Self poisoning – A study in Edinburgh

Years ago the problem of self-poisoning was not recognised. People poisoned themselves, of course, but few survived. The picture today is different. In Edinburgh more than a thousand adults are admitted to hospital each year after such an act. The great majority of those who poison themselves survive, and this fact goes far towards explaining why the practice has spread. Poisoning used to be regarded as fatal. Instances of someone taking poisons deliberately to harm himself, but with the intent ion of surviving, are hard to find. Juliet did so, but Romeo had so little thought that she might not be dead that he killed himself in despair. He knew, as everyone knew, that if you took poison you died. This is not so today. The growth of pharmaceutical products has brought about the change. The growth of self poisoning has come about in the train of a rapid rise in number of highly dangerous preparations employed therapeutically, together with a great contemporaneous increase in prescribing. The way has thus been opened for self poisoning to flourish, since few who practise it have their minds set on dying. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Winter 1965-66, 5(1): 7-12 doi: 10.2218/resmedica.v5i1.445 SELF POISONING A STUDY IN EDINBURGH By P rofesso r Neil Kessel M .D ., M .R .C .P ., M .R .C .P .B .. D .P .M . Professor of Psychiatry, Manchester University , formerly of the Departm ent of Psychiatry, Edinburgh University. Y e ars a go th e p r o b le m o f se lf -p o iso n in g was n o t recogn ised . P e o p l e p o is o n e d th em se lv es , of course, b u t f e w survived . T h e p ic tu re to d a y is d if feren t . In E d in b u r g h m o r e than a th o u sa n d adults are a d m it te d to hospital each year a fter su ch an act. T h e great m a jo r i ty o f th o se w h o p o iso n th e m se lv e s sur­ vive, a n d this fac t goes far to w ards e x p la in in g w h y the p ra ct ice has spread. P o is o n in g used to b e regarded as fatal. In ­ stan ces o f s o m e o n e ta k in g p o is o n s de lib erate ly to harm him self , b u t w i t h th e in te n t io n o f surv ivin g, are hard to find. Juliet d id so. b u t R o m e o had so l i t t le th o u g h t th at sh e m i g h t n ot be dead th a t he kil led h i m s e l f in despair. H e k n e w , as e v e ry o n e k n e w , that if you to o k poison yo u died. T his is n o t so today. T h e g r o w t h o f p h a rm a c e u t ic a l p ro d u c ts has b r o u g h t a b o u t th e c h a n g e . T h e g r o w t h o f selfp o is o n in g has c o m e a b o u t in th e train o f a rapid rise in n u m b e r o f h i g h ly d a n g e ro u s p re ­ p arat ion s e m p lo y e d t h e rape n tica l ly . to g e th er w it h a great c o n te m p o r a n e o u s increase in p re­ scrib ing. T h e w ay has thus b e e n o p e n e d for se lf -p o iso n in g to flourish, s in ce fe w w h o pra ct ise it have their m in d s set on d y in g . In E d i n b u r g h th e R o y a l In f irm a ry has had a w ard for p a t ie n ts w h o require o v e r la p p in g m e d ic a l and p sychiatr ic care, and it serves as a tr e a tm e n t c e n tr e of cases o f p o is o n in g oc c u rr in g in th e C i t y o f E d i n b u r g h a nd th e su rr o u n d in g region. T h i s s tu d y e m b r a c e s th e full range o f survivors o f d e l ib erate se lf -p o iso n in g acts o c c u rr in g in E d in b u r g h b e t w e e n June 1962 and June 1963. Social a n d cl in ica l data w e re o b ta in e d from every p a t ie n t w h i le still in hospital, e x c e p t in g th e h a n d fu l w h o d ie d w i t h ­ o u t re g a in in g con sc iou sn ess . I f th e p a t ie n t and fa m i ly are seen later at ou t-p a t ien t c linics o f te n an id e n tica l , idealised and false p ic tu r e is p re sen te d . T h e in ju n c t io n ap p lies to 15 1 m e n a n d 314 w o m e n w h o w e re a d m it te d to th e w ard. In th e s e 465 p e o p le , 522 a d m is sio n s w e re m a d e , for so m e rep eated th e act. Index o f Endangering Life S elf -p o iso n in g refers to th e in te n t io n o f ta k in g too m u c h o f a p o is o n o u s su bstan ce , b e l ie v in g th at it will b e n ox iou s. T h e r e arc th ree essentia l c o m p o n e n t s o f th e act; th a t it m u st b e d e lib erate n o t a cc id e n ta l ; th a t th e q u a n t i t y m u s t b e k n o w n to b e excessive; and th a t it is realised th a t this m a y b e h a rm fu l . P o iso n ed p a tie n ts n o t sat is fy in g th ese criteria w e re ex c lu d e d . A s s e ss m e n t o f th e d e g r e e o f d a n g e r to l ife th at th e p a t ie n t e xp o se d h im se lf to is difficult. T h e q u a n t i t y o f p o is o n , a n d th e e x t e n t to w h ic h th e a ct io n is c o n c e ale d or d is­ c losed . are o f equal im p o rta n c e . I f th e p a t ie n t to o k a fatal q u a n t i t y o f p o ison and t o o k steps to avoid disco very , d e a th is certain i f n o t d is ­ co v ered . S m a ller doses a n d / o r ta k in g steps to ensure q u ic k discovery , p u t p a tie n ts in to a “ d e a th u n l ik e ly " or “ c e rtain to su rv iv e ” category. Table 1. — Index of Endangering Life Predictable Outcome Males Females of Act (170) (352) Death ................................ 19% 19% Death probable .................. 11% 11% Death unlikely .................. 28% 21% C ertain to survive ......... 40% 49% Unclassified ...................... 2% 0

