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PAPERS: Bertil Jacobson and Marc Bygdeman Obstetric care and proneness of offspring to suicide as adults: case-control study BMJ 1998; 317: 1346-1349 [Abstract] [Full text]

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Sucide, the birth trauma and the near-death experience

Karl Jansen   (18 November 1998)

Climate bias?

Gregory Rose   (19 November 1998)

No climate bias

Bertil Jacobson   (20 November 1998)

Obstetric care and proneness of offspring to suicide as adults: case

Ivan Buzov   (20 November 1998)

Birth trauma and suicidal ideation in psychotherapy

Olavi Noronen   (23 November 1998)

VIOLENT SUICIDES AND PERINATAL EVENTS

Michel Odent   (26 November 1998)

Communication in social and family contexts is more important than birth trauma

Martin Anderson   (26 November 1998)

Details of birth are indeed remembered

N B Vissel   (26 November 1998)

Infant-maternal bond effect

Janet Menage   (30 November 1998)

Prospective vs retrospective study

Michael Gdalevich   (30 November 1998)

Obstetric care and proneness of offspring to suicide as adults: case-control study

Riadh T Abed   (1 December 1998)

Applicability of ecological data

Bertil Jacobson   (3 December 1998)

Purpose of study

Bertil Jacobson   (3 December 1998)

Birth trauma - a challenge for memory and trauma research

Olavi Noronen   (7 December 1998)

The imprinting hypothesis

Bertil Jacobson   (9 December 1998)

Imprinting revisited

Riadh T Abed   (15 December 1998)

Correction and comments

Bertil Jacobson   (9 January 1999)

Mehodological flaws cast doubt on conclusions

David Gunnell   (30 January 1999)

No methodological flaws

Bertil Jacobson   (7 February 1999)

Migration as a putative confounder

Bertil Jacobson   (26 February 1999)

Perinatal disorders and suicide: is there a link?

Gaia Meneghel   (29 June 1999)

