorded at various other times
and places in history. For example, in 1666, many Russian zealots, convinced
the Antichrist would soon appear, determined to escape directly to heaven
by committing religious suicide. Encouraged by fanatical priests and other
unscrupulous individuals, whole communities starved themselves to death or
died in flames (Rose, 1928).
The Jonestown mass suicide of the Peoples Temple in 1978 was lead
by the grandiose Jim Jones, self-styled prophet and miracle worker, who
promised his followers togetherness in the afterlife, and spoke of the orgasm
of the grave. Jones probably believed that he was a god (Reston, 198 1).
Sylvia Plath died of suicide on 1 1 February 1963, roughly four months
after she was separated from her husband, Ted Hughes (Stevenson, 1989).
Almost certainly she suffered from a bipolar disorder. She was depressed,
sometimes furiously angry, excited, perhaps sometimes briefly ecstatic, and
preoccupied with suicidal images of metamorphosis in the months before she
put her head in the gas oven. (Plath is increasingly inviting the notice of
suicide specialists - see Leenaars and Wenckstern. in press)
When Plath insisted, Hughes left their home early in October 1962; by the
end of the month she was oscillating between spells of profound depression
and intense rage. She had been subject to angry, sometimes violent, paranoid
outbursts for years, but now friends found her distraught and noticed that
sometimes she talked hysterically. She had difficulty sleeping. She became
morbidly (and unrealistically) afraid she was poor, or threatened with poverty.
She often seemed paranoid. In January 1963 she seemed excited and ecstatic. A friend noticed she had a quality of incandescent desperation. The
night before her death she was found standing motionless in a freezing cold

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hall; she claimed she was having a wonderful vision (Stevenson, 1989, pp.
26 1-299).
During October 1962 she was feverishly and brilliantly creative, sometimes writing several poems in one day. Some of these, for example Lady
Lazarus, are ecdysial in theme: Written at the end of the month, it refers to
her suicide attempt of 1953, an act she narrowly survived, and concludes with
the image of a violent, reborn red-haired phamix ready to eat men, rising from
ashes. She compares herself to the cat which has nine lives, and comments
she has done it three times before. On October 20 she had written in Fever
103:
Does not my heat astound you. And my light. . . .
I think I am going up,
I think I may rise The beads of hot metal fly, and I, love, I
Am a pure acetylene Vigin
Attended by roses, . . .
(My selves dissolving, old whore petticoats) To Paradise.
(Plath. 1992, p.232)
Grandiose themes of elation, destruction, ecdysis, and heavenly assumption repeat themselves in the self-referential bee poem Stings of the same
period, written on 6 October.
They thought death was worth it, but I
Have a self to recover, a queen.
Is she dead, is she sleeping?
Where has she been,
With her lion-red body, her wings of glass?
Now she is flying
More terrible than she ever was, red
Scar in the sky, red comet
Over the engine that killed her The mausoleum, the wax house.
(Plath, 1992, p. 214)

In an earlier version of this poem Plath said the bees were suicidal, destroying themselves by stinging the gloves of the bee-keeper (probably an image
of Ted Hughes condensed with that of her father, an apiologist; she was the
bees) (Plath, 1992, p. 293). She was well informed on bees and was surely
aware that in the course of development they undergo two metamorphoses
after hatching: from larva to pupa, from pupa to imago (the adult form).

295

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What does ecstatic suicide mean?

Plainly there are a number of elements in ecstatic suicide which can be teased
apart. Reality testing is abandoned, the certainty of death is denied, a magical
lethal ecdysial act is carried out, the horror of self-disintegration (annihilation
anxiety) is warded off, sadism and hatred against the patients objects are
expressed, and in fantasy the patient arrives transformed and perfected in the
afterworld. Suicides of this kind represent desperate, paradoxical, last minute
efforts at self-rescue, analagous to sawing off the mainmast in a humcane,
and throwing the ballast overboard.
Freud contrasted the psychological circumstances of depression, in which
the superego (in its function as self-critic) is set over against the ego (self) in
a punishing way, with the circumstances of mania:
On the basis of our analysis of the ego it cannot be doubted that in cases
of mania the ego and the ego ideal [superego in the sense of what the self
might be if perfect] have fused together, so that the person, in a mood
of triumph and self-satisfaction, disturbed by no self-criticism, can enjoy
the abolition of his inhibitions, his feelings of consideration for others,
and his self-reproaches. (Freud, 192 1, p. 132)
In the psychoanalytic sense metamorphic suicide can be understood as
a magical means whereby such a fusion of the ego and the superego are
attempted: through a transformative ecdysis the dying patient rises again as
the ideal self.
Lewin (1950) formulated the wish to die as a regressive yearning to return
to the state of peaceful, blissful infantile sleep wherein all differentiation
between self and object (the madonna-like mother of earliest childhood)
dissolves. The wish is to fuse with total, absolute maternal succor. The state
for which the suicidal patient yeams is total surfeit, protection, safety, and
happy oblivion. Lewin believes the wish to die is the wish to sink away with
utter passive surrender into the arms of the primal mother, becoming one
with her, and that suicide, for this reason, often involves a confusion between
death and the deepest sleep, for which it stands symbolically.
Lewins studies of a series of patients whose inner lives were marked
by extraordinary denial and grandiose fantasies concerning sleep and death
satisfied him that closely related to the fusion fantasy of sleep was the wish
to be devoured, another means whereby self-object differentiation would be
dissolved and the person eaten might become a part of the very tissue and
fabric of the eater. We may recall the early martyrs who sought to be eaten by
wild beasts. As a means to the same end, Lewin described a third element of
his oral triad: To the wish to be devoured and the wish to sleep, he added
the wish to devour the object. The achievement of this very deep primitive

