NEUROSCIENCE AND
BIOBEHAVIORAL
REVIEWS
PERGAMON
Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
www.elsevier.com/locate/neubiorev
Review
The prisoners of despair: right hemisphere deficiency and suicide
I. Weinberg
P.O. Box 331, Giv’at-Shemuel 54103, Israel
Received 12 April 2000; accepted 14 August 2000
Abstract
This paper presents an integrative approach to understanding of the inner experience of suicidal persons in terms of hemispheric
asymmetry. The right hemisphere is involved in formation of polysemantic context. Polysemantic context is determined by multiple
interconnections among its elements, while each concrete element bears the stamp of the whole context. Left hemisphere functioning
leads to formation of monosemantic context. It is suggested that due to functional insufficiency of the right hemisphere the suicidal person
demonstrates a compensatory shift to left hemisphere functioning. This shift manifests itself in reversed asymmetry of neurotransmitters,
tendency to dissociation, alienated and negative perception of the body, lower sensitivity to pain, disintegration of self-representation,
cognitive constriction, overly general nature of personal memories, difficulties in affect regulation as well as such personality traits as low
openness to experience and personal constriction. This hypothesis raises a number of suggestions for future research. 䉷 2000 Elsevier
Science Ltd. All rights reserved.
Keywords: Suicide; Hemispheric asymmetry; Dissociation; Self-representation; Body perception; Affect regulation; Cognitive rigidity; Pain perception; Early
development
Contents
1. The right and the left hemispheres: the problem of context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Right hemisphere deficiency and suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. Right hemisphere: structural abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Neurotransmitters: reversed asymmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. EEG: right hemisphere dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.4. Dissociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.5. Disintegration of self-representation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.6. Body perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.7. Pain perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.8. Affect regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.9. Cognitive style: constriction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.10. Overly general memories of suicidal persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.11. Dead to the world: psychological suicide and low openness to experience . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. The suicidal crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Early development and etiology of suicidal tendencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
In this paper I will delineate a new holistic approach to
understanding of the personal experience and dynamics of
suicidal persons in light of various psychological and
physiological findings. Suicide is defined as a deliberate,
E-mail address: [email protected] (I. Weinberg).
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lethal self-injury with or without a conscious attempt to
die [177]. Accordingly, suicide intent is defined as intent
to commit suicide. Suicidal state of mind encompasses
various aspects of personal experience of suicidal people,
such as feelings, thoughts and attitudes, before making a
suicidal act. The proposed approach offers a systematic,
0149-7634/00/$ - see front matter 䉷 2000 Elsevier Science Ltd. All rights reserved.
PII: S0149-763 4(00)00038-5
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I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
integrative, and holistic understanding of this state of mind.
It attempts to view the personal experience of suicidal individuals in terms of findings from various fields of research,
and it is based on the convergence among these domains. I
contend that suicidal state of mind cannot be understood
without reference to various emotional, cognitive, neurochemical, and morphological aspects and processes that
jointly generate it. The deadly interaction of these processes
produces suicidal state of mind that can express itself in
various forms of suicidal behavior: suicidal ideation, suicidal attempts or completed suicide. Some recent findings
concerning the hemisphere asymmetry allow deeper understanding of these processes.
1. The right and the left hemispheres: the problem of
context
Studies focusing on brain asymmetry have been increasing since the first investigations by Sperry, Gazzaniga and
their associates [64,65,207]. The first theoretical conceptualizations suggested that the left and the right hemispheres
process qualitatively different information [64,65,207]. In
particular, the left hemisphere was thought to be involved
in processing verbal material, signs, and symbols, whereas
the right hemisphere was thought to be involved in handling
non-verbal material, images, melodies, and spatial information.
However, other researches refuted this point of view. In
fact, in split brain subjects the right hemisphere is able to
process verbal constructions, if they are not too complicated
[49]. Electroencephalogram (EEG) activity in the right
hemisphere predominates during reading stories, whereas
EEG activity in the left hemisphere predominates during
reading science textbooks [160]. Although all melodies
are a type of non-verbal information, right ear (e. g. the
left hemisphere) is superior to the left ear in perception of
dichotically presented melodies if they differ only in rhythm
[73]. Split-brain subjects are able to report their dreams
[86], even though a dream is a visual experience. The left
hemisphere is superior to the right hemisphere in perceiving
faces with outstanding features (such as a very long nose
[161]). Language signs for hearing impaired people are nonverbal. However, the ability to use signs is damaged by the
left-hemisphere strokes [23].
According to another approach, human hemispheres
differ in terms of information processing [73]. That is, the
left hemisphere processes verbal and non-verbal sequential
information. The function of the right hemisphere is singlestage, parallel processing of many elements of information
as a single whole. However, that point of view cannot
account for findings that the left hemisphere is also able to
grasp a series of data simultaneously, and can do so as
rapidly as the right hemisphere does [170].
According to yet another point of view [72,71], the left
hemisphere is responsible for the maintenance of familiar
forms of behavior, whereas the specialization of the right
hemisphere includes detecting novel and unexpected events.
However, even this approach cannot account for all existing
data. It cannot explain the advantage of the left hemisphere
in identification of strange faces, or the advantage of the
right hemisphere in identification of normal faces with
which the subject is familiar [161].
To explain the diversity of results in the field it was
suggested [178,180,182,183] that the difference between
the two fundamental and most important strategies of thinking (which are customarily associated with functions of the
left and right hemispheres of the human brain) is reduced to
the opposite modes of organizing the contextual connections among elements of information. Left hemispheric, or
formal, logical thinking organizes any sign material
(whether symbolic or iconic) so as to create a strictly
ordered and unambiguously understood context. Its formation requires the active choice out of innumerable, real and
potential connections between the multiform objects and
phenomena, of few definite connections that would not
create internal contradictions. The choice would be the
one most appropriate for facilitation of a sequential analysis.
This type of thinking makes it possible to build a pragmatically convenient, but simplified model of reality. This
model is based on probabilistic prognosis [53] and a search
for concrete cause-and-effect relations. In fact, probabilistic
prognosis is a function of the left hemisphere [135]. It is
precisely for this model that the vector-time orientation
exists.
In contrast, the function of right hemispheric, or image,
thinking is to simultaneously “capture” an infinite number
of connections and through that capture to form an integral
but ambiguous context [180]. In that context, the whole is
not determined by its components, because all specific
features of the whole are determined only by interconnections between the parts. Any concrete element of such a
context bears an imprint of the whole. Perception of each
concrete moment is brought in line with the entire past
experience, with the already shaped picture of the world
and with the impact of this capture on the status of thinking.
Individual aspects of images interact on several planes
simultaneously. Examples of such contextual connections
are the connections between images in sleep dreams. In
fact, dreaming is associated with increased activity of the
right hemisphere [63]. The advantages of that strategy of
thinking manifest themselves only when the information
itself is complex, internally contradictory and basically irreducible to an unambiguous context. In that case, some existing connections, from the viewpoint of formal logic, can be
perceived as mutually exclusive and, accordingly, many of
them remain unrealized, forming the basis for intuition and
creative realization.