Sucide, the birth trauma and the near-death experience 18 November 1998
Karl Jansen Send response to journal: Re: Sucide, the birth trauma and the near-death experience	EDITOR- The suggestion that some violent suicides are scripted by a traumatic birth relates to theories that the near-death experience (NDE) is a re-activation of birth memories in symbolic form.1 Like birth, NDE's involve travel through a tunnel into light. Some are blissful but others involve panic and paranoia. 2,3 New data show foetal memory at 20 weeks 4, and adults have appeared to re-experience birth in LSD and ketamine research. 2,3 The birth trauma frequently appeared as a core imprint, described by Grof in 4 parts: (1) The amniotic universe: no boundaries. The re-experiencing adult describes ocean, galaxy, heaven, cosmic unity beyond time and space. Arriving toxins or lack of nourishment link with images of poison, danger, and evil forces.(2) Engulfment and no exit: stage 1 of delivery. There are contractions but the cervix is closed so there is no way out. Symbolism includes engulfment and imminent disaster, expulsion from Eden, the sense of original sin (to have deserved this fate) and hell: entrapment in a claustrophobic, endless nightmare of pain from which escape is impossible. (3) The death-rebirth struggle: contractions continue but the cervix is dilated. The baby moves through the birth canal, struggling against suffocation and compression. Symbolism includes a titanic struggle with energy building up towards explosive release, cataclysm, with sadomasochistic, aggressive elements. The person may identify with both killer and victim, relevant to violent suicide. (4) The death-rebirth experience: Tension is released, the child is born into light. In adults, annihilation of all previous reference points, ego death, is followed by rebirth: visions of white light, arriving in paradise, and positive feelings about self, others and life. The stages may not be worked through sequentially, and may be repeated many times.3 A 're-doing' of birth within a therapeutic alliance allows some resolution of the trauma. Ego death can resolve a deep sense of inadequacy, an unrealistic need to be prepared for hidden dangers, and a compulsion to be in control linked to negative aspects of birth. NDE's can be followed by more joy in living, less anxiety and neurosis, and a sharp fall in suicide attempts.2 In over 1,000 patients, death-rebirth psychotherapy using ketamine has had good results at longterm follow-up.5 The safe induction of NDE's for psychotherapeutic purposes, as may be achieved with anesthetics and guided imagery, may offer a powerful treatment for those at risk: a brief ego death that may be life-saving. *Dr. Karl L.R. Jansen, MB.ChB., M.Med.Sci., D.Phil. (Oxon), MRCPsych. Current appointment: Director, The Chaucer Centre, 13 Ann Moss Way, off Lower Rd, Rotherhithe, London SE16 2TH Professor Bruce Greyson, M.D. Current Appointment: Bonner-Lowry Professor of Personality Studies Current Address: Division of Personality Studies Box 152, Health Sciences Center University of Virginia Charlottesville, VA 22908 U.S.A. Dr. Evgeny Kupritsky, M.D., Ph.D., DSci. Current Appointment: Chief of the Research Laboratory Current address: St.Petersburg Regional Center of Alcoholism and Addictions, Novo-Deviatkino 19/1, St.Petersburg Region 188661, Russia. No authors have a competing interest. 1. Jacobsen B, Bygdeman, M. Obstetric care and proneness of offspring to suicide as adults: case control study. BMJ 1998 ; 317: 1346-9 (14 November). 2. Jansen K L R. The ketamine model of the near -death experience: a central role for the NMDA receptor. Journal of Near-Death Studies 1997; 16: 5-27.(http://www.iands.org/jndsind.html) 3. Grof S. Realms of the Human Unconscious: Observations from LSD Research. New York, Viking Press, 1975. 4. Evans W S. Ontogenesis of auditory perception and memory at 20 weeks' gestation. Abstracts of the 1998 Annual Conference of the British Psychological Society, Brighton, 1998, p8. 5. Kupritsky EM, Grinenko AY. Ketamine psychedelic therapy (KPT): a review of the results of ten years of research.J Psychoactive Drugs 1997; 29:165-183.
Climate bias? 19 November 1998
Gregory Rose, post-doc research staff SUNY@Stony Brook Send response to journal: Re: Climate bias?	To whom it may concern, I don't think you have fully considered the test subjects living enviornment before going on to examine the route causes of their suicides. It is common fact that humans living in environments deviod of sunlight are far more likely to commit suicide than their human counterparts in other climates. Why did you choose test subjects living in Sweden of all places to do your research? Before you make assumptions dealing with embryonic memory maybe you should do a little anthropological research first.
No climate bias 20 November 1998
Bertil Jacobson Send response to journal: Re: No climate bias	Biological siblings were used as matched controls, and they were likely exposed to the same amount of sunshine as the cases.
Obstetric care and proneness of offspring to suicide as adults: case 20 November 1998
Ivan Buzov Send response to journal: Re: Obstetric care and proneness of offspring to suicide as adults: case	EDITOR–Even before Jacobson and Bygdeman related obstetric care and proneness of offspring to suicide as adults (1), Jacobson et al (2) wrote that the “notion that a traumatic birth is of importance for suicide proneness is not new “. They attributed the origin of the term “trauma of birth” to psychoanalyst O. Rank. I want to point that S. Freud in 1909 edition of his book “The Interpretation of Dreams” added to a footnote: “Moreover, the act of birth is the first experience of anxiety, and thus the source and prototype of the affect of anxiety” (3). Also, eight years later, Freud (4) wrote how a gynaecologist told him what had happened at the examination for midwives. When a candidate was asked about meconium in the amniotic water at birth, she replied that ‘it means the child’s frightened’. Winicott (5) in 1948 published a number of ideas which can corroborate the Jacobson and Bygdeman conclusion. I cite only one :”…(trauma of birth) means a temporary loss of identity.” He believed that this provided a basis for “…even a congenital (but not inherited) hopelessness in respect of the attainment of a personal life.” Also, already in 1942, a British gynaecologist G. Read (cf. 5) also believed that psychology of an individual could be studied at the time of birth, and that the experiences at this early time are significant. Ivan Buzov, psychiatrist KBC-KZPM, Kispaticeva 12, Zagreb, Croatia 1 Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: case-control study. BMJ 1998;317:1346-9.(14 November) 2 Jacobson B, Eklund G, Linnarsson D, Sedvall G, Valverius M. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987;76:364-371. 3 Freud S. 1900. The interpretation of dreams. London: The Hogarth Press, 1953, p. 400. 4 Freud S. 1917. Introductory lectures on psycho-analysis. Part: III.London: The Hogarth Press, 1963, p. 397. 5 Winnicott DW. 1949. Birth memories, birth trauma, and anxiety. In: Winnicott DW. Through pediatrics to psycho-analysis. London: The Hogarth Press, 1975. p. 174-93. Competing interest: None
Birth trauma and suicidal ideation in psychotherapy 23 November 1998