296
triple fusion fantasy would open the way to triumph over suffering, loneliness,
defectiveness, helplessness, and pain.
Freeman (1971) has more recently commented on the psychoanalytic
understanding of mania.

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A comment on whether depression is a sine qua non for suicide

When depression dominates the clinical picture and hypomanic features,
however striking, are insufficient to justify a mixed diagnosis, a depressive diagnosis usually will be made. Further, some depressed patients show
remarkable grandiose and other hypomanic features in mental confenf,but
not otherwise. In my opinion the present diagnostic style of international
psychiatric nosology, whatever its substantial advantages, tends to obscure
hypomanic and grandiose phenomena from research scrutiny.
A small proportion of patients evidently take their lives with no evidence
of depression whatever (Ronningstam & Maltsberger, in press.) But suicide
must hardly ever occur in mania or hypomania without some depressive coloration of the mental state. Nevertheless patients who suffer from Kraepelins
mixed states do indeed destroy themselves from time to time; sometimes the
depressive undertones are not o b v i ~ u s Kraepelin
.~
(1921) refers to excited
depression; (p. 104) and to chronic irritable temperament (pp. 130-13 I).
More recent research demonstrates what clinical workers have long believed,
that patients with depressive mania are indeed at risk to commit suicide
(Schweizer et a]., 1988; Dilsaver et al., 1994; Strakowski et a]., 1996). Post
and his colleagues (1989) have coined a new term, manic dysphoria, denoting affective lability, imtability, anger, and depression admixed with other
characteristic features of the manic syndrome. They appear to refer to this
same group of patients.
A review of the protocols of the St. Louis suicide series (Robins, 1981)
shows that many subjects could be described as irritable dysphorics; 28%
of the 134 cases were subject to outbursts of rage, and 53% of the alcoholic
subgroup were. None could be labelled manic dysphorics. None appear to
have committed suicide in a mixed state, though I suspect that contemporary
psychiatrists would assign a diagnosis of bipolar I1 disorder to one of Robinss
cases (patient 119, pp. 284286). Inspection of the protocols make it evident
that a high proportion of the suicides Robins classified in the alcoholic group
were probably comormid for personality disorder diagnoses, narcissistic personality disorder in particular.
One of the St. Louis patients (a schizophrenic) heard the voice of God
speaking to him (patient 113, p. 342-343) and an alcoholic expressed the
belief that if his life was hell he would be in heaven after suicide (patient

297
022, pp. 228-229), but otherwise there are no suggestions of grandiosity in
the records.

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Questions for empirical investigation

Once the descriptive epidemiology of ecstatic and grandiose suicide has
been worked out it will become necessary to sort out different suicidal
types according to the various psychodiagnostic groups and psychosocial
contexts in which they occur. What are the differences between suicides in
mixed-state, hypomanic, non-depressed narcissistic, borderline, depressed,
schizophrenic, and other patients with respect to grandiose, ecdysial, and
ecstatic phenomena?
At present we do not have a sufficiently clear or detailed understanding
either of the exact mood ranges or the mental content of any psychodiagnostic
group of patients who go forward to suicide or to deadly attempts. Research
advances have been made possible by the development of the Feighner diagnostic criteria (Feighner et al., 1972) and their nosological descendants. Further advances might be expected if certain terms used in making research
diagnoses (e.g., dysphoria) were refined, just as diagnoses have been. The
phenomena of suicide have not been fully described, and, where described,
they have not been empirically studied with much effort to discriminate
between the various details of mood and those of mental content.
Mood

