Branko Kolarić

Dario Bagarić

Kresimir Radic

Maja Vilibić

Maja Zivkovic

Marko Curković

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  285Psychiatria Danubina, 2015; Vol. 27, No. 3, pp 285-287 Case report © Medicinska naklada - Zagreb, Croatia SUICIDE AS THE FIRST MANIFESTATION  OF FIRST-EPISODE PSYCHOSIS IN 21-YEAR-OLD MAN:  A CASE REPORT Maja Vilibić1, Dario Bagarić1, Branko Kolarić2,3, Kresimir Radic1,  Marko Curković1 & Maja Zivkovic1 1University Psychiatric Hospital Vrapce, Zagreb, Croatia 2Department for Social Medicine and Epidemiology, Medical School, University of Rijeka, Rijeka, Croatia 3Department of Epidemiology, Teaching Institute of Public Health “dr Andrija Stampar”, Zagreb, Croatia received: 5.5.2015; revised: 7.8.2015; accepted: 28.8.2015 *  *  *  *  *  INTRODUCTION In literature data as well as in everyday clinical practice high suicide risk in patients with first-episode psychosis (Pompili et al. 2011, Preti et al. 2009, Foley et al. 2008, Sanchez-Gistau et al. 2013, Barrett et al. 2010, Flangan & Compton 2012) is shown. Suicidality is highly present in schizophrenia (Brecić et al. 2009, Marcinko et al. 2005, Pompili et al. 2009, Brugnoli et al. 2012, Lopez-Morinigo et al. 2012, Sharaf et al. 2012), particularly in first-episode patients. The early years of illness (early episodes) present the period of the highest risk. Some recent studies were focused on identifying factors that increase suicidality risk in patients with first-episode psychosis, and in that context some investigators stressed the presence of command auditory hallucinations in particular, but not auditory hallucinations, in general (Marcinko et al. 2005), while the others propose the presence of more intensive de-pressive symptoms (Barrett et al. 2010, Flanagan et al. 2012), higher insight (Barrett et al. 2010, Flanagan & Compton 2012) and negative beliefs about psychotic disorder (Barrett et al. 2010) as critical ones. There is still little evidence regarding suicidality risk factors in patients with prodromal symptoms. Having in mind that suicide is a leading cause of death among patients with psychotic disorders, as well as the lack of well known predictors of suicidal behavior in patients with prodromal symptoms and with first episodes of psychosis, careful clinical approach with application of available therapeutic and preventive measures (Jakovljević 2007, Jakovljević 2008), should be used in each case of suicidal manifestation and/or increased suicidality risk in patients with first episodes of psychosis. Reducing suicide and attempted suicide rates to the lowest possible level should be an imperative for all clinicians who work with patients with early episodes of psychosis. CASE REPORT A 21-year-old male student committed suicide by jumping through a high-floor window. He was never previously psychiatrically observed and/or treated. Prior to his demise he never reported explicit symptoms or manifested behaviors that would imply psychotic prodromes. He was a good student, socially popular, in a stable, few-years-long emotional relationship, gene-rally healthy. He lived with his father. When he was twelve years old, his mother died of disseminated malignant gynecological carcinoma, at the age of forty seven. For more than two decades prior to her death she was treated of paranoid schizophrenia. After a busy day (filled with seminars, lectures, meetings with friends and girlfriend, lunch, study time, talking to his father and neighbors), he wrote a suicide note and in the evening committed suicide by jumping from the high floor window. His father reported his son had never previously manifested any prominent symptoms, signs or behaviors that would imply the first-episode psychosis or prodro-mal symptoms. By exploring in detail son's suicide note, father found various parts that could be in relation with various psychosis symptoms, very likely belonging to the first-episode. Paranoid delusions: fear and feelings of danger and hopelessness because of anticipated impossibility of requesting and receiving police protec-tion due to a belief that police officers were involved in spying him and acting against him; as well as feelings like being on the edge and like everybody were watching him in everyday social interactions, were clearly stated. Student also described feelings of dan-gerous, unsecurity and overwhelming fear associated with feelings of intensive suffering and hopelessness. Based on the information from the suicide note, such symptoms started a month before suicide. During coun-seling and support session, student's father confirmed that his son had partialy reduced the usual social contacts in last two weeks, which were qualified as non-Maja Vilibić, Dario Bagarić, Branko Kolarić, Kresimir Radic, Marko Curković & Maja Zivkovic: SUICIDE AS THE FIRST MANIFESTATION  OF FIRST-EPISODE PSYCHOSIS IN 21-YEAR-OLD MAN: A CASE REPORT          Psychiatria Danubina, 2015; Vol. 27, No. 3, pp 285–287    286significant. No major changes in usual conversation or regarding quality of student's usual activities were observed. Partial reduction of his social contacts in the last couple of weeks was explained by greater study load in that part of the academic year.  