Olavi Noronen Private practice Send response to journal: Re: Birth trauma and suicidal ideation in psychotherapy	EDITOR - Being a therapist, and having no experience on scientific research, I would like to add some words on the discussion. During last twentyfive years I have used Gestalt therapy, transpersonal psychotherapy, awareness and encountering techniques. In those techniques a client is not pushed to any assumed experience. In individual therapy and in group therapy, as well as in therapy workshops, I have witnessed hundreds of times how people emotionally re- experience their birth trauma. Finally I started to feel a push to put my experience forward in a book. It was published in Finnish in 1996. In the 12th chapter I wrote on birth trauma and it's after effects on the suicidal ideation in adults. We are now translating the book into English, and the following text is by the translator, quoted from the 12th chapter (Suicide Theories): ***The perinatal matrix influencing suicidal behaviour is as follows. First the child has an experience of paradisiacal life. Gradually he starts feeling bad and anxious. The anxiety increases and continues - there is no end to it. Then pressure starts to be felt from all sides. The pain becomes infernal. "I am no longer loved". "I am hated"." It hurts". "This is horrible". The pressure increases. Everything turns black. The child is unaware of losing consciousness. By then he is already out of the womb. He thinks he is dying. Merciful darkness descends over the pain. No more squeezing. No longer horror. No more eternal suffering. The child has had his first concrete experience of death as a liberator from suffering. This is the "death drive", desire to die that is related to suicide. When death has already once freed a person from suffering, why would it not work again? I have so much experience in the connection between suicidal desire and loss of consciousness at birth that I recommend suicide researchers to study the issue.*** Shortly, in my clinical experience I have seen that there are many roots for suicidal ideation in adults, and a near-death experience in birth is clearly one of them. From the research article I personally find that the researchers have carefully approached the issue.
VIOLENT SUICIDES AND PERINATAL EVENTS 26 November 1998
Michel Odent Send response to journal: Re: VIOLENT SUICIDES AND PERINATAL EVENTS	B. Jacobson and M. Bygdeman found that men who commited suicide by violent means were more likely to have had birth complications and high birth "trauma scores".(1) The hypothesis of a cause and effect relationship may be tested via multiple complementary perspectives, including a comparative study of the fluctuations of suicide rates in different countries. Let us recall that according to a BMJ "suicide round-up" (2), the rate of young suicides is rising in most countries ....except the Netherlands. It is well known that in the Netherlands the organisation of obstetrics and midwifery is unique. References. 1. Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: case-control study. BMJ 1998; 317:1346-9. 2. Suicide Round-up. BMJ 1994; 308:7-11. --
Communication in social and family contexts is more important than birth trauma 26 November 1998
Martin Anderson Send response to journal: Re: Communication in social and family contexts is more important than birth trauma	EDITOR-Jacobson and Bygdeman’s study into obstetric care and adult suicide considers the link between birth trauma and the subsequent risk of male suicide but has neglected other major research in the field of adolescent suicidal behaviour (1). Appleby’s editorial response to thepaper was absolutely correct in pointing out that the findings of the study would attract most attention by concluding that complications during delivery is likely to be linked to violent suicide in later life (2). I tend to agree with Professor Appleby’s point about the weakness of this evidence as support for the suggestion that suicide by hanging is connected to a forceps delivery. I agree less with his main point that the link in this study is more likely to be associated with ‘mental illness’. My reason(s) for this view arises from research in the field of adolescent suicide. Jacobson and Bygdeman pick up on this in the final two paragraphs of their paper, but more use of this research is needed if this study is to provide evidence for provisions to reduce violent suicide in adults. One of the most important factors is what happens to people during adolescence, and in particular what can be said about the family life of young people who attempt suicide. Kerfoot et al have provided some of the most influential work in this area, basing their work on the knowledge that many children and adolescents who attempt suicide live in families where there is disturbed communication (3). This is seen as such an important factor that a treatment package has been developed for work with families. Indeed, this is an issue that has to be raised as a counter reaction to Jacobson and Bygdeman’s findings, but also to Professor Appleby’s extension to the debate. As Appleby concludes ‘the road to self destruction is long’, it is long but is also complex. Mental illness may well be part of violent suicide (there is no question of that), yet it is likely that a persons immediate environment and social context is of more importance in the relationship. Kerfoot et al provide evidence for depression as a risk factor in young people who take overdoses, and again family dysfunction is seen as a more relevant factor in terms of service provisions for reducing suicide (4). The issue of communication within the social and family contexts is pivotal in my argument here. Suicidal behaviour needs to be recognised as a form of communication in its own right. A suicidal act, as a response to a breakdown in communication in another part of the individual’s life, is the ultimate response. This has been a key part of other theoretical development in this subject (5). Trying to understand such an individuals circumstances will tell us more about how to care for these people, but also about how to prevent the disaster of violent suicide. JacobsonB, and Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: case control study BMJ 1998; 317: 1346-9 ApplebyL. Violent suicide and obstetric complications The link is mental illness BMJ 1998; 317: 1333-4 KerfootM, Harrington R, and Dyer E. Brief home-based intervention with young suicide attempters and their families Journal of Adolescence 1995; 18, 557-568. KerfootM, Dyer E Harrington E, Woodham A, and Harrington R. Correlates and Short-term Course of Self- poisoning in Adolescents British Journal of Psychiatry 1996; 168, 38-42. AldridgeD. Family interaction and suicidal behaviour: a brief review Journal of Family Therapy 1984; 6 309-322. Martin Anderson Lecturer in Mental Health School of Nursing, Postgraduate Division Faculty of Medicine and Health Sciences University of Nottingham, NG7 2UH
Details of birth are indeed remembered 26 November 1998
N B Vissel, retired Send response to journal: Re: Details of birth are indeed remembered	I would like to draw attention to the work of Stanislaus Grof (1-3). Reviewing the contents of the altered states of consciousness that he invoked through a special breathing technique he found that these experiences could be viewed as a re-enactment of the specific details of a persons birth. Moreover he postulated that the way in wich a person acts in adult live follows the patterns of that persons birth details. A sallient example would be the person who has been extracted by forceps or vacuum. These people have a 'habit' of starting on a project with great enthousiasm and than, towards completion all energy disappears and someone else has to help them to complet the activity. The famous Wimbledon final of Jana Novotna suggests that she has been born with a low forceps. Anecdotal evidence is abundantly documented by those who facilitate these experiences. It is not clear 'where' the memories are stored. People generally donot find exact images of their birth as would be expected. The child has no frame of reference for what it is 'seeing', but the essence of the process is indeed remembered. moreover, it seems that the only way to change this pattern of repeating the birth pattern is through reliving it in the way described. Stan Grof has documented a great number of sessions . Introduction of the method on a wider scale could be of benefit to many. References: 1) Grof S.Beyond the Brain:Birth, Death, and Transcendence in Psychotherapy.1985, State University of New York, Albany 2) Grof S. The Adventure of Self-Discovery Dimensions of consciousness and new perspectives in psychotherapy and inner exploration 1988, State University of New York, Albany 3) Grof S et al.The Holotropic Mind The three levels of human consciousness and how they shape our lives 1992, HarperSanFrancisco, San Francisco