This approach [180] states that only the right hemisphere
functions according to the kaleidoscopic model and to the
model of neural networks with parallel connections. Overlap and crosstalk are the main advantages of right
I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
hemisphere thinking, which provide the creation of the
polysemantic context and the combination of two or more
concepts in a unitary pattern. The complicated interaction
between concepts only exists for the linear monosemantic
left-hemisphere system. That is especially true if all those
concepts are encoded by the same units of the system and an
overlap appears. For this reason, the encoding of information in a linear system is successive and not parallel. In
contrast, the parallel system for the encoding of information
represented simultaneously in many units is a mechanism of
polysemantic context. The combination of different
concepts, each represented in every unit of the holographic
system, can be seen as illustrative of the proposition that the
holographic system of the right hemisphere includes not the
separate concept, but rather a holistic and mosaic picture of
the world. Each separate concept is only a small component
of that picture. Hence, every newly perceived component is
integrated in the mosaic picture together with all the other
components. The process, therefore, is one of integration
and not of inference.
In contrast, left-hemisphere mechanisms bring about the
distinguishing and structuring of some pragmatic monosemantic results extracted from the polysemantic mosaic. It is
evident that the declared differences are most similar to the
differences between the iconic and the symbolic systems of
representation. The main distinction is that this approach
emphasizes the arrangement of contextual relations rather
than the consecutive or simultaneous nature of the synthesis
[180,194].
Research provides increasingly abundant evidence that
the ability to organize polysemantic context is a specific
function of the right human hemisphere and need not be
further amplified by the brainstem reticular formation. The
ability of the right hemisphere to generate polysemantic
contexts is associated with the pronounced alpha-activity
in that hemisphere [182]. Particularly, in healthy subjects
tested under normal conditions, the left hemisphere is
always more active than the right, as revealed by the
frequency and the amplitude of the alpha rhythm, or by
the alpha-index. The intensity and uniqueness of daydream
images show a positive correlation with the alpha-index
[103]. Vivid mental visualization does not decrease EEG
synchronization for persons who have well-developed
image thinking [45]. In meditation, which corresponds to
the right hemisphere pattern of thinking, alpha waves have
high amplitude and become generalized [159]. People with
high ability to generate polysemantic contexts display high
alpha-activity over the right hemisphere. Conversely,
people with low potential for formation of polysemantic
contexts demonstrate desynchronized pattern of EEG in
the right hemisphere [182].
The left hemisphere data-processing pattern, contrary to
that of the right hemisphere, requires higher cerebral activity for the sole reason that it attempts to arrange the available information and distinguish the few relevant links in a
multitude of irrelevant relations.
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A number of studies supported the suggestion that the
right hemisphere organizes information into polysemantic
context, while the left hemisphere is involved in formation
of monosemantic, strictly organized, and logical context. In
has been found that while the left hemisphere activates only
closely related information, the right hemisphere activates
both closely and distantly associated information to the
same degree [22]. In line with this, Coney and Evans [39]
reported that the right hemisphere immediately and exhaustively activates various meanings associated with a word,
while in the left hemisphere access is restricted to the dominant meaning. It seems plausible that for these reasons, only
the right hemisphere is able to comprehend lexical metaphors [12]. Similarly, right hemisphere damage leads to
decreased ability to understand metaphoric material
[33,225].
Emotions are closely associated with the right hemisphere [68,92,93,94,95,98,115,180,183]. Emotional experience is essentially polysemantic and multidimensional.
Words can name emotions, but they cannot convey the
essence of emotional experience. Emotions continuously
transform themselves into other emotions. That continuous
transformation is the essence of personal experience. Only
polysemantic context, formed by the right hemisphere, can
sustain emotional experience in its uniqueness, inner
complexity, and elusiveness. Studies demonstrated a close
association between the right hemisphere functioning and
emotions. Particularly, patients who suffer right-hemisphere
damage are less facially expressive than patients who suffer
left hemisphere damage [28] and have impaired recognition
of facial expression of emotions [30]. Facial expressions are
more intense on the left side of the face than on the right side
[29]. The right hemisphere is faster and more accurate than
the left hemisphere in discriminating between facial expressions of emotions [108,209] and is more efficient in processing emotional words [76]. Similarly, the cortical surface
regions that best correlate with impaired recognition of
emotion are the right inferior parietal cortex and the right
mesial anterior infracalcarine cortex [3]. What is important,
the left-hemisphere lesions do not produce impairment in
emotions recognition [3].
Western culture assumes that an activity should always
have a purpose; a known goal should be accomplished.
However, the activity of the right hemisphere in creation
of the polysemantic context involves no statistical predictions and sets no cause-and-effect relations. The right hemisphere is responsible for predictions that extend beyond the
actual statistics and thus come close to the experience
brought about by insight. Its mechanism is yet to be identified. Right-hemisphere predictions may be kaleidoscopic in
nature: many versions of the future exist simultaneously and
are equally probable. As a result, the occurrence of any
event, even if it is improbable from the perspective of past
experience, has the same weight as a product of reasoning
[180,181].
The development of the right hemisphere depends on the
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quality of the relationship with the caregiver during the first
years of the development [181,193]. If these interactions are
mostly positive and mutual, they enable the infant to explore
his or her emerging capacities in the safe environment
created by affirming interaction. These interactions generate
positive affects while negative affects are regulated by the
caregiver as well as by the growing abilities of the infant.
Mutual positive affects are accompanied by elevation in
such substances as dopamine and norepinephrine that stimulate neural tissue growth, increase mutual connections
between cortical cells and enable further maturation of the
right cortex [192,193,194]. These enable the emergence of
“the potential space” [226] — one of the most important
abilities of the right hemisphere. However, severe traumata
or repeated emotional stresses, which cannot be adaptively
balanced by the emerging infant’s capacities, lead to predominance of unmanageable negative affects that elevate
corticosteroids [194]. This increase in corticosteroids inhibits dendritic branching, reduces brain nucleic acid synthesis, and leads to axonal death [95,194]. Dopamine
increases under stress [25] and induces neurotoxic inhibition
of mitochondrial respiration and defective energy metabolism [24], which may lead to programmed cell death [124].
These stress-induced neurochemichal changes lead to structural and functional alterations in the right hemisphere,
which become the general, non-specific predisposing factor
for psychopathology. In fact, the right hemisphere dysfunction is involved in various forms of psychopathology
[41,58,181]. Early traumata experienced as the “psychic
catastrophe” [27] lead to formation of functionally insufficient right hemisphere that cannot form polysemantic
context and regulate affects.
The ability of the right hemisphere to generate polysemantic context makes possible perception of spatial information, pain, and music, representation of self- and bodyimage [96,179,180], processing of emotions and emotionally laden memories [183], and affect regulation [194].