We know that psychic anxiety is a significant predictor of suicide in patients

with affective disorders - Fawcett and his colleagues have demonstrated this
(Fawcett et al., 1987). Just what psychic anxiety may be, however, remains
obscure; it is an item only briefly defined in the Schedule for Affective
Disorders & Schizophrenia (SADS) inventory, an instrument administered to
the series of patients Fawcetts group reported (Endicott & Spitzer, 1978).
Manic dysphoria is not much clearer - we understand that it has elements of depression, anxiety, anger (Post et al., 1989). but the phenomenon
requires refined definition. Dysphoric mood, according to the Feighner diagnostic research criteria, is characterized by symptoms such as the following:
depressed, sad, blue, despondent, hopeless, down in the dumps, imtable,
fearful, womed, or discouraged (Feighner et al., 1972). The definition goes
no further. (Note the absence of the term anguish or any of its synonyms.)
Robins grouped sixteen different symptoms together under the rubric dysphoria, and some of them are highly dissimilar. From his list compare: easily
hurt feelings, indecisiveness, high strung, outbursts of rage, having fears,

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298
seeming to feel like hurting someone, feeling sad, joylessness (Robins, 198I ,
pp. 52-53). Obviously such definitions of dysphoria remain too general to
help very much in discriminating which dysphoric patients are the suicidal
ones, however appropriate a broad definition may have been at the time of
Robinss work.
Anguish as a term does not appear in any of these lists, but intuitively one
would expect that anguish, especially when coupled with intense self-hate
and a high level of hopelessness, might be more associated with suicide than
indecisiveness or being high strung. The hiad of anguish (often accompanied by psychomotor agitation), self-hate, and despair is typical of many
mixed-state patients. Shneidman (1 993) believes that psychache, his neologism for mental anguish, lies at the heart of most suicides. Zanarini (in press)
has taken a step in the right direction in developing her dysphoric affect
scale.
It is sobering to reflect that a patient with intense anguish, ecdysial daydreams about the afterlife which he found exciting, profound suicidal intent,
powerful self-hate, and sleeplessness but with little loss of interest in his
daily affairs, good ability to concentrate, intact appetite, and no psychomotor
disturbance would qualify neither for a diagnosis of major depressive episode
nor a mixed state under the current rubrics.
Kraepelin (1921) made it clear that many patients experienced intensely
painful physical sensations in connection with anguished mood. Precordial
distress, a sense that the core of the body has turned to ice, and a sense
of tremor in the abdomen and thorax are familiar complaints in suicidal
melancholia. We do not know how commonly associated with suicide these
body sensations may be (sometimes they appear to rise to the level of visceral
haptic hallucinations).
Mental content

What we know about the mental content and fantasy life of patients on the
verge of suicide is anecdotal. Fantasies of metamorphosis, or ecdysis, appear
to be quite common, however, and many suicidal patients are grandiose in
thought, if only occasionally are they ecstatic in mood. Further studies are
needed to define and describe what patients think about death when in suicidal
states.

Acknowledgements

The author acknowledges the helpful suggestions of Dr. Michael Bostwick,

Ms. Joanne Despres, and Dr. Elsa Ronningstam.

299

Notes

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The first two patients (Mrs. A. and Miss B.) meet the DSM-4criteria for both narcissistic
personality disorder and borderline personality disorder. The third patient (Miss C.) qualifies
for a DSM-4 diagnosis of borderline personality disorder. All three have recurrent major
depressive episodes. The first and third patients (Mrs. A. and Miss C.) also give histories of
hypomanic spells. and therefore qualify for bipolar diagnosis.
All three patients have been treated with many drug combinations, including mood stabilizers, for long periods of time, by sophisticated psychophmacologic experts. The therapeutic response has been disappointing in each instance.
For aspirin (acetylsalicylic acid) the LDw, is 200-500 mg/Kg. Miss B.s aspirin overdoses
were in the range of 250 mg/Kg of her body weight.
The normal hematocrit (volume of packed red blood corpuscles per 100 ml of blood) for an
adult woman is 42 f 0.5. We estimated that Miss C. ex-sanguinated herself of more than half
her total blood volume over a week.
Ecdysis is a borrowed entomological term. It ordinarily refers to the shedding of an outer
cuticular layer in the metamorphosis of insects; molting is a synonym. The word comes from
Greek ekdysis, which means a getting out, an escape. Its more general Greek meaning invites
its application to those suicides in which patients believe that to die will result in something
like the transformation of a pupa into a brilliantly beautiful adult butterfly.
We would now label a patient formerly diagnosable with a mixed state of manic-depressive
disease as a mixed episode of mood disorder, or a manic episode with prominent irritable
mood or major depressive episode with prominent irritable mood. See DSM-4.

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Address for correspondence: John T. Maltsberger, 38 Fuller Street, Brookline, MA 02 146,

U.S.A. Telephone: 617 731 2488; Fax: 617 277 2619; E-mail: maltsb@tiac.net