Oliver Sacks, is a wonderful writer who uses his finely honed clinical skills as a Neurologist to add the texture to his stories about people. In his column, A Neurologist’s Notebook, which appeared in the New Yorker magazine he writes about the actor and writer Spalding Gray who experienced a frontal lobe injury in a motor vehicle accident in June of 2001 following which he became depressed, obsessive in his thinking, angry and suicidal. Spalding Gray eventually took his life on the Staten Island ferry early in 2004 following many rehearsals for his suicide and some two months later his body was washed up by the East River.
Gray’s life changed after surgery to remove skull fragments which were pressing against his right frontal lobe. The damaged part of his skulls was replaced with titanium plates and a shunt was placed to drain cerebral spinal fluid. His injury at first was thought to be a broken hip which was surgically pinned, but shortly after that surgery his wife, Kathie Russo, noticed a dent near his right eye. X-rays revealed a compound fracture of eye socket and skull. In 2003, Gray was visited by Oliver Sacks, MD and Orrin Devinsky, MD another noted neurologist.
Gray had suffered from episodic depressions for the 20 years prior to his accident, but had always responded to talk therapy and, sometimes, to lithium. According to Dr. Sacks this post-brain injury depression was of “unprecedented depth and tenacity”. His 10-year old son and 16-year old step-daughter felt that their father was “transformed” and “no longer himself”. Gray had been an avid reader and a prolific writer, now he was not reading or writing. In 2003 Gray went for neuropsychiatric testing at UCLA’s Resnick Hospital. His scores indicated “attentional and executive deficits typical of right frontal lobe damage”. The doctors warned of the likelihood of further deterioration caused by scarring. His wife reported that he was “morally devastated” by the diagnosis. When Gray saw Dr. Sacks he reported that he was thinking about suicide constantly and regretted not killing himself at the UCLA hospital. Doctors Sacks and Devinsky discussed brief respites in his mood states which occurred after general anesthesia.
Our frontal lobes play an enormously important role in regulating our perceptions, feelings, moods and behaviors. When compromised they can lead to difficulties with intellectual activity and creativity. Yet, Gray saw no change in his intellectual function and he could no longer bring his creative talents to bear. He spoke of rehearsing his suicide and called his wife during one event which resulted in his hospitalization at Kessler Institute in a specialized brain injury unit. He returned briefly to performing in late 2003, but in early January 2004 after taking his children to a movie, he was last seen boarding the Staten Island Ferry.
In our work at the Neurologic Rehabilitation Institute at Brookhaven Hospital and at the Neurologic Rehabilitation Institute of Ontario we often see patients who, much like Spalding Gray, ruminate about their suicide. For some, it occurs through passive suicidal preoccupations like wishing that a bus would hit them as they crossed the street and, for others, the thought of suicide is ongoing and the person engages in planning and rehearsals of the act which will lead to their death. With all of these situations we realize that the risk is very real and the thinking can rapidly escalate into the event. The role of impulse becomes all the more important in our assessment of risk and in creating a safety net around the person. Sometimes, we use involuntary hospitalization to enhance safety.
Dr. Sacks’ story about Spalding Gray highlighted the importance of understanding suicidal risk in brain injury. We all have heard about the professional athletes in the NFL and NHL who have taken their lives. Additionally, there is a high rate of suicide among returning soldiers. Is another aspect of brain injury as “the signature injury” of the Iraq and Afghanistan wars seen in suicidal behavior? Are we adequately understanding the effects of multiple concussions and blast injuries in our returning soldiers.