From the perspective of this understanding of the functioning of the brain hemispheres, it can be proposed that suicidal
persons demonstrate functional deficiency of the right hemisphere. Under the burden of mental pain, the right hemisphere collapses. Consequently, the person’s mode of
experiencing and functioning is largely determined by the
left hemisphere. Mental pain coupled with decreased right
hemisphere functioning determines the suicidal state of
mind. Below I will review some findings that support this
understanding of the personal experience of suicidal people.
2. Right hemisphere deficiency and suicide
2.1. Right hemisphere: structural abnormalities
Suicidal persons demonstrate structural abnormalities in
the right hemisphere, and right hemisphere injury may
increase suicidal tendencies. In fact, Altshuler and colleagues [8] studied structural abnormalities in brains of 17 non-
suicidal victims, 12 schizophrenics, and 10 psychiatric
controls. The study demonstrated that, similarly to schizophrenics, suicidal persons displayed smaller area of the right
parahippocampi than did the controls. Moreover, the shape
of hippocampus and parahippocampus was smaller on the
right side of brains of suicidal persons as compared to brains
from two other groups. This study demonstrates an association between the abnormalities in the right hemisphere and
suicidal tendencies. However, it does not clarify whether the
relationship between the two is causal or purely correlative.
This question received a preliminary answer in a study by
Persinger [167]. Persinger studied 50 patients who had
sustained a traumatic injury. The patients were given a
complete neuropsychological assessment. The results
demonstrated that patient who suffered from the injury to
the right hemisphere displayed a particular form of disintegration of self-sense of presence [166]. Sense of presence is
defined as the feeling of some sensed “entity” — mystical
or not. Sometimes the patient even actively searches for “the
other person in the room”.
The relationship between the right hemisphere injuries
and the “sense of presence” has been supported by the finding that electrical stimulation of the right amigdala elicits
fear and a sense of someone standing nearby [69]. Similarly,
rebound tempo-parietal stimulation following right
temporal lobectomy evoked paroxysmal “feeling of somebody being nearby” [6]. Moreover, the right hemisphere
injuries lead to sense of presence as well as to elevated
suicidal tendencies. In fact, the occurrence of sense of
presence is significantly correlated with suicidal ideation
[167]. These findings demonstrate the close association
between right hemisphere damage, disintegration of the
self-representation, and suicidal tendencies. More importantly, right hemisphere damage precedes the increase in
suicidality and may actually predispose to suicidal behavior.
It would be important to verify this finding in the future
studies.
2.2. Neurotransmitters: reversed asymmetry
A number of studies demonstrated that suicidal persons
show a reversed hemispheric asymmetry of serotonin functioning. Particularly, Arato and colleagues [5] compared the
imipamine binding — the measure of activity of serotonin
autoreceptors — in the right and the left hemispheres of
brains of 23 suicide victims and 23 controls. The findings
were clear-cut: non-suicidal persons demonstrated
increased binding in the right hemisphere as compared to
the left hemisphere, whereas suicide victims showed
elevated binding in the left hemisphere as compared to the
right hemisphere. This asymmetry was more pronounced
among violent suicides. This finding was supported in
other studies ([44,210]; however, see Ref. [14] for negative
findings). Another study [97] demonstrated that normal
persons display increased noradrenergic activity in the
right hemisphere, whereas the young schizophrenics who
I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
committed suicide do not demonstrate such asymmetry.
Taken together these results emphasize that non-suicidal
persons show increased right hemisphere functioning and
decreased left hemisphere functioning, whereas suicidal
persons are characterized by the reversed hemispheric
activity.
2.3. EEG: right hemisphere dysfunction
Another pioneer study pointed at right hemispheric
dysfunction among suicidal persons. Graae and colleagues
[75] compared EEG activity of 16 suicide attempters with
matched 22 normal adolescents. It was found that normal
subjects demonstrated greater alpha activity in the right
hemisphere than in the left, whereas suicidal persons
showed a trend in the opposite direction. Moreover, nondepressed attempters, but not depressed ones, displayed
greater alpha activity in the left hemisphere than in the
right one in the posterior regions. Alpha asymmetry over
these regions was related to suicidal intent, but not to the
depression severity. This study needs further replication.
However, it clearly demonstrates decreased alpha-activity
in the right hemisphere of non-depressed suicidal attempters. Since decreased alpha-activity is a concrete expression
of decreased ability to form polysemantic contexts
[126,182], it may be concluded that suicidal persons have
diminished ability to generate polysemantic contexts. This
difficulty affects personal experience of suicidal persons,
their cognitive style, body and pain perception, contributes
to disintegrated self-perception, and to inability to regulate
one’s affects.
2.4. Dissociation
Dissociation is defined as a state of mind characterized by
a break in the continuity of conscious experience. Dissociation manifests itself in such states as depersonalization,
derealization, psychogenic amnesia, identity disturbances,
as well as in detachment, loss of ability for self-monitoring,
numbness, daydreaming, absorption, and emotional blunting [171]. Dissociation is related to deficiency in right hemisphere functioning. In fact, the functionally insufficient right
hemisphere leads to difficulties in formation of polysemantic contexts. This failure of organization may concretely
express itself in dissociative reaction. The relation between
dissociation and right hemisphere dysfunction has been
supported in the study of brain activity of a person with
multiple personality disorder (MPD). Since very high utilization of dissociation is implicated in the etiology of MPD
[172], the study of people bearing such diagnosis makes
possible understanding of the mechanism of dissociation
as well. Mathew and colleagues [130] explored cerebral
blood flow in a woman with three personalities. When she
demonstrated one of the split-off personalities, she also
displayed increased activity on the right parietal lobe. Simi-
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larly, Flor-Henry [59] reported that MPD is associated with
the dysfunctional right hemisphere. These studies support
the close relation between right hemisphere deficiency and
dissociation.
The relation between dissociation and suicide has already
been proposed by a number of authors. Orbach [150]
hypothesized that early traumata that cannot be contained
by the still developing capacities of the child lead to utilization of dissociation as an ultimate defense against mental
pain. Later the person employs dissociation in face of every
painful emotion: shame, guilt, humiliation, sadness, and
anxiety. The over-employment of dissociation facilitates
suicidal acting-out by dissociating body-image from the
self-representation and, consequently, by appeasing fears
of death.