Years ago the problem of self-poisoning was not recognised.People poisoned themselves, of course, bu t few survived.
T h e picture today is different.In Edinburgh m ore than a thousand adults are adm itted to hospital each year after such an act.T h e great majority of those w h o poison themselves sur vive, and this fact goes far towards explaining w h y the practice has spread.
Poisoning used to be regarded as fatal.In stances of som eone taking poisons deliberately to harm himself, but with the intention of surviving, are hard to find.Juliet did so.but R om eo had so little thought that she m ight not be dead that he killed him self in despair.H e knew , as everyone knew, that if you took poison you died.T his is not so today.
T h e growth of pharm aceutical products has brought about the change.T h e growth of selfpoisoning has com e about in the train of a rapid rise in num ber of highly dangerous pre parations em ployed th erape ntically .together with a great contem poraneous increase in pre scribing.T h e w ay has thus been opened for self-poisoning to flourish, since few who practise it have their minds set on dying.
In Edinburgh the Royal Infirmary has had a ward for patients w h o require overlapping medical and psychiatric care, and it serves as a treatm ent centre of cases of poisoning occurring in the C ity of Edinburgh and the surrounding region.T h is study embraces the full range of survivors of deliberate self-poisoning acts occurring in Edinburgh betw een June 1962 and June 1963.
Social and clinical data were obtained from every patient while still in hospital, excepting the handful w h o died w ith out regaining consciousness.If the patient and fam ily are seen later at out-patient clinics often an identical, idealised and false picture is presented.
T h e injunction applies to 151 m en and 314 w om en w ho were adm itted to the ward.In these 465 people, 522 admissions were m ade, for som e repeated the act.

Index of Endangering Life
Self-poisoning refers to the intention of taking too m uch of a poisonous substance, believing that it will be noxious.T h e re arc three essential com pon en ts of the act; that it must be deliberate not accidental; that the quantity m ust be know n to be excessive; and that it is realised that this m ay be harmful.Poisoned patients not satisfying these criteria were excluded.Assessment of the degree of danger to life that the patient exposed himself to is difficult.T h e quantity of poison, and the extent to which the action is con cealed or dis closed.are of equal importance.

