Psychogenic Death: Why Do Healthy People Give Up on Life?

Pauline Anderson

October 16, 2018

Some individuals who are exposed to extreme trauma, including prisoners of war and survivors of shipwrecks and air crashes, develop a syndrome that has been labeled "give-up-itis" (GUI). It is characterized by progressively severe demotivation that can end in inexplicable death.

Dr John Leach

Investigators led by John Leach, PhD, Extreme Environmental Medicine and Science Group, University of Portsmouth, United Kingdom, lays out what they have learned about GUI during more than 20 years of research.

Leach told Medscape Medical News that GUI is a clinical expression of mental defeat and embodies a normal coping response.

He also noted that patients with GUI typically move through five distinct stages. These include withdrawal, apathy, aboulia, psychic akinesia, and psychogenic death. The time from the first symptoms of GUI to death is about 3 weeks, he said.

"Baffling" Cases

Early in his career, while carrying out research into human behavior and performance in extreme environments, Leach studied shipwreck survivors and wondered what personality traits or other factors contributed to their survival.

Finding no clues was "baffling," he said. He then realized he was asking the wrong question; he should have been trying to determine why some individuals who are seemingly physically healthy just give up and die.

The term "give-up-itis" was coined by male prisoners of war during the Korean conflict, he reported. Women held by the Japanese in Malaysia had another term, "face the wall syndrome."

Leach said he believes patients with GUI pass through five progressive phases, which he describes in an article published online in Medical Hypotheses. These include the following:

Withdrawal: This stage is characterized by social withdrawal and diminished motivation, mood, and initiative but normal consciousness and cognitive function. Individuals in this stage can have normal behaviors, but they are slower to initiate these behaviors. The behaviors are of shorter duration than before.

Apathy: In this stage, people experience an increased lack of motivation. They have normal consciousness and cognition, although they may experience some executive dysfunction and have difficulties with working memory, planning, and maintaining goals and subgoals.

Aboulia: If not checked, the syndrome can progress to an even more severe loss of motivation that includes a dampening of emotional response, an inability to make decisions, and loss of speech initiative. In this stage, individuals are dependent on others to take actions, but if they are motivated externally, they can perform actions correctly. The lack of spontaneous mental activity and inability to concentrate was called "brain fog" by some individuals in concentration camps, said Leach. One sea survivor described it as having "a mind like mush."

Psychic akinesia: This stage is characterized by a further reduction in motivation and executive function, although consciousness and general cognitive function remain intact, as does the ability to speak. Sufferers have profound apathy; indifference to pain, thirst, or hunger; and an absence of motor or psychic initiative.

Psychogenic death: Patients in this final stage have given up on life. However, shortly before they die, there seems to be a brief recovery of motivation, executive function, and a degree of hedonia.

Leach attributes technical and other advances in neuroscience for his ability to "develop models and patterns" to create his GUI hypothesis.

Coping Mechanism

According to Leach's theoretical model, "people come to accept death" to deal with a stressful situation, Leach said. "What I think is going on here is that the brain accepts it is a coping mechanism and then initiates the normal stages of death, which we go through anyway. Death is perfectly natural."

The key factor is that the death is inexplicable. "People repeatedly say there is no need for this death, that there was nothing wrong with the person," said Leach.

If there's a coroner's report, it will often state that the cause of death is unknown, or it will state a cause that does not match the circumstances, he added.

Leach cited one case report written by a German surgeon in the 1990s. The patient had undergone surgery but considered it a failure and died within 24 hours of the operation. The autopsy indicated no reason, toxicologic, anatomic, or otherwise, for the death, and it was deemed psychogenic.

Another example involved a mountain aircraft crash. The plane had a pilot and two passengers. The pilot and one of the passengers were badly injured, but the second passenger, who was merely bruised, was found dead.

There do not appear to be any risk factors for GUI. It affects both men and women, those who are optimistic as well as those are are less optimistic, the sick and weak, as well as the healthy.

"You would think that it would be the weakest ones that would go to the wall, but you get frequent reports of people being surprised that somebody has died, because they were the stronger ones on the team," said Leach.