A number of studies demonstrated that suicidal persons
utilize dissociation to a higher degree than non-suicidal
people [153,156]. Orbach and colleagues [153] compared
26 depressed suicidal persons to 19 depressed non-suicidal
inpatients and 27 normal subjects with respect to suicidal
tendencies and utilization of dissociation. As expected,
suicidal persons displayed the highest suicidal tendencies
as well as the highest levels of dissociation. Moreover,
suicidal tendencies were highly connected with dissociative
tendencies. Suicidal people displayed more affective dissociation feeling of changes in affective life, and more control
dissociation feeling of changes in control. Another study
[156] extended these findings and found that suicidal
persons with such diagnoses as schizophrenia and personality disorders demonstrate increased utilization of dissociation. The relation between dissociation and suicidal
tendencies has been further supported in other studies
[50,84,154,157,158]. In conclusion, the relation between
suicidal behavior and dissociation seems to be well established. This fact supports the relationship between suicidal
behavior, dissociation, and right hemisphere dysfunction. It
seems that right hemisphere dysfunction manifests itself in
general failure of organization and failure to achieve adaptation by means of integration of various aspects of functioning and self-representation.
2.5. Disintegration of self-representation
Self-representation is defined as “the unconscious,
preconscious, and conscious endopsychic representation of
the bodily and mental self in the system ego” [208, p. 179–
80]. The right hemisphere is the seat of the self-representation [95,179,180,193]. Particularly, only polysemantically
organized context formed by the right hemisphere (which
is characterized by multiplicity of interconnections among
various self-representations as well as by multiple connections with personal and emotional experiences) allows
representing polysemantic and emotionally laden selfimage [183]. However, when the right hemisphere functions
deficiently, self-representation tends to disintegrate. In fact,
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right hemisphere damage is associated with such manifestations of disintegration of self-representation as sense of
presence [166], as well as with a shift to egocentric frame
of reference [19]. Various degrees of self-representation
disintegration in suicidal persons may be arranged on the
following continuum:
1. In most general terms, suicidal people have non-cohesive
self-representation [18].
2. This tendency for self-disintegration is more pronounced
among people with narcissistic vulnerability. Specifically, the tendency for self-disintegration is the core of
narcissistic disorder [101]. Ultimately, people with
narcissistic vulnerability have an increased risk of suicide
[10,177].
3. Even more pronounced tendency for self-disintegration
expresses itself in the fantasy of eternal self. Suicidal
persons often believe that they will continue to live in
some way (e.g. in heaven) after death [120].
4. Yet another manifestation of self-disintegration is
fantasy of the existence of a double, which is also associated with suicidal tendencies [173].
5. At a higher degree of self-representation disintegration,
fantasy of the double attains hallucinatory quality of
fantasized companions [195]. These fantasized companions are usually perceived as real persons — enemies or
allies — with voices that emanate from them. The
appearance of imaginary companions can be usually
traced to the early childhood and to the dates of the
earliest narcissistic injuries [16]. The fantasized companions are associated with suicidal states and may even
command the person to commit suicide [195].
6. The most extreme degree of self-representation disintegration manifests itself in MPD. Persons who suffer from
MPD have an increased risk of suicide [172].
To conclude: when — due to narcissistic vulnerability —
painful injury cannot be contained, processed or worked
through, the right hemisphere collapses, which leads to catastrophic disintegration of self-representation. This disintegration may express itself in non-cohesive selfrepresentation, narcissistic vulnerability, fantasy of the
double, imaginary companions, as well as in MPD. Ultimately, the right hemisphere deficiency that parallels disintegration of the self-representation can lead to suicide.
2.6. Body perception
The right hemisphere contains one important aspect of
self-representation, namely, body-representation [96]. The
superiority of the right hemisphere in processing of all
forms of stimuli associated with one’s body — such as
somesthetic and tactile-spatial-positional information, has
been demonstrated in a number of studies (for review see
Ref. [96]). When the right hemisphere is damaged, patients
may experience peculiar disturbances that involve their
bodies
[40,66,70,85,94,99,109,140,142,184,185,188,218,219]. These patients may fail to perceive stimuli applied to the
left side; wash, dress, and groom only the right side of the
body; confuse body-positional and spatial relationships;
misperceive left-sided stimulation as occurring on the
right; fail to realize that their extremities or other body
organs are in some manner compromised; and/or literally
deny that their left arm or leg is truly their own. When
confronted by their unused or paralyzed extremities, such
patients may claim that they belong to the doctor or a person
beside them or, conversely, seem indifferent to their condition.
Such reactions parallel the generally alienated and negative attitude of many suicidal persons to their bodies.
Maltsberger [119] describes the body experience of suicidal
persons in the following way:
For many suicidal patients…body…may be experienced as a prison house in which one is helplessly
confined, escape from which is passionately desired.
It may be experienced as a crowded tenement where
others press in. It may be experienced as a frightening
place swarming with vermin, or an alien chamber into
which evil spirits or monsters penetrate and crowd out
the self. It may be experienced not as part of the self at
all, or, if it is, not experienced as essential self, but
disposable self-part, escape from which is not lethal,
at least to the essential self, which is mental (p. 149).
Maltsberger [119] contends that rejection, abuse or lack
of acceptance during the first years of development lead to
the tendency towards dissociation of body-representation.
During the suicidal crisis the person identifies or confuses
the body or some its part with hostile and persecuting introject. During the suicidal act, the person revengefully attacks
the body that is experienced as an enemy or an alienated
self-part. Similarly, Furman [61] states that neglect, rejection and other negative bodily experiences in the process of
early development interfere with normal development of
body care. Consequently, the person develops negative attitude towards the body, fails to attend to bodily needs and to
indulge in pleasant activities. Orbach [151] adds such
destructive processes, that shape body experience in suicidal
persons, as lack of moderating self-directed aggression, lack
of attunement to bodily needs, lack of representational
learning to care for the body, symbolized hate toward the
body, and dissociation of body-image. Negative attitude
toward the body, anhedonia, and alienation from the body
among suicidal persons have been observed by other authors
[104,105].
This hypothesis has been supported by empirical studies.
Orbach, et al. [154] found that depressed suicidal persons, as
compared to depressed non-suicidal ones as well as to
normal subjects demonstrate a significantly more negative
attitude toward their body. Suicidal persons also demonstrated a significantly higher discrepancy between the
I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
ideal perception of the body and the actual one than the two
control groups. Orbach and colleagues [156] extended these
findings to suicidal patients with such diagnoses as schizophrenia and personality disorders (see, also Refs. [157,158]
for further replication of the findings). Finally, Orbach and
Mikulincer [155] reported that suicidal persons demonstrate
decreased investment in their body in the form of: (a) more
negative image, feelings, and attitude about the body; (b)
less body care; (c) less body protection; and (d) less comfort
from physical touch. Suicidal persons were found to display
higher anhedonia. The association between anhedonia and
suicidal behavior was further supported in other studies
[52]. Taken together, these studies convincingly demonstrate the close association between suicidal tendencies
and body perception. I suggest that right hemisphere
dysfunction contributes to the negative and alienated attitude about their bodies in suicidal people.