Infant-maternal bond effect 30 November 1998
Janet Menage, GP Bulkington, Warwickshire Send response to journal: Re: Infant-maternal bond effect	Professors Appleby, Jacobson and Bygdeman may well be right that the traumatic effect of obstetric procedures on the new-born infant predisposes the child to mental illness and suicide (1). However, of equal significance may be the effect on the baby of his mother’s mental state after the birth, due to her trauma as a result of obstetric technology and style. In my research (2), I demonstrated that some women develop Post- traumatic stress disorder (PTSD) after obstetric procedures, particularly where the woman felt powerless, felt that she had not given consent, where she had little information, where the doctor/midwife seemed unsympathetic and where she was in physical pain. The more invasive or urgent the procedure, the less likely are the wishes and views of the patient to be heeded. Other researchers have found negative emotional reactions in mothers after childbirth, associated with loss of control and lack of information (3). Indeed, some women feel violated by vaginal procedures (4). Depression in later life is known to be associated with significant losses in childhood and where infant-maternal bonding is disrupted due to maternal psychopathology, the child suffers a loss, the effects of which may not be remediable. Birthing mothers sometimes feel dehumanised and patronised by the system. By gving them a voice, we indirectly also support the traumatised babies. References: (1) Appleby,L. (1998) Violent suicide and obstetric complications. BMJ. No.7169. (2) Menage, J. (1993) Post-traumatic stress disorder in women who have undergone obstetric and/or gynaecological procedures. Journal of Reproductive and Infant Psychology. Vol.11,p221-228 (3) Green,J.M.(1990) Who is unhappy after childbirth? Antenatal and postpartum correlates from a prospective study. Journal of Reproductive and Infant Psychology. Vol.8,175-183 (4) Kitzinger,S.(1992) Birth and violence against women. In: Roberts,H.(ed) Women’s Health Matters, Routledge, London
Prospective vs retrospective study 30 November 1998
Michael Gdalevich, epidemiologist Yahalom 17 st, Kiriat Ekron 70500, ISRAEL Send response to journal: Re: Prospective vs retrospective study	Jacobson and Bygdeman classify their study as a prospective case- control design.(1) One of the main features of a prospective study is the ability to calculate and compare incidence rates in groups that differ in exposure levels.(2) It involves analysis in which information about the study factor is known for all subjects at the beginning of the follow up period.(3) In Jacobson and Bygdeman study a group of subjects who committed violent suicide was compared to their siblings for presence of perinatal factors, such as birth trauma, opiate treatment, etc. Therefore, the methodology described in this paper appears to be a clear case of a retrospective case-control analysis, which involves a backward design that compares a group of cases with one or more groups of non cases with respect to previous “exposure” levels.(3) No inception cohort was assembled. The main outcomes measures of this study are termed relative risks, estimated by the odds ratios. However, the calculation of risk is analogous to the calculation of incidence rate, where the numerator and denominator are the number of events that occur in a defined period (suicides) and the population at risk of experiencing the event during this period, respectively.(2) If the odds ratio is interpreted as a relative risk it will always overstate any effect size (4), in this case not by much as the event under study is rare. 1 Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: case-control study. BMJ 1998;317:1346-9. 2 Last JM. A dictionary of epidemiology. Oxford University Press 1995. 3 Kleinbaum DG, Kupper LL, Morgenstern H. Typology of observational study designs. In Epidemiologic Research. Van Nostrand Reinhold Company Inc. 1982:63-93. 4 Davies HTO, Crombie IK, Tavakoli M. When can odds ratios mislead? BMJ 1998;316:989-91. Michael Gdalevich, MD, MPH
Obstetric care and proneness of offspring to suicide as adults: case-control study 1 December 1998
Riadh T Abed Send response to journal: Re: Obstetric care and proneness of offspring to suicide as adults: case-control study	EDITOR- Jacobson and Bygdeman (1) show a fundamental misunderstanding of the concept of imprinting. They state that they had based their hypothesis on the assumption that through a process of imprinting individuals who had suffered birth trauma will show an increased risk of violent suicide because of a presumed subconscious tendency to recreate the the sensation experienced at birth. Imprinting is an ethological term that refers to 'a species specific type of learning that occurs within a limited period of time early in the life of an organism and is relatively unmodifiable thereafter' (2). In other words imprinting is a species specific evolved adaptation that has been shaped by natural selection to serve a certain survival or reproductive function for the organism. Are the authors suggesting that neural systems have evolved within humans for the express purpose of recreating the painful experiences endured during birth? What survival or reproductive value could such a system have had and what other benefits could such a trait have served for its bearers? Imprinting is mediated through neuro-biological systems that have evolved because of their contribution to the organisms' inclusive fitness (3) and do not arise and spread randomly. Also apart from the clearly maladaptive nature of the behaviour under study (i.e. violent self- destructive behaviour) it would be difficult to make a credible case for any adaptation having arisen as a consequence of birth trauma as in the original human environment such trauma must have been associated with physical damage, reduced survival and therefore reduced reproduction. Therefore while I agree with the reservations expressed in the editorial by Appleby (4) my objections to the use of the concept of imprinting are more fundamental. The use of the term 'imprinting' can only be justified if the authors can present arguments and evidence to show that self-destructive behaviour following birth trauma is a specific behavioural strategy that could have arisen through natural selection by contributing to inclusive fitness. Riadh T.Abed Consultant Psychiatrist and Hon. Clinical Lecturer, Rotherham District General Hospital, Rotherham S60 2UD 1 Jacobson B., Bygdeman M., Obstetric care and proneness of offspring to suicide as adults: case control study. BMJ 1998; 317:1346-9. 2 Hilgard, E.R., Atkinson R.L., Atkinson R.C., Introduction to psychology. 7th ed. New York:Harcourt Brace Janovich, 1979. 3 Hamilton W.D., The genetical evolution of social behaviour, I & II. Journal of Theoretical Biology, 1964;7:1-52. 4 Appleby L., Violent suicide and obstetric complications. BMJ 1998;317:1333-4.