Social F in din gs
Individual self-poisoning rates for the 23 W ards of Edinburgh were calculated.W ards with the highest rates lie in the central areas, where overcrowding and slum conditions are m ost frequent.T h e low est rates were found in the solid, respectable, predom inantly m iddle class areas on the west of the C ity. Post-war housing estates also show high rates, such as Craigm illar, where those living in the worst of the central area we re rehoused.H owever, Sighthill, a new housing estate, with a prosper ous and secure working population, has a low rating.Significant associations were found with overcrowding, and those living in a non-fam ily setting i.e. lodging houses and hostels (and including crim inals).N o significant correlation was found with single person households, as in suicide.T h ere is a difference between the sexes.M ale rates for 20 -64 years remain fairly constant.
T h e fem ale rate is much higher but shows a gradual fall with years until at age 45 there is little difference between the sexes.In fem ale teenagers aged 15-19, 1 in every 500 Edinburgh girls poisoned herself.N ew ly married women, even though in a normal home-setting, are em otionally isolated, having changed from an active social life to one of dom esticity; thus they may have no-one to share feelings with or give expression to.Unhappiness m ay therefore explode at a m om ent of crisis.

M arital Status
In those patients who had been married, 30% of the m ale cases, and 2 6 % o f the fem ale had been either separated or divorced, often in the m onth prior to the self-poisoning act.
(N early half had ended 5 years before the act.)B u t of those that rem ained m arital relations were nearly always bad.U nfaithfulness, jealousy, grum bling, and above all, excessive drinking, were often encountered.
N early every patient had a bad relationship with a key individual; spouse, relative, or friend.Absence and disharm ony also occurred with high incidence in the parents of patients.w hy so m any patients cannot be classed as ill.N obo d y takes poison, a little or a lot, to hurt or to die, unless at that m om ent lie is distressed beyond what he can bear, and so desperate he cannot see a m ore rational solution.T h e suicide says, in effect, " There is no way ou t" ; the self-poisoner, " I cannot see a way o u t" .T h ey find them selves trapped: they are desperate: and their distress drives them to an action that is both stupid, and the same time, a blow for liberation.

M otive
T h e sorts of predicam ent w hich cause people such distress are legion.Som e thought that their feelings about the world were faulty (not always with self-blam e); others explicitly incrim inated bad relationships with som eone else, generally the spouse.N o t m any m entioned material circum stances -debt or unem ploy m ent for instance, and very few held them to be the only factors at work.Physical ill health was rarely m entioned, though such a handicap probably contributed to the p atien t's state of m ind.T h e im m ediate spark to m any acts was a quarrel; and where the relationship is bad taking poison is often the im petuous result.

Impulsiveness
Tw o-thrds of all acts were im pulsive.m inutes, som etim es one m inute, before the act took place, the idea of taking poison was not in the person's m ind.H e may, however, have thought about doing it in the past.Hours of rum ination m ay have preceded the determ in ation which was form ed in a single m om ent.B u t in the event, a feeling of despair arose, often suddenly from a trivial cause, and was as suddenly acted upon." W h y did you do it?"the patients are asked." I d o n 't know.It just cam e over m e" , they reply.A n d they do not know.It is not that they have forgotten.T h e y are not prevaricating -they never worked it out.It just cam e over them .
M en and wom en acted im pulsively in equal proportions.Im pulsive acts were not related to alcoholism , being no m ore com m on am ong the inebriated than am ong the others.
Im pulsiveness w as m ore com m on than pre m editation, at all ages, though its incidence was rather less in wom en of 55 and over, due to an increase in depressive illness in this group.Patients with form er psychiatric illnesses pre m editated self-poisoning m ore often than did others, but even am ong these im pulsiveness characterised over half the acts.Im pulsive acts were less life-endangering than prem editated ones.Still 16 % had a predictable outcom e of death.
People who act im pulsively have a chance to seek aid im m ediately afterwards.Prem edit ation, on the other hand, carries w ith it the opportunity to warn som eone in advance.A young wom an who took aspirins told her hus band that she was thinking of taking her life.H e did not take her seriously.U nfortunately, that is com m only the case.
Such warnings are part of the " appeal" quality of self-poisoning acts.Stengel (1958) urged that the appeal is usually unconscious.A m ong our patients, it was com m on to find it was quite conscious.