2.7. Pain perception
Perception of pain is another function of the right hemisphere. In fact, abnormal activity in the right hemisphere
can lead to sensations of pain. For example, Head and
Holmes [79] reported a patient who suffered attacks of
“electric shock-like” pain that radiated from his foot to
the trunk. A glioma in the right hemisphere was subsequently discovered. McFie and Zangwill [133] reported an
individual who began to experience intense, extreme pain in
a phantom arm after a right stroke. That association has been
supported in other instances [38,186,227].
If increased activity in the right hemisphere is associated
with abnormal pain perception, then right hemisphere deficiency should be associated with decreased pain sensitivity.
It is now widely recognized that suicidal people display
distorted perception of pain. In fact, Furman [61] suggested
that following painful rejection, harsh demands, or abuse
during childhood, suicidal people develop disturbed perception of pain. Consistent with that conclusion, it has been
found that suicidal persons demonstrate higher sensation
and pain thresholds as well as higher pain tolerance than
psychiatric inpatients and normal controls [156]. This finding is valid for such diagnoses as affective disorders, nonaffective psychotic disorders, and personality disorders
[100,156, 157,158,175,197]. It seems that there are two
processes that lead to low sensitivity to pain among suicidal
persons. First, right hemisphere deficiency manifests itself
in general insensitivity to pain. Second, due to disintegration
of self-representation, suicidal people fail to integrate painful stimuli in self-representation. Interestingly, pain threshold and pain tolerance are highly and negatively correlated
with personal distress in suicidal persons [156,157,158].
That is, in non-suicidal persons intense mental pain is associated with high sensitivity to bodily pain. Conversely,
among suicidal persons, intense mental anguish is associated with low sensitivity to bodily pain. This negative
805
correlation between mental pain and sensitivity to bodily
pain could be explained as following. During a suicidal
crisis, the feeling of mental anguish is high. Consequently,
due to the functional deficiency of the right hemisphere,
functioning of the right hemisphere deteriorates. As a result,
sensitivity to bodily pain decreases, too. Conversely, among
non-suicidal people negative affect increases sensitivity to
bodily pain [164].
2.8. Affect regulation
Affect regulation refers to the conscious and unconscious
procedures people use to maximize pleasant and minimize
unpleasant emotions [220]. Affect regulation is hypothesized to be the right hemisphere function [192]. In fact,
the ability to generate polysemantic context enables one to
work through and to contain painful affects. In addition, the
right orbitofrontal cortex regulates autonomic aspects of
emotional arousal [192]. Alternatively, deficient functioning of the right hemisphere compromises one’s ability to
process affective experiences and leads to employment of
inefficient strategies of affect regulation [193]. Ultimately,
inability to regulate negative affects may lead to suicide.
Maltsberger [118] contends that suicide stems from inability
to regulate such negative affects as aloneness, selfcontempt, and murderous rage. When important sources of
self-regulation are lost or when inner turmoil is beyond the
ability of the individual to soothe oneself, the person is
flooded with emotional pain that exceeds one’s ability to
tolerate, contain or endure it. In such a way the inability
to regulate negative affect elevates suicidal tendencies. A
very similar view has been formulated from the bio-social
perspective. In particular, Linehan [114] states that parasuicides — acts of self-mutilation and non-fatal suicidal
attempts — stem from inability to regulate one’s affects,
behaviors, and cognitions. Importantly, an act of parasuicide
enables one to regulate one’s affects, behaviors and cognitions. In line with these hypotheses, empirical studies
supported the relationship between suicidal behaviors and
low ability for affect regulation [221,228].
The immediate consequence of poor affect regulation is
impulsive behaviors. In fact, studies demonstrate that suicidal persons are characterized by high impulsiveness [11].
More importantly, at more extreme levels this tendency
forms a temperamental disposition. Persons who lack internal affect regulatory mechanisms — or self-soothing introjects that perform self-consoling and regulatory functions
during emotional upheaval — suffer from borderline
personality disorder [2]. These patients also have a very
high risk of suicide [46,62,136,174,206].
In conclusion, it seems that right hemisphere dysfunction is associated with low ability to regulate affective
experiences, high impulsiveness or borderline personality disorder that are also associated with suicidal
behavior.
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I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
2.9. Cognitive style: constriction
The ability of the right hemisphere to generate polysemantic context forms the basis for perception and tolerance
of contradictions and paradoxes, and for ability to think
creatively. Specifically, creative approach is based on divergent thinking — ability to use rare associations and unusual
meaning in a productive way [78]. On the other hand, only
the right hemisphere activates both dominant and sub-dominant meanings [39] as well as close and distant associations
[22]. The left hemisphere activates only the dominant meaning and close associations [22,39]. In addition, in creative
subjects creative activity is associated with increased alphaactivity in the right hemisphere [159,223]. Alternatively,
among non-creative people the solution of creative
problems is not accompanied by the intensification of the
alpha-activity. Martindale [126] found that creative persons
do not demonstrate additional activation of the right hemisphere during the solution of creative tasks. On the other
hand, low creative subjects display increased activity —
that is, decreased alpha-index — in the right hemisphere
during the solution of the same tasks. These results were
further supported in other studies [127,128,129].
However, when this ability to form polysemantic contexts
is impaired, the person’s approach to reality is determined
mainly by monosemantic, logic context formed by the left
hemisphere [181]. Left hemispheric approach is devoid of
creative potential. It includes a set of over-learned
responses, it lacks ability to see reality in a polysemantic
way, cannot tolerate ambiguity and is oriented towards
search for clear-cut solutions.
It seems that during suicidal states people demonstrate
left-hemispheric approach to reality. In these persons, the
functionally insufficient right hemisphere collapses under
the burden of mounting emotional distress. The person
remains without his/her right hemisphere capacities. Consequently, the mode of experiencing and functioning is determined almost exclusively by the left hemisphere and the
creative ability is seriously compromised.
This state of mind accounts for inflexible, constricted, and
non-creative thinking of suicidal individuals. Suicidal individuals demonstrate a disposition to think in a somewhat
rigid manner [26,35,48,139,199,204]. The rigidity of thinking manifests itself in cognitive constriction, “tunnel thinking” or difficulty to develop new, alternative solutions to
existing problems [201]. The person with tunnel thinking
lives in a continuously narrowing world with fewer and
fewer options available for solution. The rigidity traps the
person in the unbearable situation that is perceived and
experienced as inescapable. The person desperately clings
to what he or she has and rejects any new possibility. In fact,
Neuringer [144] demonstrated that suicidal persons are
more socially rigid and inflexible as well as incapacitated
in ability to shift problem-solving strategies than non-suicidal patients. They cannot shift from one previously successful but inappropriate problem-solving strategy to another
plan. That result has been replicated in another study
[111]. Levenson [110] found that suicidal persons experience difficulties in finding alternate uses of common objects
— the common test of creative thinking. In addition, suicidal persons have a restricted perceptual range — they do not
perceive objects on the periphery of the visual field [110].