Applicability of ecological data 3 December 1998
Bertil Jacobson Send response to journal: Re: Applicability of ecological data	Dr Michel Odent brings up an important issue. He suggests that ecological data should be used for testing a cause and effect relationship by comparing suicide rates in different countries. Such studies on aggregated data (for example whole populations in countries) have important applications but also limitations. The origin of the present study was a serendipitous finding twenty years ago of a remarkable regularity in the suicide rates of five-year birth cohorts in the United States during 1937-75. After an extensive search considering some thirty variables, of which eleven were thoroughly tested, I found a possible explanation. Path analysis showed for example that the suicide rate 1971-75 for ages 15-24 in the 48 contiguous states was significantly correlated only with three variables during relevant periods for the studied birth cohort: parental alcoholism, broken homes and birth injury. Variables such as income, poverty, unemployment, perinatal 'asphyxia' and congenital malformations were not significant. Of the three significant variables birth injury had the largest path coefficient. This led to the hypothesis, which could not be rejected on the basis of the data. Ecological data are useful for developing hypotheses. But an association observed between variables at an aggregate level (states in this case) does not necessarily represent the association that exists at an individual level. Not reckoning this difference is generally referred to as the 'ecological fallacy' (1). Hence, suicide rates in whole countries or states might be associated with certain obstetric practices without having any relevance for the individual cases. It is necessary to make studies on individual cases to reach any conclusion about causalities. Dr Odent rightly draws attention, however, to the interesting circumstance that the suicide rate is exceptionally low in the Netherlands and that the organisation of obstetrics and midwifery is unique. This observation certainly warrants further studies, particularly at the individual level. Reference 1. Last JM. A dictionary of Epidemiology. Oxford University Press 1995
Purpose of study 3 December 1998
Bertil Jacobson Send response to journal: Re: Purpose of study	We found that the attribution from a traumatic birth to violent suicide was merely 17% (95% confidence interval 5 to 32). This leaves room for many other causes, and there is no contradiction between our results and the view that other factors might be more important, such as mental illness (Professor Louis Appleby) and disturbed communication (Dr Martin Anderson). These two factors are, however, irrelevant to this study. The cause of an event must precede it, and the subjects were born before they got ill. The purpose of our study was to investigate if painful perinatal trauma were related to violent suicide, and also, as a practical consequence, if obstetric practices might be of importance. The focus is on perinatal events; not on any later links. A disturbed infant-maternal bond mechanism (GP Janet Menage) is indeed relevant, which we could only touch upon in our article. But bringing in mental illness and disturbed communication seem only to confuse the issue. Besides, the fact that schizophrenics are prone to suicide is not an explanation why they kill themselves by violent means; why not poison? Relevant issues to discuss would instead have been for example: 1. Is there an omnipotent prenatal or natal factor that causes a multitude of disparate perinatal effects (meconium, breech presentations, altered obstetric and neonatal practices) and at the same time, through a delayed effect, causes the subject as an adult to be prone to violent suicide? 2. Is there a non-causal explanation to the disturbing fact that changed obstetric practices are associated with a subsequent increase in the rate of violent suicide? 3.Why is opiate medication to mothers associated with a decreased risk for violent suicide in offspring, whereas the same medication is associated with an increased risk for subsequent drug addition? 4. Why have those who poison themselves not had a traumatic birth? The possibility that particular types of perinatal conditions might be of some relevance for particular types of adult behaviour should not be denied.
Birth trauma - a challenge for memory and trauma research 7 December 1998
Olavi Noronen, Private practice Send response to journal: Re: Birth trauma - a challenge for memory and trauma research	N.B. Vissel drew attention to the work of Stanislav Grof. For the academic scientific community Grof has not much to offer, because the interest lays on hard statistical data. Before I became familiar with Grof's (1, 2) COEX-theory (COEX = condensed experiences), I had come to realize as a therapist that experiences with similar emotional content are located in close connection with each other in the subconscious, as if intertwined or in layers. In a therapy session this means that experiences from different ages and occasions are activated in sequence, but their emotional content and structure resemble each other. In every COEX there is a core experience around which the later experiences constellate. The deepest parts of COEX are usually the most intense ones, originating from early childhood or perinatal phase with the superficial parts relating to more recent periods of life up till the present. In my opinion it is exactly when the present resembles the past that the emotional charges of COEXs and unfinished business are agitated. Since late 1970's I have only just recently come across similar ideas on the Internet in an electronic journal called Traumatology where Thomas, Laurance, Jacobs and Nadel (3) write how emotional experiences in a case of trauma shattered into fragments due to certain chemical processes. They continue: "Given current knowledge, the most parsimonious way to think of emotional memory fragments is that they belong to a pool (or population) of relatively independent elements," and later: "A pool of emotional memories might consist of many similar fragments (little variability), many different fragments (wide variability), and may be normally distributed, skewed, or multimodal." From my experience I have seen how a birth trauma can be a core of a "suicidal COEX", an in addition to it there can be mental illness (Louis Appleby), infant-maternal bond (Janet Menage) disturbed communication (Martin Anderson) and other childhood traumas, of which, incest is remarkable. I saw the research of Jacobson and Bygdeman being focused on birth trauma, which has been widely ignored, but not denying the other factors. References: 1) Grof, Stanislav: Realms of The Human Unconscious. The Viking Press. New York 1975. 2) Grof, Stanislav: Beyond The Brain; Birth, Death and Transcendence in Psychotherapy. State University of New York Press 1985. 3) Thomas, Kevin G. F., Laurance, Holly E., Jacobs, W. Jake and Nadel, Lynn: On the Veracity and Variability of Traumatic Memory. Traumatology, 2:2. http://rdz.stjohns.edu:80/trauma/art3v2i2.html
The imprinting hypothesis 9 December 1998
