Is this patient reaction the calm before the storm?
PSYCHIATRIC VIEWS ON THE DAILY NEWS
Last Tuesday, our daily column was on “Tragedies should not be deemed senseless.”1 Now I have another word—really, words—that can not only be very misleading, but dangerous to misinterpret.
As written about recently in the Washington Post in the article “Michigan Schools order investigation after staff raised alarms about suspect hours before fatal shooting,”2 the superintendent was quoted as saying that the school counselors did not take action against the perpetrator in large part because he “appeared calm” after a discussion about his graphic drawing of blood and gunshot wounds. Unfortunately, appearing calm for no clear and meaningful reason is generally not a good sign in the midst of psychological turmoil. Too often, it is a reflection of someone in distress who has decided to commit homicide or suicide, with an ensuing sense of relief in the decision. In this case, it was homicide.
In another case back in the news, it was a case of suicide. Again in the Washington Post, there was a long article titled “Jamie Raskin’s year of grief and purpose.”3 At the end of December, 2020, Representative Rep. Raskin recalled that his son, who had long been suffering from clinical depression, did not seem depressed and upset. Rather, “it was a sign of serene calm.” Now, almost a year after the suicide, Raskin wrenchingly recognizes that it was a sign of something going awry—that his son had indeed decided to commit suicide and did not want to be talked out of it. Interestingly enough, the article conveys that his son saw his long-term psychiatrist the day before he died, but the psychiatrist did not have any increased concern and was astonished like everyone else.
Yes, it is counterintuitive to presume that someone who had been agitated and depressed would be doing worse if they suddenly present with a sustained calm. It would seem logical to presume that they were getting better, and that is possible, but only if there is an obvious psychological reason for the improvement. Otherwise, increased suicide or homicide risk is likely imminent. We in mental health care should not only be attuned to that risk, but continually educate the public and patient families about the looming danger.
In my experience in reviewing such situations, reports of being surprised by suicidal or homicidal behavior, with the depressed person seemingly doing better from a superficial perspective, is all too common, and I would anticipate many more showing up if we did more psychological autopsies. The good news is that these tragedies may be headed off with proper caution and deep assessment of what erroneously seems like mental status improvement.
Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric TimesTM.
1. Moffic HS. Tragedies should not be deemed senseless. Psychiatric Times. November 30, 2021. Accessed December 7, 2021. https://www.psychiatrictimes.com/view/tragedies-should-not-be-deemed-senseless
2. Pietsch B. Michigan schools order investigation after staff raised alarms about suspect hours before fatal shooting. The Washington Post. December 5, 2021. Accessed December 7, 2021. https://www.washingtonpost.com/nation/2021/12/05/oxford-shooting-school-investigation-ethan-crumbley/
3. Gibson C. Jamie Raskin’s year of grief and purpose. The Washington Post. December 6, 2021. Accessed December 7, 2021. https://www.washingtonpost.com/magazine/2021/12/06/jamie-raskins-year-grief-purpose/