Case
A rigid, respectable, intolerant, m iddle-aged m an, whose w ife had le ft him suddenly, a m onth earlier, took about 25 aspirin tablets." T o tell you the truth, it was exhibitionism , really.I thought it m ight arouse her sym pathy.I 'd tried everything -letters, flowers, nylons, the m inister, a lawyer -so I thought I 'd try this.T o be very truthful, I m ade enquiries as to the fatal dose.O f course I d id n 't do so directly.I w ent to the chem ist and said " W e 've been arguing in the canteen about the num ber o f aspirin yo u 'd need."H e said that about 40 would probably be fatal.So I took between 25 and 30."I asked him why he had not taken 40, and the answer was im m ediate: " Selfpreservation.L ifes too sweet."

C ase
Such patients are often condem ned as frankly m anipulative, and therefore som ehow undeserv ing.W h e n the purpose is so apparent, the distress and despair are less obvious.Adm ission to the ward, having poisoned oneself, can be, for instance, a powerful weapon in bringing back errant boyfriends.T h e girls who resort to it are, all the same, very m uch distressed; in their despair they do som ething stupid and senseless, and it works.Should we judge them harshly on that score?

Statem en t of In ten tio n
O nce they had recovered, 6 0 % of the patients claim ed that they were intending to die, while a quarter said categorically that this was not their purpose.T h e rest either did not know , or were evasive.L ittle credence can be placed on these statem ents.T h e intention is not usually worked out at all, let alone with such precision in terms of living and dying.Betw een those w ho said that they had intended to die, and those who had said that they had not, there was som e, but little, difference in the degree to which they had endangered their lives.W e find it m ore profitable to em phasise with the patient any constructive purpose there may have been in his act, than to stress the destruc tive elem ent, which in any case evanescent.V ery few patients, and they were alm ost all severely depressed, said after physical recovery, that they still wished to take their lives.

P revention
Since the outcom e of self-poisoning acts is often beneficial, ought we to try to prevent them?Such an argum ent cannot be countered.It is not the result of the self-poisoning which produces the benefit, but the disclosure and solution of the underlying problem , and there are certainly better ways to bring these pro blem s to light.S elf-poisoning is a dangerous practice.
T h e lessening o f the disturbed backgrounds from which patients com e; the parental separ ation; the bad social circum stances, require political action rather than m edical.A ll we may do is to add the knowledge that these con ditions generate self-poisoning.B u t as the m ajority of self-poisoning acts arise from strains within the fam ily setting, then the person to shoulder the responsibility is the general practi tioner in his chosen role o f fam ily doctor.

Prescribing
Certain preventive measures arc suggested by our study of the means adopted, bearing in m ind that two-thirds of the acts were im plusive.C onsider first the sale of salicylates.No-one would wish to sec aspirin available only on prescription, but it is not necessary for it to be sold in lethal quantities w ithout any check on the reason w hy it is being purchased.H owever, it is only a small part o f the problem .T h e m ajority of poisons taken were obtained on prescription.T h a t this arose soon after the beginning of the N ational H ealth Service m ay be no m ore than coincidence.B u t certainly, in the m atter of m ethods, the physician leads, the layman follow s.
T o anyone who works in a centre for the treatm ent of poisoning, the conclusion is in escapable that dangerous substances arc pre scribed unnecessarily often and in excessive quantities.Several of our patients recounted their surprise that sleeping tablets were pre scribed so readily.T h e grow ing frequency of self-poisoning m akes it im perative to use the utm ost circum spection in the prescribing of barbiturates.T h e average num ber of tablets on a single prescription in 19 59 (Brooke and G le tt, 1964), was :-P h enobarbitone-60, Son eryl-44, A m ytal-49, N em butal-40, Drinam yl-48.It is difficult to credence that all this barbiturate was really necessary.
Considerable quantities o f drugs for the mental state arc prescribed to just those patients who are liable to indulge in overdosage.A fter an episode of illness, supplies of every' kind of tablet com m only remain in the house; in a m om ent of crisis they are there, an irresistible tem ptation.T h e greatest single pu blic health m easure to reduce the extent of self-poisoning in B ritain would be the removal o f these stocks o f drugs.
B u t cut off from a supply of drugs, would the patients resort to m ore dangerous means?slashing wrists -jum ping from heights?I do not think this likely.
F ew self-poisoning patients w ant to damage themselves irreparably.T h e y would probably seek a m ore healthy way of obtaining the help they desperately claim.