Bertil Jacobson Send response to journal: Re: The imprinting hypothesis	Riadh T. Abed shows a ‘fundamental misunderstanding of the concept of imprinting’ (1,2,3). To serve the purpose of survival of a species, the imprinting stimulus must be of the correct kind. In countless experiments by ethologists many species have been imprinted by unnatural stimuli resulting in adult non-beneficial behaviour. Konrad Lorenz’s male ducklings imprinted on his shoes when sexually mature preferred the shoes to available female ducks (4). No duck-shoe bastards were born! Besides, natural imprinting does not always secure survival as demonstrated by extinct species. Whatever imprinting mechanism helped them to develop, it was not good enough in the long run. During the cold war Homo sapiens might also have been extinct if all hydrogen bombs were detonated. It would not be an anomaly if the human species were equipped with a merely temporarily beneficial imprinting mechanism. Is it inappropriate to speculate that Homo sapiens made it for now because of an appreciation of violence and risk-taking by killing other competing hominids? The history of mankind is filled with violence (gladiators, Aztec sacrifices, crusades). The number of murders on television shows an obsession with violence. Our violent trait must have some origin. From a registry study of birth parameters involving a comparison of 9794 accident-prone subjects (multiple hospitalisations) with their 15435 siblings (no hospitalisations) we have reason to believe a traumatic birth might be of importance for various types of violent behaviour and risk- taking. Suicide should merely be seen as an atypical extreme possibly caused by unfit imprinting. The imprinting hypothesis is emotionally disturbing. But this is not a scientific reason for rejecting it. See our response to Professor Appleby’s editorial and (5)! Early in our studies we could not systematise apparently disparate observations without assuming the existence of a mechanism, that (i) engraved memories during the perinatal period (ii) had a greater effect on males than females (male dominance of drug addiction, suicide), (iii) resulted in different types of behaviour depending on perinatal circumstances (pain, administered drugs), (iv) was relatively unmodifiable (difficulty treating drug addicts). Whether or not to call this mechanism imprinting is a semantic question. The hypothesis has allowed us to predict outcomes that could not have been done without it (e.g. opiate effect on suicide proneness). If another single hypothesis were equally suitable, we would gladly abandon any thought of imprinting. In judging our study emotional reactions or semantics are unessential; the results are. References 1. Bateson PPG. The characteristics and context of imprinting. Biol.Rev. 1966;41:177-220. 2. Salzen EA. Imprinting in Birds and Primates. Behaviour 1967;28:232-254. 3. Bateson PPG. The development of social attachments in birds and man. Adv Sci 1969;25:279-288. 4. Lorenz K. Der Kumpan in der Umwelt des Vogels. J Ornithology 1935;83:137-213 and 289-413. 5. Popper KR. The logic of scientific discovery. London: Unwin Hyman 1980.
Imprinting revisited 15 December 1998
Riadh T Abed Send response to journal: Re: Imprinting revisited	EDITOR- Jacobson is no nearer to a correct usage of the concept of imprinting despite his recent reply. It is an inescapable fact that imprinting as a species specific developmental event will always have a speicific survival or reproductive purpose (i.e. a 'function'). However, aberrant outcomes can and do occur as Jacobson points out. This, however, is no different from any other developmental process that can go wrong when the process is disrupted by damaging events or crucial developmental stages fail to take place. If the authors are now suggesting that birth trauma is a process of 'aberrant imprinting' analogous to Lorenz's experiment with male ducklings (which was not suggested in the original article) they would still require to explain what exactly is the putative process of 'natural' imprinting that they claim has been disrupted (which the original article and the later reply failed to explain). If they cannot do so there would be no justification for continuing to suggest that a process of imprinting is involved. If correctly employed the concept of imprinting would claim to identify a fundamental developmental milestone in a given species and the matter is therefore not simply 'a semantic question'. Riadh T. Abed Consultant Psychiatrist and Hon. Clinical Lecturer, Rotherham Distict General Hospital, Moorgate Road, Rotherham S60 2UD.
Correction and comments 9 January 1999
Bertil Jacobson Send response to journal: Re: Correction and comments	Dr Michael Gdalevich is correct in pointing out the unsuitability of the term 'prospective study'. In the submitted manuscript we actually used the term 'historic prospective study', which others have found appropriate when investigating long term effects of already recorded data. In the editing process the word historic was removed. I am at fault not insisting on the reinsertion of the word. To solve the semantic question one could use 'mal-imprinting', coined by Desmond Morris, for violent suicide if caused by a perinatal trauma and keep 'imprinting' for the evolutionary presumably advantageous process by which such trauma enhances human male violence. This is not, however, in accordance with most ethologists, who do not distinguish between beneficial or harmful effects of imprinting. Something seems to be missing in the discussion. After all, the first two words in our title are 'Obstetric care'. With the exception of Dr Michel Odent no obstetrician seems to have taken the suggestion seriously that perinatal trauma elicited by obstetric practices might have resulted in increased suicide rates. Nor that obstetric medication might result in drug addiction in the offspring as suggested in our 1990 study. The medical community at large seems to have regressed to a denial on a grand scale. Other studies are urgently needed with similar groups of subjects. Then the importance of using siblings as controls cannot be emphasized enough. Many other pitfalls should also be avoided, and those considering similar studies might want to request an extensive memorandum from the corresponding author with a detailed description of our method of analysis.
Mehodological flaws cast doubt on conclusions 30 January 1999
David Gunnell Send response to journal: Re: Mehodological flaws cast doubt on conclusions	Dear Editor Jacobson and Bygdeman present intriguing data suggesting that suicide risk is influenced by birth trauma and may be associated with recent rises in youth suicides.1 In our view there are serious deficiencies in both the design and analysis of this case-control study. These deficiencies should be addressed before the findings of this study are accepted or possible mechanisms considered. The significant findings in Jacobson's paper are confined to a sub-group of males who committed suicide using violent methods, were born and died in the catchment area of the Forensic Medicine Department in Stockholm and had siblings with available birth records. Assuming there were roughly equal proportions of violent and non-violent suicides over the study period the 175 males in whom the significant associations were found represent less than a quarter of all suicides. Furthermore one third of the period, and presumably one third of the cases included in this analysis, overlaps with those in an earlier report which covered 1978-84.2 In this earlier study strongly significant associations were reported between suicide risk and perinatal factors. Inclusion of these cases is likely to influence the results of this larger investigation. In addition, the authors suggestion that the phenomenon they observe is restricted to violent suicides might be tested by presenting separate risk estimates for violent and non-suicides and testing for heterogeneity. In case-control studies controls should be chosen from the source population that gave rise to the cases.4 In neither Jacobson's, nor Salk et als3 studies were attempts made to identify whether the chosen controls were still resident within the study catchment area. Migration may be associated with