87. RETHINKING STRUCTURAL CONSIDERATIONS IN THE DIFFERENTIAL DIAGNOSIS OF GERIATRIC 3D: AN INDIGENOUS ELDER’S SUICIDE BY SELF-IMMOLATION IN TAIWAN

Abstract

Introduction

This is a 71-year-old Indigenous male patient who was admitted to a medical center after self-immolation during a protest. He was hospitalized in the Burn ICU for treatment of third degree of major burns to his face and upper limbs, an inhalation injury and sepsis. Following extubation, the psychiatrist team was consulted to evaluate his suicide attempt, insomnia, and episodic agitation.

Upon psychiatric evaluation, the patient was alert and oriented to place, but not fully in time. He reported feeling “dysphoric” for months, with poor sleep, appetite, and a sense of hopelessness. Long-term land dispossession and a recent government demolition order targeting his tribe’s homes contributed to his distress. He revealed that he premeditated his self-immolation, purchasing gasoline two days before and leaving a note: “burn, not yet consumed.” Tracing his personal history, born in his traditional territory, he had left young due to colonial land policies, working high-risk jobs in cities. Decades later, he returned post-retirement, but his resettled community was devastated by typhoons. Despite his outgoing nature, his family observed increasing impulsivity and rumination over land issues This self-immolation act was his first time considering and attempting suicide. There’s no violence, substance or any psychiatric history for him. His has type 2 diabetes under regular medication control, otherwise he’s healthy. In later psychiatric follow-up evaluation, he expressed regretful feeling about his suicide, stating he “heard God’s voice saying this [suicide act] was wrong” and “visioned a battle between God and Satan.

Methods

Tentative psychiatric diagnoses include geriatric depression, delirium, and consideration of neurodegenerative disorder, like mild behavioral impairment. His laboratory results showed hypoalbuminemia, thrombocytopenia, and anemia, which were related to his major burn injury. The psychologist attempted a neurocognitive test but could not complete it due to the language barrier, as the examination tools were not available in the patient’s native tongue.

Results

This case brings up a challenging reflection on the health disparity in standard evaluation for suicide and differential diagnosis among marginalized populations like Mr. M, who falls into the classic geriatric "3D" categories: depression, delirium, and dementia (neurocognitive disorder).

The SADPERSONS scale, a standardized suicide risk tool, was utilized in the patient’s evaluation. Some static demographic factors were score positive such as male gender, old age, and the organization of his suicide plan. However, the interpretation of his “dysphoric and angry mood” as “depressed mood” and his vivid, unusual experiences (noted as visual and auditory hallucinations) reflected his cultural and spiritual background. These experiences may not necessarily indicate “loss of rational thinking” in the scale items. Diagnostic debates arose from these atypical manifestations that did not fit the description of diagnostic criteria and tool items.

His method of suicide—self-immolation during a protest—suggests broader cultural, social, historical, and political forces beyond the individual level. By reviewing literatures and as far as we know, there is no prior record of Indigenous self-immolation documented in Taiwan, indicating this act is not rooted in the indigenous traditional cultural practices. He carried a cross on his back during the act and left a note stating, “burn, but not yet consumed,” symbolizing his Christian religious faith. He also cited land and housing injustices affecting his community as major stressors. His life encapsulated the colonial trauma that Indigenous people continued to endure collectively, including displacement from traditional territories and marginalization in modern society. Moreover, the limitation of neurocognitive assessment tools is significant, as no culturally adapted neurocognitive instruments in his native language or cultural context available.

Conclusions

In summary, when differentially diagnosing a geriatric patient from a marginalized group, it is crucial to consider cultural, social, historical, and structural factors, as these elements shape their psychopathology and may lead to atypical manifestations that don’t fit into the diagnostic criteria or items of examination tools, increasing the risk of misinterpretation or misdiagnosis. Furthermore, acknowledging the multifaceted meanings behind their suicide and symptoms is essential in developing a treatment plan aimed at alleviating the suffering of marginalized elders experiencing radical acts of suicide.