Cognitive rigidity manifests itself in dichotomous thinking. Inflexible thinking restricts suicidal persons to the
narrow world with only two options available. The ability
to bear uncertainty and ambiguity and to perceive paradox is
seriously compromised. Consequently, everything is polarized: feelings, thoughts and perceptions of solutions and of
possible outcomes. A number of studies showed that suicidal persons display polarized thinking [143,145,146]. Suicidal people live in the world of “all”, “none”, “always”, etc.
It is known that depressed persons also tend to think in rigid
dichotomies. However, suicidal individuals demonstrate
this thinking pattern to a more pronounced degree [147].
It seems that due to right hemisphere insufficiency suicidal persons demonstrate low ability to think creatively, to
perceive ambiguity and paradox and to resolve contradictions. Consequently, they display rigid, inflexible, and
dichotomous thinking that traps them in unsolvable conditions.
2.10. Overly general memories of suicidal persons
The ability of the right hemisphere to form polysemantic
context allows the representation of personal experience in a
multidimensional way, with all inner complexities, paradoxes and affective nuances. More importantly, polysemantic context formed by the right hemisphere is a necessary
condition for encoding, storage, and retrieval of personal,
emotional, and episodic memories [183]. In fact, the right
prefrontal cortex is involved in retrieval of episodic
memories [56,83,214], while right hemisphere damage is
associated with inability to retrieve memories of autobiographical episodes (for review, see Ref. [125]). Similarly,
remembering one’s past and free associating to one’s
memories is accompanied by the right hemisphere activation [13]. Therefore, the involvement of the right hemisphere in retrieval of episodic memories seems to be well
documented.
However, when the right hemisphere fails to form polysemantic contexts personal experiences are represented
monodimensionally. The memories of such experiences
are prosaic, emotionally flat, and devoid of any specificity.
If suicidal persons are conjectured to have deficiently functioning right hemisphere, then their memories should be
impersonal and non-specific. This is exactly what has
been found.
Williams and Broadbent [224] studied characteristics of
memories among 25 suicide attempters, 25 inpatients and 25
normal subjects. The subjects were asked to recall events
associated with cue words (such as happy, sad, sorry, hurt).
I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
It has been found that suicide attempters tended to retrieve
less affective memories. Moreover, the recalled memories
were over-general, such as “when I am in bed” or “the first
few years of my marriage”. This tendency was not a result of
the subjects’ not having understood the instructions.
These findings were further replicated in another study
[51].
The overly general nature of memories of suicidal individuals sheds the light on the personal experience of these
persons. It seems that due to the right hemisphere dysfunction suicidal people live in a flat, monodimensional and
simplified world determined by the left hemisphere functioning.
2.11. Dead to the world: psychological suicide and low
openness to experience
Yet another painful consequence of the inability to use
the right hemisphere is a particular trait of suicidal persons,
namely, lack of openness to experience. Openness to experience [134] is defined as need to move beyond existent
cognitive or behavioral concepts. Openness to experience
is closely related to right hemisphere functioning [183]. The
right hemisphere is “open” to real-life occurrences as
opposed to the openness of the left hemisphere to constructing logical structures that are shut-off from the outside world
[180]. The relationship between openness to experience and
right hemisphere functioning has been empirically verified
[121]. Similarly, other authors suggested that the right hemisphere specializes in perception of novelty [72,71]. Only the
right hemisphere enables one to sustain experiences in their
complexity and in interactive and mutually enriching
connections between their various components. Furthermore, this ability to represent the experiences in a multidimensional way generates need for new experiences in
order to further enrich, deepen, and organize them.
However, when the right hemisphere cannot sustain the
polysemantic context, the person withdraws into the shutoff world of the left hemisphere.
In fact, suicide victims demonstrate very low openness to experience [47]. They prefer the familiar to the
novel, follow routine and avoid challenges. They are
uninterested in open discussions and philosophical arguments. Consequently, they are closed to any new event
or experience, they are not open to feelings and find
them unimportant.
Another process that characterizes suicidal persons refers
to personality constriction. Some clinical observations go in
line with that conception. A number of authors [81,139,200]
contended that long before the actual suicidal act, suicidal
persons commit psychological suicide, while Firestone [57]
described this characteristic of suicidal people as inwardness of their existence. They distance from every expression
of their inner being, from spontaneity, and liveliness. They
are alienated from inner experiences and life occurrences
charged with emotional and personal meaning. Conse-
807
quently, they live in a routine world, devoid of “spontaneous
gestures” [226]. The person is “dead to the world” [81].
This state of mind is …characterized by a marked
diminution or near-cessation of affect involving both
hemispheres of concern, the inner and the outer
world. Here it is if the person’s primal springs of
vitality had dried up, as if he were empty or hollow
at the very core of his being. There is a striking
absence of anything but the most perfunctory and
superficial social interactions; output as well as
intake is at a minimum. The person is a non-conductor. To him the human species is wholly uninviting and
unlovable, a monotonous round of unnecessary duplicates; and since everything he sees and every alternative opportunity for action seems equally valueless
and meaningless, he has no basis for any choice ([81]
p. 317)
I contend that psychological suicide reflects inability to
use the right hemisphere capacities and an almost exclusive
reliance on left hemispheric functioning. This over-reliance
on left hemisphere functioning culminates in the suicidal
state of mind and, ultimately, leads to suicide.
3. The suicidal crisis
The suicidal person feels unbearable mental painpsychache [201,202,203]. Psychache is the pain of
frustrated important psychological needs. It is experienced
as the pain of guilt, shame, humiliation, loneliness, or fear.
When psychache becomes unbearable, the person is in
danger of suicide. The stronger is the pain, the higher is
the suicidal risk. Studies demonstrate that, as compared
with non-suicidal people, suicidal persons experience to a
stronger degree such negative affects as guilt [141], shame
[32], depression [169], anxiety [149,169], hopelessness
[21], and loneliness [87].
Unlike normally experienced negative affective states,
the mental pain of suicidal persons is experienced during
a particular state of mind that is determined exclusively by
the left hemisphere functioning. I contend that intolerable
anguish, felt by the suicidal person, cannot be understood
without taking into account that particular state of mind.
Due to right hemisphere insufficiency, mental anguish leads
to further exacerbation of the right hemisphere dysfunction.
Since suicidal people have a functional deficiency of the
right hemisphere, their right hemisphere functioning is
particularly sensitive to negative affects. In fact, the baseline
right hemisphere activation (decreased alpha-activity) — a
measure of the right hemisphere deficiency — predicts
more intense negative affect following negatively toned
clips. The intensity of negative affect is predicted by the
right hemisphere activation, but not by the baseline negative
affect [212,222]. The induction of negative affects interferes
with performance of tasks involving the right hemisphere
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I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
in people with low alpha-activity over the right hemisphere
[17,213]. Similarly, the deterioration in right hemisphere
functioning following negative affects is specific for people
who demonstrate decreased alpha-activity over the right
hemisphere during the baseline [212,122,222]. The functional deficiency of the right hemisphere makes it more
reactive to negative experiences and makes its activity
more labile. Consistent with this, the variability of right
hemisphere activity as well as high activity over it during
remission is associated with a history of depression [43,82].