socioeconomic and health related factors which in turn may confound the observed associations. In addition, Jacobson and Bygdeman's analytical approach to the assessment of confounding indicates a misunderstanding. Confounding factors are those that are associated with both the disease and the exposure under investigation. The statistical significance (or its lack) of a factor as a predictor of the disease does not justify inclusion (or exclusion) of the factor in the multivariable model. The important issue is whether inclusion of the factor in the multivariable models influences the strength of the observed association.4 Factors that were likely to be associated with both suicide risk and obstetric practice, such as year of birth, were not included in the final model and so risk estimates may still be biased. The epidemiology of suicide is complex and it seems unlikely that the factors investigated in Jacobson's study are risk factors for such a high proportion of suicides. We suggest that further analysis of these data is required. Analyses should include violent and non-violent suicides and proper adjustment for confounding factors. The years included in the earlier study should be excluded as should those controls who no longer reside in the study area. Yours sincerely David Gunnell Senior Lecturer in Epidemiology and Public Health Medicine Department of Social Medicine, Bristol University Andy Ness Senior Lecturer in Epidemiology Department of Social Medicine, Bristol University Elise Whitley Lecturer in Medical Statistics Department of Social Medicine, Bristol University 1. Jacobson B, Bygdeman M. Obstetric care and proneness of offspring to suicide as adults: a case-control study. BMJ 1998;317:1346-1349 2. Jacobson B, Eklund G, Hamberger L, Linnarsson D, Sedvall G, Valverius M. Perinatal origin of adult self-destructive behavior. Acta Psychiatr Scand 1987;76:364-371 3. Salk L, Lipsitt LP, Sturner WQ, Reilly BM, Levat RH. Relationship of maternal and perinatal conditions to eventual adolescent suicide. Lancet 1985 (I) 624-627 4. Rothman KJ, Greenland S. Modern Epidemiology. Lippincott-Raven, Philadelphia 1998.
No methodological flaws 7 February 1999
Bertil Jacobson Send response to journal: Re: No methodological flaws	Gunnell et al raise four interesting questions: CASES: Our 1987 study indicated that suicides by violent means were closely associated with birth trauma. Then subjects from the general population were used as controls, which made it impossible to control for genetic, socio-economic and demographic factors. Could such factors have made certain women more prone to difficult deliveries and at the same time also likely giving birth to subjects with an increased proneness for violent suicide? To answer this question the controls from the general population had to be replaced with biological siblings. Since we wanted to check if our previous result was an artifact due to such improper control for confounding, we had no reason to exclude the old cases. However, in a regression of 177 cases acquired after 1984 with their 290 siblings, thus excluding old cases, maternal age and sex do not quite reach significance. But if left in the regression odds ratios are for one opiate dose OR=0.45 (0.25—0.80, p=0.007), and for a single birth trauma for women OR=0.87 (p=0.76) and for men OR=2.74 (1.54—4.9, p=0.0006) consistent with earlier results. Recalculated attributable percentages would be larger than before. No flaw. NON-VIOLENT SUICIDES: Since the purpose was to test if birth trauma was associated with violent suicide, we had no reason to include non- violent suicides that previously had been found to have normal births. No flaw. RESIDENTIAL AREA: No factor after birth including migration can influence perinatal events. Admittedly, migration might have increased the risk of erroneously including a control that actually was a violent suicide elsewhere (three controls committing violent suicide were excluded). But suicides among siblings are rare and the possible error small. YEAR OF BIRTH: Forcing year of birth into the regression including 242/403 cases/siblings, the odds ratio for one opiate dose merely changes from OR=0.51 (p=0.007) to 0.52 (p=0.012), and the odds ratio for a single birth trauma for men increases from OR=2.21 (p=0.002) to 2.32 (p=0.0009). We regard it as methodologically incorrect to include a non-significant variable into the regression when it enhances one of the studied risk factors. No flaw. Besides, anyone experienced in matched logistic regression techniques could not expect year of birth to be significant, since there was only a slight average difference between cases and siblings (0.08 year, that is, 0.2% of the period 1945-80). This demonstrates the advantage of MATCHING each case with its own sibling(s).
Migration as a putative confounder 26 February 1999
Bertil Jacobson Send response to journal: Re: Migration as a putative confounder	We are most grateful to Drs. Gunnell, Ness and Whitley for pointing out that migration of siblings could be relevant (1). Originally when subject's birth hospitals were determined, complete personal code numbers were usually also supplied but not for all siblings. These random omissions, depending on the habit of the particular employee answering our requests at the parishes, made it presently difficult to determine the residency for 81 (20.1%) of the 403 siblings. Of the 322 that can now easily be identified, 2 (0.6%) had died, for 3 (0.9%) data are unavailable because of protected identity, 45 (14.0%) have moved outside and 272 (84.5 %) are now living within the Stockholm area. In a logistic regression of 317 siblings with migration as the dependent variable, opiate administration was non-significant. The trauma score gave odds ratios in the range 1.8 to 2.2 (p=0.04 to 0.09) depending on inclusion of other variables such as maternal age, year of birth and civil status. This means that siblings with birth trauma have tended to move away from Stockholm. A new conditional logistic regression of remaining 178 suicides with 272 non-migrant siblings as matched controls was made as suggested by Gunnell et. al. including year of birth, maternal age, sex, opiate administration and the trauma score. It is of interest to compare new results with those published in our article (old). One single birth trauma gives an odds ratio for men 3.3 (1.7 to 6.3, p=0.0003) as compared to old 2.2 (1.3 to 3.6, p=0.002). A single dose of opiates given to mothers during delivery yields an odds ratio 0.39 (0.21 to 0.73, p=0.004) as compared to old 0.51 (0.31 to 0.83, p=0.007). Perinatal trauma and absence of opiates entered as indicator variables result in odds ratios 3.7 and 2.2, corresponding to attributable percentages of 21% (old 17%) and 49% (old 43%). New estimates are likely somewhat inflated, since present migration data had to be used; not data when siblings had the same age as subject committing suicide, that is, when they had been equally 'exposed' to suicide risk having lived the same number of years as subject. Thus Gunnell et. al. are correct in pointing out that migration of siblings should have been considered. But, contrary to what they suggest, the attributable percentages originally given in our article were not exaggerated but conservative estimates. 1. Jones ME, Swerdlow AJ. Bias caused by migration in case-control studies of prenatal risk factors for childhood and adult diseases. Am J Epidemiol 1996;143:823-31.
Perinatal disorders and suicide: is there a link? 29 June 1999