A lcoholism
O ne of the com m onest clinical characteristics, certainly of m ale patients is alcoholism .A lcoholics take poison because they are de pressed, and cut off from care and support.If proper treatm ent for alcoholism were provided, few er m ight be driven to self-poisoning, and indeed to suicide.

M anagem ent
Prevention is best.B u t cases w ill continue to arrive in large num bers at our hospitals, and w e have to deal w ith them .T h e necessary medical care and prom pt and thorough psych iatric assessment required, m ust be carried out.A t present it still goes by default in m any hospitals.T h e m anagem ent of the patient by adm inistering a m assive dose o f psychiatric treatm ent quickly, should form an integral part of every unit for the treatm ent of poisoning.

Discussion
I have throughout used the wording "self poisoning" rather than "attempted suicide", for I consider the latter term to be both clinic ally inappropriate, and misleading.It is true that in the popular m ind deliberate self-poisoning is linked, linked indeed romantically, with the idea of suicide. is true that some of our patients had done all they could to encompass their deaths; that minority can be said to have failed at suicide.But for four-fifths of the patients the concept of attempting suicide is wide of the mark.They performed their acts in the belief that they were comparatively safeaware, even in the heat of the moment, that they would survive their overdosage and be able to disclose what they had done in good time to ensure their rescue.W h a t they were attempt ing was not suicide.Moreover, what they were attempting they commonly achieved.To that end the simulation of death, consciously or not, the hint of suicide, heightened its effectiveness.But the act was not attempted suicide.Doctors do not have to be deceived by their simulation; the drama was enacted for their own circle only.
If the term "attempted suicide" were just meaningless it could be tolerated, but it is positively wrong, and should be discarded.The motives of our patients clearly proclaim this.In the first place the majority of acts were impulsive.Then, too, they were stupid and senseless, and the patients themselves acknow ledge this.N ot thus does a man drive himself to suicide.Also they demonstrated some pur posefulness; but this purpose was to alter their life situation, not to die.These patients were not attempting suicide.That term leads to errors of judgment.The chief of these is to measure the need for psychiatric treatment by the yardstick of the physical state of the patient.If he has taken only a small quantity of drugs then he was not really attempting suicide, so the argument time and again runs, he was just making a suicidal gesture which need not be taken seriously.W hether or not the patient receives psychiatric help must not depend upon whether the doctor in the out-patient department thinks the patient is physically ill enough to need admission.This doctor will be more impressed by the dozen tablets that the patient has taken than by the threescore that he was prevented from swallow ing.The extent of physical damage is no criterion either of the seriousness of psychiatric illness or of the need for psychiatric care.
The index of endangering life -our measure of the seriousness of the act -is not correlated with the need for psychiatric treatment.
Mistakes occur and result in many tragedies because doctors cling to the notion of attempted suicide.Attempted suicide is not a diagnosis.It is not even a description of behaviour.It is an interpretation of the motives for the act of self-poisoning -an unnecessary and usually a wrong interpretation.The alternative is simple.Everybody who has poisoned himself warrants psychiatric examination.
The fashion of self-poisoning will almost certainly be with us and continue to grow for years to come.W e cannot afford to miss the point of it by calling it something else.

Conclusion
Deliberate self-poisoning is becoming more and more common and a matter of public health concern.Its management, other than resuscitation, is best achieved by psychiatric methods.The means of self-poisoning are usually provided by physicians, and it is as a general medical problem that the poisoned patient first presents.
I have attempted to illuminate each of these aspects by a clinical and epidemiological study of one year's cases in Edinburgh.This has led to an explanation of the recent rapid rise in incidence and to suggestions for prevention and for management.An understanding of all aspects is necessary to the proper appreciation, both of individual patients and collectively, of an important medical problem.
Professor of Psychiatry, Manchester University, formerly of the Department of Psychiatry, Edinburgh University.