In addition, children who display low alpha-activity over the
right hemisphere cry more following separation from their
mothers than children with high alpha-activity over the right
hemisphere [42]. These findings demonstrate that functionally deficient right hemisphere manifests itself in greater
reactivity to negatively toned events, in difficulty in affect
regulation, and in further deterioration of the right hemisphere functioning during such negative experiences.
Importantly, such deterioration escalates and generates a
vicious self-destructive circle of negative affects that
decreases the right hemisphere functioning, which in turn
further exacerbates mental pain.
The functionally deficient right hemisphere of suicidal
people makes them vulnerable to negative affects. When
they experience negative affects, the functioning of their
right hemisphere decreases, leaving them without the
right hemisphere capacities. Consequently, the functioning and the mode of experience of the suicidal person
are determined solely by the left hemisphere. Due to
right hemisphere dysfunction, the person remains without cognitive flexibility and affect-regulation strategies
needed for processing of mental pain and effective
coping. In fact, during a suicidal crisis people demonstrate increased impulsiveness [163] and more rigid
thinking [165]. The low ability for affect regulation,
coupled with high levels of negative affects is particularly destructive. Moreover, the shift to left-hemispheric
mode of experience leads to unusual thinking. In fact,
among acutely suicidal patients unusual thinking is even
more closely associated with suicidal tendencies than
the level of hopelessness [137]. Soon, the person
views suicide as the only available solution. Mental
pain coupled with left-hemispheric mode of experiencing elevates suicidal potential. Alternatively, the
normally functioning right hemisphere enables one to
work through the negative affects [192,193] and to
grow from the painful experience [88].
These processes have been described in the literature.
Alvarez [9] called suicidal state of mind “the closed world
of suicide”. He described it as follows:
First and most important, suicide is a closed world
with its own irresistible logic…The logic of suicide is
not rational…The logic of suicide is different. It is like
the unanswered logic of a nightmare or like the
science-fiction fantasy of being projected suddenly
into another dimension: everything makes sense and
follows its own strict rules. Yet, at the same time
everything is also different, perverted, upside down.
Once a man decides to take his own life he enters a
shut-off, impregnable but wholly convincing world
where every detail fits and each incident reinforces
his decision (p. 120–21)
Similarly, other authors described the trance quality
of the pre-suicidal state, during which the person is
increasingly driven towards self-destruction [57,80].
This logic of suicide is the logic of the left hemisphere.
When the right hemisphere collapses, the person lives in the
self-sufficient, detached world of the left hemisphere. This
mode of experience is determined by narrow-mindedness
and search for new evidences supporting existent believes
coupled with inability to verify them critically and reject
them following contradicting feedback. In this world, every
detail falls on its place to support some preexisting conclusion or state of mind. This logic perfectly fits the logic of
delusions: in fact, delusions are generated by the left hemisphere [181]. Delusional persons do not reject the delusional
belief when confronted with contradicting information. On
the contrary, they integrate the new information in their
delusional system and employ that information to support
the delusional belief. Alvarez points at a similar process
among suicidal people: they utilize every new event —
whether positive or negative — every interpersonal encounter, or every new experience to confirm and expand the
suicidal state of mind.
The relationship between the delusional states and the
suicidal ones has already been emphasized in the clinical
literature [4]. However, the suicidal state and the delusional
system are different in one important point: while delusions
refer to a particular belief, the suicidal crisis is associated
with a particular state of mind that is much more general
than a given belief.
Baumeister [20] calls this state of mind “cognitive
deconstruction”. During this state of mind the personal
meaning of event is destroyed in order to avoid unbearable mental anguish. In addition, the person focuses on
the immediate goals and avoids long-range projects. The
person lives in the present without the future and the
past. I contend that those processes ultimately reflect
right hemisphere dysfunction. More specifically, under
the burden of mental pain the right hemisphere
collapses and fails to maintain the personal experience.
Without the right hemisphere the person cannot sustain
the personal meaning of events, cannot integrate the
personal aspects of future and present in the experience
of time, and, consequently, refers to the immediate
goals. The price the person pays is high: he or she
lives in an ever-constricting world that lacks flexibility
of the right hemispheric thinking and ability to
regulate affects, and to sustain cohesiveness of the
self-representation.
I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
4. Early development and etiology of suicidal tendencies
I believe that early negative emotional experiences are
implicated in the development of the functionally deficient
right hemisphere, which contributes, ultimately, to elevated
suicidal tendencies. In fact, disturbed family environment,
early emotional experiences and negative life events during
childhood are implicated in etiology of suicidal tendencies.
In particular, parental restrictiveness [168], neglectful and
overprotective parenting [205], low family cohesiveness
[15,102], poor communication [217], and low family organization, expressiveness, and independence [138] have been
related so suicidal behavior. Families of suicidal adolescents
are less cohesive and the suicidal adolescent usually has
poor communication with parents (for review see Ref.
[217]). Parental psychopathology, such as affective disorder, personality disorders, alcohol and substance abuse, are
also associated with suicidal behavior (for review see Ref.
[217]). Lack of empathy and parental unavailability predict
suicidal behavior. In fact, in a prospective study that
assessed parent–child relationship by a researcher rating
(rather than by self-report data), lower maternal responsiveness and harsher paternal demands were predictive of
suicide attempt [54]. Suicidal adolescents usually perceive
their parents as less warm [216]. In addition, neglect, sexual,
physical or emotional abuse are strongly associated with
suicidal behavior [31,77,116,198]. Losses due to death,
separations, divorce of parents or suicide are associated
with suicidal behavior. Moreover, losses during early
years interact with more recent losses and elevate the suicidal risk (for review see Ref. [1]).
The peculiarities of the right hemisphere development
make it more vulnerable to pathogenic influences of such
negative experiences during the early development. First,
the right hemisphere matures later then the left one. In
fact, the myelination of the right hemisphere is completed
later than that of the left hemisphere [96]. Similarly, while
alpha-phase in the left hemisphere attains 80% of adult
values by the age of 6 years, alpha-phase in the right hemisphere does not reach 90% of adult value until approximately 10 years of age [211]. While verbal ability — a
concrete measure of left hemisphere functioning — is not
related to the rate of maturation, the spatial ability — a
measure of right hemisphere functioning — is [215].
Second, as measured by the EEG activity, the right hemisphere is more active during the first four years of life [37].
The right hemisphere dominance during the first years of
development was further supported neuroroanatomically
[36,162] and by functions attributed to it [67,106,107].
These factors make development of the right hemisphere
dependent on the affective quality of relationship with the
caregiver. In fact, early negative experiences interfere with
development of the functionally sufficient right hemisphere.
