Jodi Arias, convicted of first degree premeditated and felony murder, on 24/7 suicide watch

Jodi Arias looks distraughtly and imploringly at her defense attorney Jennifer Willmottt after jury returns with a guilty verdict following nearly 15+ hours of deliberation.

It’s no wonder that mental illnesses have the stigma they do, when the only time we hear of it is in the aftermath of tragedy. It leaves little room for sympathy, much less for empathy.

Jodi Ann Arias took to the camera only 20 minutes after the guilty verdict came down on her. In lieu of an apology or an expression of remorse, the murderess, whose 5 year reprieve and 4 month trial, tells local Arizona Fox news affiliate that, she “prefers the death penalty.” Shortly thereafter, she was placed on suicide watch, which is protocol for freshly convicted felons. After court was abruptly cut short the next day for her sentencing phase, much speculaqtion landed on Arias’s possible incompetency to stand. By the end of the day, it was discovered she was taken to Buckeye Hospital’s Forensics Psych Ward, the only of its kind near the Phoenix courtroom.

This tweet posted by Arias’s friend Bering hours before the verdict, coupled with her immediate media interview, are responsible for Arias’s current placement in the Buckeye Psych Ward.

 

This is not all surprising considering her history of suicidal ideation. When Arias first took the stand in her own defense back on February 4th, she testified that she thought a lot about suicide in the weeks after Travis Alexander’s murder and her incarcation awaiting trial. She even alleges an attempt to end her life by taking OTC blood thinning pain-killers and putting a razor to her wrist, but stopped short of actually piercing her skin. In later testimony she references ripped diary entries discussing, in her own written words, suicidal ideation as an escape.

But then, Jodi Arias also wrote in her diary as if she had no idea how Travis died. So we’ll leave the determination of credibility up to you.

What is for certain is that turning to suicide seems to be the trend for Arias, who was diagnosed as having a borderline personality disorder by state appointed psychologist DeMarte. When something bad happens she instantly takes to ending her life to escape the issue instead of dealing with it head-on. Is Jodi Arias suffering from a serious mental disorder such as Borderline Personality Disorder? According to the National Institute of Mental Health:

“The DSM, Fourth Edition, Text Revision (DSM-IV-TR), requires that at least five of the following symptoms must occur to be diagnosed with borderline personality disorder:

• Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
• A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
• Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
• Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
• Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
• Intense and highly changeable moods, with each episode lasting from a few hours to a few days
• Chronic feelings of emptiness and/or boredom
• Inappropriate, intense anger or problems controlling anger
• Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

In addition, seemingly mundane events may trigger symptoms.” It does sound a lot like Arias, whose father admitted during police interviews to her strange and self-destructive behavior even in his daughter’s teenaged years.

In a bid to save her life and spare her from the death penalty, will her defense lawyers use the diagnosis the State endowed her with? Is someone with a potential mental illness worth saving, or was her crime so heinous that the diagnosis is minute?

We’ll have to wait until May 15 to find out.

Tricyclic Antidepressant Overdose: A Scientific Overview

Image: http://www.medscape.org

I recently wrote an article about Morgan Ingram, a 20-year-old woman who may or may not have committed suicide. Her death was caused by (as yet undetermined intentional/unintentional) amitriptyline intoxication. The case is still pending but it had me researching amitriptyline and its lethality when abused. Because TCAs rank so highly on the list of overdose agents, it is imperative that the pharmacokinetics of TCA overdose be reviewed.

Tricyclic antidepressants are the most widely used class of antidepressants. Although it is also among the oldest, with safer antidepressants now more widely available, doctors tend to prescribe TCAs with more frequency than any other class. This may be due to apparent cost advantage over other antidepressants as well as its high availability and proven efficiency. Perhaps due to this, TCAs have become an agent of notoriety in emergency departments across the globe in instances of intentional and accidental poisonings due to drug overdoses. It is counted as the 8^th and 7^th leading cause of toxicity in 2007 and 2008, respectively¹.  Amitriptyline is the most commonly abused TCA, followed by nortriptyline and doxepin².

TCAs exert lethality by acting as sodium channel blockers⁴. They slow both the digestive process and absorption from the intestines and the heart until it stops beating. Death is usually officially achieved by retarded depolarization of the cardiac action potential². These cardiac arrhythmias due to blockage of sodium and potassium channels usually develop in the first 2-6 hours of digestion³. Also, because it metabolizes slowly, onset of symptoms associated with toxicity occur most often 2 hours after ingestion³, with death occurring within 12 to 24 hours⁴. Although they slow the digestive processes, TCAs are rapidly absorbed from the gastrointestinal tract but may be delayed in some cases due to inhibition of gastric emptying. Intentional overdoses may sometimes be accompanied by an antiemetic drug to reduce gastric discomfort.

6 grams of a TCA is considered lethal. Self-poisoning with a “cocktail” of 6 grams amitriptyline, 300 mg benzodiazepine, and an antiemetic drug is fairly common as reported by medical examiners and emergency room departments. Unbound tricyclics may increase if acidosis occurs due to respiratory distress³.  After ingestion, TCA metabolites are conjugated in the liver via first pass metabolism utilizing glucuronic acid and excreted by the kidneys.

Impulsive suicides in persons who generally have not exhibited prior psychiatric disorder are commonly motivated by anger, the desire to “get even,” the wish to frighten or punish others, or the need to avoid intense shame³. Suicide attempts by drug overdose is greater than women than in men and is most prevalent in persons aged 20-29 years^3.

People who usually attempt suicide by TCA intoxication find time to death exceptionally long (36 hours) and may change their minds. In cases where rescue was successful, overdose patients complained of sinus tachycardia⁴. Labored breathing, low blood pressure, shock, enlarged pupils, coma, agitation, hallucinations, muscle rigidity, convulsions, and agonal breathing were also reported. If you suspect someone may be suffering some a TCA overdose, contact 911 and the National Poison Control Center at 1-800-222-1222 immediately to ensure the best outcome of survival.

References:

1. Suicide attempts involving amitriptyline in adults: a prospective, demographic, clinical study

Turk J Med. Sci.

2011; 41(2): 243-249

medsci@tubitak.gov.tr

2. Tricyclic antidepressant toxicity in emergency medicine

Vivian Teal

Emedicine.medscape.com

3. Guide to a Humane Self-Chosen Death

Dr. Peter Admiraal

4. Tricyclic antidepressant overdose: a review

G.W. Kerr, A.C. McGuffie, S.W. Willkie

Dr. Kerr: gary.kerr@aaaht.scot.mhs.uk

Emerg.Med.J 2011; 18, 236-241

Emj.bmj.com/content/18/4/236