M
e a n s A d o p te d Ju st over h a lf the acts in v o lv e d b arb itu rate s.M o s t drugs w ere o b ta in e d le g a lly or on p re scrip tio n (b u t alw ays w ritte n fo r th e p a tie n t).D ru g s used w ere o fte n fo r illn e ss's w h ich occu rred so m e tim e b efo re .T h irty -fiv e years ago non -dru g p o iso n s (lysol, etc.) to g e th e r w ith coal gas, acco u n te d fo r n early all the cases.B a rb itu ra te s have th u s b ec o m e th e n ew m eans o f se lf-p o iso n in g , an d d o cto rs seem o n ly to o ready to p rescrib e th em .D ru g s fo r p sy ch iatric d isord ers arc also on th e in crease (c h lo rp ro m azin e ).Yearly adm issions o f poison patients 1928-1963 show ing m e tho d used.(F ro m Kessel, B .M .J. 1965, 1259) P e o p le o f d iffe re n t ages e m p lo y d iffe rin g m e th o d s.T h e p e rce n ta g e u sin g b arb itu rate s and coal gas rises w ith age.T h o s e u sin g salicylate s falls.In so m n ia o ccu rs as age in creases an d can perh ap s exp lain th is rise.Y o u n g p e o p le have easier access to salicylate s th an to sle e p in g tab lets.O ld e r p e o p le m ay also have carried the trad itio n o f coal gas p o iso n in g w ith th e m from their earlie r years.

D
ia g n o sis C o n v e n tio n a l p sy ch ia tric n o m e n c la tu re is ill suited to d e scrib in g se lf-p o iso n in g p a tie n ts.T h e d ecisio n is o fte n b ased b etw e e n d ep ressive illness or in to le rab le livin g c o n d itio n s.M e n suffered m o re from p e rso n ality a b n o rm a lity ; w o m en fro m d e p re ssiv e illn ess.D e te rm in a tio n o f p sych iatric illn ess in th e E d in b u rg h d e p a rtm e n t d e p e n d s on clin ical h istory.I f th is is n e g ative th en th ere are no gro u n d s fo r co n c lu d in g th e p a tie n t is psychiatric a lly ill.D istre ss is n o t th e e xclu siv e p ro vin ce o f th e m e n ta lly ill.H o w e v e r, th o se w ith no p sy c h ia tric illness ten d ed to b e y o u n g e r, and also to in d u lg e in less life -e n d a n g erin g acts (use o f salicylatcs).T h e c o m b in a tio n o f d ep ressio n an d p sy ch o p a th y o fte n o ccu rred , p e rso n a lity disorder o ccu rrin g in 4 1 % o f m en an d 2 7 % o f w o m e n .A sso ciate d facto rs in clu d ed a lco h o lism , d ru g a d d ictio n , ep ile p sy and su b n o rm a lity .T h e d o m in a n t fa c to r in m en w as alco h o lism ( 3 7 % w ere alco h o lics).5 6 % o f m en an d 2 3 % o f w o m en had been d rin k in g b e fo re th e a c t to o k p lace.O f th e 6 p a tie n ts (4 : 2) w h o killed th em selves w ith in 1 year o f d ischarge, 5 w ere alco h o lics.D istress M o v in g n o w to those asp ects o f th e person al situ atio n o f th e p e o p le in vo lv e d -is th e re a u n ify in g basis to se lf-p o iso n in g acts?D istress drives p e o p le to se lf-p o iso n in g acts.It m ay arise from w ith in (th e p erson w ith d ep ressive illn ess), or it m ay b e g e n e rated from o u tsid e, fro m th e in to le ra b le , y e t in so lu b le social situ atio n in w h ich he is ca u g h t; th at is . A married wom an of 27 whose hus band was threatening to leave her, took 50 aspirins." I d id n 't think th ey'd kill m e.I thought they m ight.I hoped they w o u ld n 't.I thought of my father and m other.I cou ld n ' t let them be hurt.I hoped really it w ould bring John back.If it d id n 't I m ight as well d ie." -Senseless and purposeful -it is a paradox we have to accept.
R E F E R E N C E S B R O O K E .E. M. a n d G L A T T , M .M .(1964).M ed.Sci.L aw , 4, 277.ST E N G E L , E. and C O O K , N .G. (1958).A ttem p ted S uicide.O x ford U niv ersity Press, London.