[ExI] pistols

[Rafal Smigrodzki]

On Wed, Apr 21, 2021 at 9:38 PM Stathis Papaioannou <stathisp at gmail.com>
wrote:

>
> Sometimes they are just suicidal gestures, but often the patient really
> intends to die at the moment they make the attempt, but change their mind
> when they wake up.
>

### How do you know that the patient really intends to die? By listening to
what they say? If they are really trying to die, why wouldn't they use a
method that's guaranteed to work, like hanging, fall from height, gunshot
or drowning? Why do the OD suicides so often message others before the
attempt, if not to reduce the likelihood of dying and to increase the
psychological impact on the intended target?

According to:

https://www.hsph.harvard.edu/means-matter/means-matter/case-fatality/

the CFR for gun suicides is 82% but the CFR for poisoning (i.e. drug
overdose) is 1.5%. This is an enormous disparity. Sure, a lot of suicides
are dumb people who wouldn't think about looking up the doses of
medications they would need to take to achieve a lethal effect but really,
shouldn't the use of a method that works only 1.5% of the time be a clue
that many if not most of ODs are not serious?

Call me a cynic but after 20 years of being a neurologist I developed a
fair amount of skepticism about what the patients are telling me. As a
neurologist I have methods for detecting some types of medical lies that
are not available in most other situations, which is why I find liars all
the time. "No, I haven't missed my medications!" - your valproate level is
0, so yes, you did. "No, I haven't done cocaine in a year" - your urine
drug screen is positive for cocaine, benzos and opiates, so yes, you did.
"I am having a seizure" - no, after seeing 1000 fake seizures I know you
are not. "I am paralyzed!" - no, after seeing 1000 fake strokes I can see
you are faking it.

Earlier this week I consulted on a 36 year-old morbidly obese man who
developed complete amnesia. A day before he was supposed to start an actual
job he claimed he forgot everything - his name, age, address, whether he
has a family and all of his life so far. I asked him - Do you remember how
many legs you have? "No, not really". But maybe just approximately? More
than three? "No, I don't think so, maybe one or two". Laughable. I gave him
the diagnosis of psychogenic amnesia, or dissociative amnesia but maybe I
should have called it malingering. After all, in this way he avoided
dragging his 448 lb to work.

Rafal
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