Gaia Meneghel, Junior Research Fellow University of Padua, Italy Send response to journal: Re: Perinatal disorders and suicide: is there a link?	EDITOR - Suicide is multidetermined, hence more comprehensive understanding of the phenomenon warrants research into many and different areas. In the 1980s, several authors, exploring biological aspects of self-harm, considered the possible association between perinatal disorders and suicidal behaviour, arousing much curiosity and interest (1,2,3). These researchers observed a higher incidence of invasive obstetric procedures at birth in suicides than in controls, advancing the hypothesis that these interventions were cause for brain lesions that might account for subsequent self-destructive tendencies in adulthood. More recently, the Swedes Jacobson & Bygdeman (4) analysed obstetric reports on the births of 242 suicides who used violent methods, comparing them with the reports of their respective 403 healthy biological siblings, born over the same period and at the same hospitals. Obstetric complications and fetal distress were significantly higher among suicides. Complications included atypical presentation, presence of meconium in the amniotic fluid, assisted delivery and neonatal resuscitation. Doses of opiates administered to mothers in the 24 hours prior to delivery were lower in cases than in controls. Although we found this study very interesting, we do not agree with the authors' interpretation of the results. On the basis of their findings and according to imprinting theory, they conclude that subjects who take their lives by violent methods unconsciously recreate the pain and trauma endured at birth. Suicide and violent suicide are postulated to be more frequent among men because animal models have shown that testosterone promotes the imprinting mechanism (4). Besides the fact that this interpretation does not explain violent female suicide and suicide in either gender by soft methods, we find it hard to imagine how the suicidal act, however inconscious, can recreate traumatic perinatal sensations. The points of convergence between the two situations are not clear and there is no mention of the correlation between perinatal distress and other important suicide risk factors. Birth is in itself an extremely stressful event and a source of serious difficulty for every fetus. It is a passage from darkness to light, warmth to coldness, silence to noise, fetal to pulmonary respiration. If complete credit were given to the conclusions advanced by Jacobson & Bydgeman, anyone would in fact be exposed to suicide risk, without substantial differences. Some years ago, we conducted a study whose objective was to assess whether suicides and attempted suicides were more frequent among subjects who had experienced perinatal complications at birth (5). We analysed 4322 subjects (53% males) born at Padua General Hospital, Italy, between 1957 and 1969 and subsequently admitted to the Neonatology Ward for perinatal disorders. The most frequent pathologies were fetal asphyxia and neonatal jaundice. With the help of the data bank of Padua University Suicidology Unit, we observed that between 1980 and 1989, 21 of the 4322 individuals (9 males and 12 females) had manifested suicidal behaviour in adulthood. The suicide rate for the test sample did not differ from the general population rate. Surprisingly, however, 17 of the 21 cases (80%) found positive for perinatal distress and suicidal behaviour were affected by a psychiatric disorder: major depression in 6 cases, drug dependency in 5 cases, schizophrenia in 4 cases, 1 case of personality disorder and 1 case of mental retardation. To assess the reliability of our results, we analysed all deaths by suicide occurring over the same period (1980-1989) in Padua for the same age groups (1957-1969). On reconstruction of the clinical history of 42 subjects, we noted that dystocia was reported in only 4 cases, born outside of Padua. Of these, 3 suffered from a psychotic disorder and 1 was a drug addict. The results of our study conducted on the Italian population differed substantially from the Swedish findings. In Italy no direct correlation emerged between perinatal complications and suicide and there was no "suicidal imprinting". We deem it insufficient to hypothesize that the difference is the result of low testosterone levels in Italian males (quite apart from the fact that it clashes with the traditional Latin lover image reserved for Italian men!). Since the Swedish suicide rate is double the Italian rate (15.3 vs 7.9/100,000) and there is no marked disparity between the professional skills of Swedish and Italian obstetricians, we believe that other factors, primarily the marked cultural differences between the two countries, account for the difference in suicidal behaviours in the two countries. The data supporting a direct association between perinatal disorders and suicidal behaviour remain inconsistent and require further convincing evidence. On the basis of our personal experience, we believe that if a link does exist between perinatal disorders and suicidal behaviour, it resides in mental illness. The psychic disorder in this case acts as a mediator and we agree in this respect with the arguments advanced by Appleby (6). As previously hyposthesized, and partly demonstrated for schizophrenia and mood disorders (7,8,9,10), perinatal distress may constitute an important risk factor for psychic disorders. It may be postulated that in the still immature, developing neonatal nervous system, perinatal complications, be they asphxyia, dysmetabolism or lesion, give rise to alterations in cerebral biochemistry, predisposing the development of mental illnesses and associating them with suicide. Considering our still limited knowledge of cerebral physiopathology, it would be premature to speculate any further. The roads leading to efficient suicide prevention are currently elsewhere. Diego De Leo° M.D., Ph.D. Gaia Meneghel* M.D °Australian Institute of Suicide Research and Prevention, Griffith University, Brisbane, Australia *Who Collaborating Centre for Suicide Research and Training in Suicide Prevention, University of Padua, Italy For correspondence: Gaia Meneghel c/o Servizio di Psicogeriatria Via Vendramini, 7 35128 Padova, Italy References 1 Jacobson B, Eklund G, Hamberger L Linnarsson D et al. Perinatal origin of adul self-destructive behavior. Acta Psychiatrica Scandinavica, 4: 364-371; 1987. 2 Solomon MI & Hellon CP. Suicide and age in Alberta, Canada, 1951 to 1977.: A cohort analysis. Archives of General Psychiatry, 37: 511- 513; 1980. 3 Murphy GE & Wetzel RD. Suicide risk by birth cohort in the United States,1949 to1974. Archives of General Psychiatry, 37: 519-523; 1980. 4 Jacobson B & Bydgeman M. Obstetric care and proneness of offspring to suicide as adults: case-control study. British Medical Journal, 317 :1346-1349; 1998 5 De Leo D, Longhin N, Ormskerk SCR & Saia O. Perinatal Disorders as Antecedent of Suicidal Behavior: Lack of Convincing Evidence. In Proceeding of XVI. IASP-CONGRESS, 1-5 September, Hamburg, 1991. 6 Appleby L. Violent suicide and obstetric complications. The link is mental illness. British Medical Journal, 317 :1333-1334; 1998. 7 Hollister JM, Laing P, Mednick SA. Rhesus incompatibility as a risk factor for schizophrenia in male adults. Archives of General Psychiatry, 53: 19-24; 1996. 8 Olin SCS & Mednick SA. Risk factors of psychosis: Identifying vulnerable populations premorbidly. Schizophrenia Bulletin, 22: 223-240; 1996. 9 Van Os J, Jones P, Lewis G, Wadsworth M & Murray R. Developmental precursors of affective illness in a general population birth cohort. Archives of General Psychiatry, 54: 625-631; 1997. 10 Verdoux H, Geddes JR, Takei N, Lawrie SM, Bovet P, Eagles JK et al. Obstetric complications and age at onset in schizophrenia: an international collaborative meta-analysis of individual patient data. American journal of Psychiatry, 154: 1220-1227; 1997.