When pain meets hope: Case report of a suspended assisted suicide trajectory in phantom limb pain and its broader biopsychosocial implications

Phantom limb pain (PLP) is a common consequence of limb amputation and frequently develops into a chronic condition [1]. Etiologically, central physiological changes and extensive neuroplastic processes are currently considered the main drivers of chronic PLP [2], making it challenging to treat with conventional therapies [3]. PLP is associated with a significant reduction in quality of life [4]. Evidence suggests that both the amputation itself [5] and, even more so, the presence of PLP are linked to an increased risk of suicidality [6].

A remarkable case report, recently published in the Scandinavian Journal of Pain, draws attention to suicidality in PLP [7]. The authors describe a 58-year-old man from the Netherlands who lost a leg in a traumatic incident more than 9 years ago. Over time, he developed persistent and progressively worsening PLP, which had a pronounced negative impact on his life in terms of sleep and daily activities. Both the patient and his wife reported PLP-associated personality changes, a loss of enjoyment in hobbies, and withdrawal from social interactions.

The patient participated in a double-blind, randomized controlled trial [8] testing the superiority of one sensorimotor intervention over another for the treatment of PLP. While the specifics of the interventions are beyond the scope of this editorial comment, it is important to note that both the experimental and the active control conditions were grounded in contemporary understanding of the neurophysiological mechanisms underlying PLP. The patient was assigned to the latter. Contrary to the patient’s initial expectations, he responded remarkably well to the intervention, experiencing a substantial reduction in PLP and its interference with sleep and daily functioning. Notably, discontinuation of the intervention as part of the trial protocol led to a marked deterioration of symptoms, prompting the implementation of a self-administered home training program, which again proved beneficial. At follow-up more than 1 year later, the patient was almost free of PLP.

What makes this case truly extraordinary is that, at the time of enrolment in the trial, the patient had already been accepted into a legally sanctioned assisted suicide program due to unbearable suffering from PLP (while the term “euthanasia” was used in the case report, the German author of this editorial comment consciously avoids its use for historical reasons). Although the patient experienced significant symptom improvement following the original intervention protocol, he initially chose not to withdraw from the assisted suicide program, wanting to ensure the durability of the therapeutic effect. However, at follow-up, he reported that he no longer harbored any thoughts of assisted suicide. Even though it must be explicitly emphasized that it is not known how the patient’s attitude toward assisted suicide developed after this last assessment, important implications can nevertheless be derived from this admittedly exceptional case.

Over the last decades, various psychological explanatory models for suicidal behavior have been developed (for a review, refer to the work of O’Connor and Nock [9]). One of the currently most influential models is the integrated motivational-volitional (IMV) model [10], a three-phase biopsychosocial framework that explains the development of suicidal ideation and behavior (Figure 1a). The model proposes a pre-motivational phase, which describes background vulnerabilities and triggering events. In the motivational phase, experiences of defeat (i.e., feelings of failure, loss, or humiliation) and entrapment (i.e., the perception of being trapped in an unbearable situation with no escape) drive the emergence of suicidal thoughts. The volitional phase then outlines factors that govern the transition from suicidal ideation to suicidal behavior.

Figure 1

IMV model of suicidal behavior. (a) Summary of the original model, as proposed by O’Connor and Kirtley [10]. (b) Proposal for exemplary additional factors and moderators relevant to the suicidal process in amputees (upper section) and amputees with PLP (lower section), as derived from the discussed case report.

By distinguishing between internal entrapment (being unable to escape one’s own bodily or psychological states) and external entrapment (feeling trapped by situational circumstances or others), this framework may be particularly well suited to capturing the nuanced risk factors of amputees beyond those observed in the general population. Some illustrative examples for specific factors in this group are presented in the upper part of Figure 1b. Disability-related adversities can be conceptualized as background factors, characterized by the physical and psychosocial consequences of amputation as well as structural and service-related barriers [11–13]. In the motivational phase, (bodily) self-concept disruption and adjustment difficulties may serve as threat-to-self moderators, potentially amplifying the experience of internal entrapment [13,14]. Social and occupational role breakdowns may function as motivational moderators, fostering suicidal ideation [13,15]. Amputation-specific volitional moderators, in the form of acquired capabilities for self-harm [16], may subsequently facilitate the transition to behavioral enaction.

