1921: Erwin Ringel

Recognizing Suicidality

April 27, 1921 – Birth date of Austrian psychiatrist Erwin Ringel.

A follower of Alfred Adler’s Individualpsychologie, Ringel was especially interested in psychosomatic medicine: he thought it was wrong to make a too rigid difference between body and mind. He was active in psychiatry in many ways; he wrote 20 books.

But most important were his achievements as a pioneer of suicide prevention efforts.

In 1953 he published a study about suicide as “the finale of a development of illness”. His study was based on systematic interviews of over 700 people who had survived their suicide attempt, and it focused on the period immediately preceding their decision to commit suicide.

Presuicidal Syndrome

In this groundbreaking 1953 study Ringel defined the Präsuizidales Syndrome, presuicidal syndrome: the typical combination of a person’s options, behavior and fantasies that indicate suicide risk. Nearly all the interviewed persons showed these three characteristics:

• Narrowing Options – you see ever less alternative options in life, until only suicide remains as the only possible option. This narrowing can happen primarily in your mind (for example by isolating thoughts), but also because your actual situation leaves your with ever less options (for example by job loss or chronic illness).
• Inverted Aggression – your feelings of aggression turn ever stronger and at the same time more inhibited, until this pent-up aggression turns against yourself.
• Suicidal Fantasies – feeling ever less adequate to cope with reality, you start to build an illusory world in which thoughts of death and suicide become ever more prominent.

Ringel stressed how important it was to recognize these tendencies in a patient, as they can constitute a clear indicator of the actual suicide risk.

Monument for Erwin Ringel at the Schlickplatz in Vienna,
by sculptor Josef Zenzmaier, 1999

Illustration

In one of his other books, Die österreichische Seele (“The Austrian Soul”, 1984) Ringel quoted a poem from a 19th-century suicide note that presented all the different elements of Presuicidal Syndrome in a typical way.

The first lines literally show the narrowing, the next lines demonstrate isolation, and the last four lines present an aggressive-suicidal fantasy:

More

In 1948, Ringel had already helped establish one of the world’s very first suicide prevention centers (in Vienna).

In 1960, he was one of the three founders of the IASP (International Association for Suicide Prevention) which is active in over 50 countries today.

Having been confined to a wheelchair the last ten years of his life, he died in 1994 at the age of 73.

Allow me to add an off-topic note here. One unrelated reason why I really do like Ringel, is that as a young student in October 1938 (half a year after the Nazis took over Austria) he took part in a public anti-Nazi demonstration in Vienna. He was one of that very small minority of Austrians who actually dared to protest against Nazi antisemitism. The Gestapo arrested him after the demonstration; he was lucky to be released three weeks later.

Footnote:

• The poem above is my in own improvised translation.
  Here is the original German text:

   
  Immer enger wird mein Denken
  immer blinder wird mein Blick,
  mehr und mehr erfüllt sich täglich mein entsetzliches Geschick.
  Kraftlos schlepp ich mich durchs Leben
  jeder Lebenslust beraubt,
  habe keinen, der die Größe
  meines Elends kennt und glaubt.
  Doch mein Tod wird Euch beweisen,
  daß ich jahre-, jahrelang
  an des Grabes Rand gewandelt,
  bis es jählings mich verschlang.