Sunday, August 19, 2018

A Preventable Tragedy in a Man with Semantic Dementia


TAKE HOME MESSAGE: All suicide attempts and parasuicidal gestures should be taken very seriously in patients with dementia.
“Previous parasuicide is a predictor of suicide. The increased risk of subsequent suicide persists without decline for at least two decades.”

A new case report on a 53 year old man1 with semantic dementia (SD) presented his prior parasuicidal gestures as “stereotypic behaviour” [ed. NOTE: repeated attempts to hang himself with a cord is “stereotyped behavior”], with tragic consequences:
The patient showed abnormal behaviours such as following around his wife and frequently visiting a drug store to purchase sleeping pills, which necessitated hospitalization. Despite having no depressive symptoms including suicidal ideation, he repeatedly attempted to hang himself with a cord during a temporary stay at home. At the time of the interview, he stated, ‘I found a cord suspended from the ceiling, and so just played with it by hanging myself. It was just a play’, indicating an absence of suicidal ideation and lack of seriousness for the event. In March 2012, he died by hanging himself with a towel inside his hospital room.

...Despite the fact that the man had been severely depressed for two years before his SD diagnosis, had a well-documented history of suicidal ideation, and had made several suicide attempts (Kobayashi et al., 2018):
In April 2009, the patient started to express suicidal ideation such as ‘I would like to hang myself’. From May to June, he was admitted to a psychiatric hospital because of a deliberate overdose. After being discharged, the patient started to show lack of ability to understand what others were saying, kept insisting on his own way, and became excessively fixated on certain things. In July 2010, he was dismissed from his job because of poor performance. In September 2010, the patient was hospitalized after multiple attempts to hang himself with a cord. During this hospitalization, he was found to have difficulty in naming familiar objects.

His difficulty in naming familiar objects could be an early sign of neurodegeneration (especially in a 53 year old man), but by itself is not diagnostic. But he also had difficulty understanding what other people were saying, i.e. a problem in language comprehension. These symptoms are characteristic of semantic dementia, a type of frontotemporal lobar degeneration associated with a profound loss of meaning words and objects don't make sense any more. He did very poorly on subsequent neuropsychological testing. Neuroimaging results revealed atrophy in bilateral (but L > R) anterior and inferior temporal cortices that is characteristic of SD.



Now, it's easy for me to sit back and be all critical. BUT: I am not a clinician, I was not involved in this case, and hindsight is often 20/20. But it always pays to err on the side of caution when suicidal actions are expressed, even in a person who denies being suicidal, but especially in one who may no longer understand exactly what he's doing.


If you are contemplating suicide or know someone who is, please consult:

Online Suicide Help directory


Footnote

1 They say he's 50 in the Abstract, but the Case Presentation starts out by saying he's 53.


Reference

Kobayashi R, Hayashi H, Tokairin T, Kawakatsu S, Otani K. (2018). Suicide as a result of stereotypic behaviour in a case with semantic dementia. Psychogeriatrics Jul 30. [Epub ahead of print]

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