A number of factors exert a chronic influence on the development of right hemisphere deficiency. Particularly, depression of mother impairs the development of the right
809
hemisphere. In fact, children of depressed mothers display
decreased alpha-index in the right frontal region [55,89].
This pattern of cerebral activity arises as early as at one
month of age [91] and is still consistently displayed by the
age of 3 years [90]. Emotional unavailability of mother is
another process that hampers the development of the functionally sufficient right hemisphere. In particular, withdrawn
style of mothering was found to be associated with
decreased alpha-index over the right frontal region in the
infants [90]. Emotional unavailability, lack of empathy and
of affective resonance with infant emotional state, as well as
disturbed family environment, do not allow elevation of
dopamine that normally modulates dendritic branching
and cortical development in response to emotional experiences [192]. It was found that low maternal care does not
allow the normal elevation of synaptophysin and NMDA
receptor expression and, in that manner, interferes with
synaptogenesis in developing hippocampus [117]. In these
ways, all these factors lead to undeveloped neuropil
and, ultimately, to the functionally deficient right hemisphere.
Other factors contribute to development of the functionally deficient right hemisphere by means of destruction of
neurons or interneuronal connections. In particular,
emotional trauma and other stressful events elevate levels
of corticosteroids, which destroy the hippocampal cells
[189,190,191] that are particularly sensitive to this
substance [74]. While the atrophy of hippocampal neurons
is reversible if the stress is short-lived, a long-lasting stress
can lead to irreversible destruction of hippocampal neurons
[132]. Due to a longer process of the right hemisphere
maturation and its high activity during the first years, such
destruction of hippocampal cells is more pronounced in the
right hemisphere. In fact, abused children display decreased
ability to identify emotional expressions [34]. Similarly,
PTSD patients show reversed hippocampal laterality
[196]. Consistent with these evidences, suicidal persons
demonstrate destruction of the right hippocampus [8].
In addition, prenatal stress impedes the development of
the right hemisphere and leads to reversal of dopamine
asymmetry in cerebral hemispheres [60]. This finding is
further supported by the fact that depletion of brain amines
follows the right, but not the left, hemisphere damage
[131,176]. Interestingly, these results parallel the reversed
asymmetry of brain amines among suicide victims. The
damage to the right hemisphere could point at the potential
mechanism that relates prenatal stress to the increased rates
of suicide. In particular, it has been found that adolescents
committing suicide experienced more prenatal stress and
more birth complications, as compared with non-suicidal
controls [187].
The studies reviewed above suggest that early negative
experiences interfere with normal development of the right
hemisphere. In this way, they could contribute to development of suicidal tendencies. While this hypothesis could
integrate the findings in the field, it needs empirical
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I. Weinberg / Neuroscience and Biobehavioral Reviews 24 (2000) 799–815
verification. In addition, it will be important to elucidate
which processes are specific to development of the functionally deficient right hemisphere and of the suicidal tendencies (for similar suggestions see Ref. [217]).
5. Conclusions
The studies reviewed above support the hypothesis that
suicidal dynamics are associated with right hemisphere
dysfunction. The proposed hypothesis describes how early
traumata lead to right hemisphere insufficiency and suicidal
behaviors. Due to early traumata — severe or cumulative
— the right hemisphere fails to develop. Functional insufficiency of the right hemisphere manifests itself in difficulties
in generation and maintenance of polysemantic context.
Right hemisphere deficiency forms the general diathesis
factor for development of suicidal states. Right hemisphere
deficiency is expressed in non-cohesive self-representation,
tendency toward dissociation, decreased sensitivity to pain,
body alienation, anhedonia, failure to attend to body needs
and care about the body. Acute anguish coupled with right
hemisphere deficiency further increases right-hemisphere
dysfunction. Self-representation disintegrates, affective
regulation fails and the person is flooded with painful feelings of injury, rejection, shame, guilt, sadness, and anxiety.
The failure to regulate affects increases impulsiveness. The
shift to left hemisphere functioning manifests itself in cognitive constriction and inflexible approach to problems. The
person enters into desperate imprisonment in the closed
world determined by left hemisphere functioning. Unbearable mental pain coupled with right hemisphere dysfunction
culminates in the suicidal act, which is perceived as the sole
escape from the intolerable anguish.
It can be still hypothesized, that the relationship between
right hemisphere deficiency and suicide could be explained
by the association of depression with suicide [112,169],
which is also connected with right hemisphere dysfunction
[58,183]. However, the reviewed studies demonstrated right
hemisphere abnormalities among suicidal persons with such
diagnoses as schizophrenia, conduct or personality disorders. Therefore, the relationship between the right hemisphere dysfunction and suicidal behavior is valid beyond
any specific nosological category.
The hypothesis developed in this paper refers to psychophysiological aspects of suicidal crises. It describes how
various psychological as well as physiological variables
generate suicidal state of mind. However, the proposed
hypothesis does not distinguish among various personality
types of suicide. In fact, it has been repeatedly emphasized
that different personality types are associated with different
risk factors as well as with different dynamics of suicide
[122]. Recently, Orbach [152] proposed a taxonomy of
risk factors that divides them into three clusters. Each cluster is associated with a particular personality type: perfectionist — depressive, impulsive, and disintegrative. It
would be interesting to verify whether the right hemisphere
deficiency is related to all personality types as opposed to
some of them. Specifically, the right hemisphere deficiency
can form a general and non-specific vulnerability factor for
development of suicidal tendencies among all personality
types as opposed to only some of them. Similarly, it is not
clear whether some manifestations of the right hemisphere
deficiency (e.g. affect dysregulation, cognitive constrictions, etc), as opposed to other manifestations of it, are
specific for a particular personality type.
In addition, the proposed approach does not differentiate
between various subgroups of suicidal behaviors, such as
suicidal ideation, attempts or completed suicide. The importance of differentiation of those forms of suicidal behavior
has been repeatedly emphasized in the theoretical [148] and
empirical literature [123], whereas Shneidman [201]
described phenomenological distinctions between suicide
attempters and completers. Linehan [113], following an
extensive literature review, differentiated suicidal persons
into two groups: completed suicides and parasuicides
(non-fatal suicidal attempts and deliberate self-harm).
Arensman and Kerkhof [7], after reviewing studies in the
field, further distinguished mild suicide attempts from
severe suicide attempts. The explanation of those differences in terms of the proposed approach needs additional
theoretical and empirical effort.
The proposed hypothesis should be verified empirically.
It points at new directions of research. In fact, it opens an
avenue for research of such functions of the right hemisphere of suicidal persons as interpersonal perception, affect
regulation, perception of humor, metaphors, and ambiguous
contexts as well as interrelationships among various psychological and physiological variables.
Acknowledgements
My sincerest thanks to Prof. V.S. Rotenberg for valuable
discussions of the topic, for suggestions on previous drafts
of the article and for personal assistance and enthusiasm. I
am indebted to two anonymous reviewers for their insightful
and helpful comments.
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