At this point, the case report [7] provides important insights into which factors should be considered within the IMV model when PLP symptomatology is of primary concern (Figure 1b, lower part). In addition to the pain severity itself, the case report highlights the critical role of communication barriers. Following the amputation, the patient received only vague and insufficient explanations about the origin of PLP and was told that the pain would only be temporary. Over the course of 9 years, no healthcare professional was able to provide him with an adequate explanation of the phenomenon. The patient himself describes that the experience of having “pain in something that is no longer there” made him feel being “not completely normal” (p. 5). This observation aligns with findings from a previous survey, indicating that many amputees feel insufficiently informed about PLP [17]. Strikingly, the same sentiment is shared by healthcare professionals [18]. If even professionals lack a comprehensive understanding of PLP, it is reasonable to assume that affected individuals are likely to encounter misunderstanding and a lack of empathy in their everyday lives as well.

This particular psychosocial context may thus create a state marked by the loss of bodily trust and control, which in turn may foster experiences of internal entrapment. Pain-induced fatigue and despair may then act as motivational factors that intensify suicidal ideation. This is particularly evident in the case report, where PLP intrusions, for instance, compromise sleep quality. The loss of hobbies and social contacts further reinforced feelings of hopelessness (p. 6: “I won’t go on like this.”) – and the patient decided to enter the assisted suicide program. The described factors are presumably not qualitatively unique for PLP relative to other chronic pain conditions [19]; however, due to the adverse amputation-related background, their impact may be more detrimental. The rare opportunity for legal-assisted suicide due to unbearable pain can then be regarded as an important volitional moderator in terms of access to means of dying.

The biopsychosocial framework underlying the chronification of pain [20] precludes attributing improvement to any single factor. Rather, multiple variables interact in a dynamic and reciprocal manner, collectively shaping the overall outcome in terms of both pain perception and psychosocial well-being. In the context of the successful intervention described in the case report [7], several key factors were modified, which may, but do not necessarily, imply a causal sequence: (a) the patient was provided with a plausible explanatory model for PLP, both for himself and his social environment; (b) he received an intervention grounded in neurophysiological principles; (c) PLP severity was significantly reduced; (d) quality of life improved, as reflected in increased sleep duration (from 2–3 h before to 6–7 h after the intervention) and enhanced daily functioning; and (e) hope for a better life was restored, as the patient described himself as “reborn” (p. 7) and began once more to make plans for the future.

It is important to emphasize that previous interventions for PLP, even those with a mechanistic orientation, have by no means consistently resulted in such positive outcomes [21]. PLP is a highly heterogeneous and multifactorial phenomenon, shaped by the interplay of numerous biopsychosocial factors [22]. The present result should therefore be considered a highly individual outcome and must not foster unrealistic expectations in future patients that may, if unmet, themselves become risk factors for suicidal behavior. Nevertheless, the clinician can, through his or her actions, increase the likelihood of a successful outcome.

According to the logic of the IMV model, different measures are required depending on the phase an individual occupies within the suicidal process [10]. Based on the considerations outlined above, a plausible explanation of PLP as a pre-motivational variable may be of central importance. The efficacy of psychoeducational programs in pain therapy, at least for cognitive and emotional aspects of pain perception, has already been empirically demonstrated [23], underscoring the importance of targeted education and training. This would likely also have a positive impact on the therapeutic relationship, which was particularly emphasized by the patient in the present case report. Specialized training would further promote the dissemination of biopsychosocially informed, multimodal management approaches, which are currently recognized as the treatment of choice for chronic pain [24]. The psychotherapeutic components of these approaches may be particularly well suited to address dysfunctional psychosocial adaptation to PLP. So-called “buddy” programs may offer additional benefits [25]. In such a program, individuals who have recently undergone amputation are paired early in the rehabilitation process with experienced amputees who can serve as peer role models in coping with the new situation. Lastly, while a thorough ethical discussion of assisted suicide legislation exceeds the scope of this editorial comment, the positive response of a program participant to an intervention addressing established neurophysiological mechanisms of PLP prompts important questions about the criteria for admitting chronic but not terminal pain patients to such programs. Without detailed knowledge of the individual case, however, further evaluation is not possible.

In conclusion, despite – or perhaps precisely because of – its exceptional nature, the case report underscores the crucial role of biopsychosocial processes in the management of chronic PLP, even when such pain has already exerted a detrimental influence on the patient’s will to live. To validate the implications for suicide prevention inferred from this case, however, rigorous large-scale investigations are imperative.