Children represent an exception to GUI. "I have never known it to occur in children," he said. When they die, it's of "obvious causes." He added that the youngest case he could find involved a 19-year-old soldier in World War II.

Underlying Mechanism

Leach emphasized that each of the five stages of GUI represents a pathologic condition and that patients "follow a spectrum."

This is much the same as schizophrenia. Leach noted that schizophrenia was originally thought to have different forms — simple, paranoid, and catatonic.

"It was only later on that we realized that there is only one form of schizophrenia, that these are progressive forms, and that if you can halt one form, then the more extreme forms don't appear," he said.

Leach believes that GUI behaviors may be linked to frontal-subcortical circuit dysfunction.

"Of the five frontal-subcortical circuits, the one that jumps out, and the only one that jumps out, is the anterior cingulate circuit," he said.

This circuit is implicated in several higher-level cognitive functions, including initiation and regulation of behavior, avoidance of painful emotions, and decision making.

Dysfunction in this circuit "produces circuit-specific behavior that is signature to GUI behavior," said Leach.

Also implicated is dopamine disequilibrium within this circuit. Dopamine plays a role in motivation and modulates stress reactions. In addition, Leach noted that other neurotransmitters may be involved.

He added that it's possible to recover from even extreme stages of GUI through medications and/or external motivators.

Psychodynamic, Biological Factors

Commenting on the article for Medscape Medical News, Anthony T. Ng, MD, chief medical officer, Acadia Hospital, Bangor, Maine, who is also chief of the Psychiatry Service at Eastern Maine Medical Center and is past chair of the disaster committee of the American Psychiatric Association, said that the hypothesis "is worth looking into."

He agreed that the theory of dopamine discussed in the article "is consistent" with the body's reaction to long-term trauma.

However, Ng said he would not "pin everything" on the theory outlined in the article. "Unfortunately, this is a hypothesis, and there's not enough of a comparison and data sample," he said.

He noted that with most deaths that are attributed to GUI in the article, an autopsy was not performed. "So we don't know what happened. As far as I know, they don't usually do autopsies in prisoner of war camps or concentration camps," he added.

Ng said he believes that people in concentration camps and other stressful environments cope differently with long-term psychological and physical trauma. "Some folks tend to cope better or grow from it, and others regress significantly from it," he said.

He stated that he's convinced that both psychodynamic and biological factors are involved in how people cope with these kinds of stress.

However, the field needs more attention, said Ng.

"Chronic trauma, especially in those extreme conditions, warrants a significant amount of research, to look into what exactly is involved in the interplay between the physiological as well as the psychodynamic piece," he said.

Worth Further Exploration

Also commenting on the article for Medscape Medical News, Elspeth Cameron Ritchie, MD, a psychiatrist who is now retired from the military and who has expertise in disaster issues, has researched prisoners captured during the Korean war.

"I found the article very interesting; I haven't seen anything like it before," she said. "It's worth exploring more."

During the Korean conflict of the early 1950s, more American prisoners of war died than other prisoners. At the time, they were thought to have "given up" because of "lax parenting," said Ritchie.

But when she closely examined the situation, she came to a different point of view, which she said "ties in" with this new article.

"When I went in and looked at it, I came to the conclusion that you had extreme emotional stress, but you also had extreme nutritional stress, and these soldiers were not getting the vitamins they needed. What we were blaming on a lack of moral fiber was actually a lack of food and vitamins as well as the prolonged stress," she said.

She questions whether the current article "lumps together a lot of different circumstances, calling it give-up-itis, for which multiple mechanisms could be involved."

Another factor that is thought to have contributed to the relatively high death rate in Korean camps was the lack of preparedness for being taken prisoner. After that war, the American military started training soldiers to better survive such situations.

As noted in the article, said Ritchie, the GUI process can be reversed "with good leadership.

"That's what is being taught in the military now — how to motivate your soldiers if you're captured, and how to survive."

Instilling hope is "intrinsically part of it," added Ritchie.

Dr Leach, Dr Ng, and Dr Ritchie report no relevant financial relationships.

Med Hypotheses. 2018;120:14-21. Abstract

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