DISCUSSION In this case of a young man with positive psychiatric heredity, suicide was the first manifestation of his most probable first-episode psychosis. It can be assumed that the student recognised his first-episode psychosis symptoms, because of his high intellectual capacity and a clear memory of the aspects and symptoms of his mother's paranoid schizophrenia, and then hid them successfully from the closest persons. At the same time, the developing psychopathology most probably over-whelmed his adaptable capacities, and intense fear, inner tension and feelings of hopelessness (as stated in the suicide note) led to the suicide. This report and other cases of suicide with unrecog-nized and/or untreated underlying first-episode psychosis, illustrate the importance of recognizing suicidality risk factors in vulnerable population. Subtle behavioral changes and/or verbally expressed symptoms can be detected and potential suicidality risk factors can be discovered even in patients (like in this case) who gene-rally do not manifest clear and significant behavioral and everyday life activities changes in comparison to the premorbid period. In this case, heterodata were obtained during supporting and counseling of the stu-dent’s father and friends, and student's subtle behavioral changes as well as discrete changes in everyday-life activities, correlated with some aspects of psychopatho-logy described in the suicide note, were confirmed. However, student's functioning in the last month before suicide was described by his closest persons as “glo-bally unchanged“, when compared with the immediate premorbid period. His father and friends noted partial reduction of student's social contacts in the last couple of weeks before the suicide, but it was qualified as „insignificant“ due to student's rationalization about increased study load prior to exam period. Heterodata also confirmed that student verbally reported subtle paranoid interpretations of regular situations during his social interactions in the last month, but they were of very short duration and never bizarre. Subtle para-noidality were then seen as a result of student's fatigue because of intense studying. Subtle depressive symptoms in this case are consi-stent with the literature data, showing depressive symp-toms and high insight (Barrett et al. 2010) as well as feelings of hopelessness (Wong et al. 2013) are impor-tant suicidality risk factors in patients with first-episode psychosis. It seems that in this young man's case an association between high insight and very high suici-dality risk was mediated by other critical variables, such as depression and, above all, hopelessness. On the other hand, here it was very difficult to identify any trait that reflected a predisposition to psychosis, except a genetic influence (or family burden) that could be very important.   CONCLUSION In each case of a patient in prodromal psychotic phase or of a patient in the first episode of psychosis, all avail-able efforts should be done in order to discover, some-times very clear while sometimes subtle and atypical symptoms, signs and behaviors that would imply an increased suicidality risk. Early detection of such signs is crucial for adequate measures of suicide prevention, and in order to lower the suicide rate in first-episode psychoses. Furthermore, early interventions with a low dose of atypical antipsychotics in persons with signifi-cantly increased risk for developing psychosis may be potentially useful to prevent the development of first-epi-sode psychosis (Tsuang et al. 2002, Seidman & Norden-toft 2015) and possibly associated suicidality risk.   Acknowledgements: None. Conflict of interest: None to declare.  References 1. 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SUICIDE AS THE FIRST MANIFESTATION OF FIRST-EPISODE PSYCHOSIS IN 21-YEAR-OLD MAN: A CASE REPORT

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