Personality Disorders in Suicide Attempters and Completers: Preliminary Findings

Personality disorders may play an important role in understanding suicide risk. The present study was designed to examine the frequency and type of personality disorder traits relevant to suicidal behavior. Four groups of subjects were compared: Suicide completers (n = 15), suicide attempters (n = 14), depressed natural deaths (n = 13), and nondepressed natural deaths (n = 15). The Structured Interview for DSM-III-R Personality Disorders – Revised (SIDP-R) was used to gather information needed to rate the presence and severity of 11 personality disorders. No differences were observed across groups on the categorical presence or absence of the different personality disorder diagnoses. However, dimensional ratings revealed that suicide completers displayed significant elevations in narcissistic, histrionic, and borderline personality traits. Suicide attempters displayed significant elevations on paranoid, avoidant, schizotypal, dependent, and borderline personality traits. At the level of specific personality traits, suicide completers displayed a sense of entitlement toward others, tended to be preoccupied with feelings of envy, and were likely to feel devastated when close relationships came to an end. The present findings suggest that personality traits are related to suicidal behavior, and that a focus on the dichotomous presence or absence of a diagnostic category fails to identify less severe forms of personality pathology.

     

Estrogen receptor gene 1 variants are not associated with suicidal behavior

Estrogen is thought to be involved in the pathophysiology of depression and suicidal behaviors. We studied gene variants of estrogen receptor alpha (rs827421, rs1913474, rs1801132, rs722207, rs974276 and rs910416) in 167 German suicide attempters (affective spectrum n=107, schizophrenia spectrum n=35, borderline personality disorder n=25), 92 German individuals who committed suicide and 312 German healthy subjects. Single markers and haplotype analysis in relation to suicidal behaviors (suicide attempters/completers) did not reveal any significant association. These were also not associated with related features, such as violence or impulsivity of suicide attempt, State-Trait Anger Expression Inventory (STAXI) and Questionnaire for Measuring Factors of Aggression (FAF) scores. In conclusion, our study does not support the hypothesis that estrogen receptor alpha gene variants are major contributors to suicide or to anger- or aggression-related behaviors.     

Suicidal ideation and attempts in bipolar I and II disorders

OBJECTIVE: Few studies have investigated the prevalence of and risk factors for suicidal ideation and attempts among representative samples of psychiatric patients with bipolar I and II disorders. METHOD: In the Jorvi Bipolar Study (JoBS), psychiatric inpatients and outpatients were screened for bipolar disorders with the Mood Disorder Questionnaire from January 1, 2002, to February 28, 2003. According to Structured Clinical Interviews for DSM-IV Axis I and II Disorders, 191 patients were diagnosed with bipolar disorders (bipolar I, N = 90; bipolar II, N = 101). Suicidal ideation was measured using the Scale for Suicidal Ideation. Prevalence of and risk factors for ideation and attempts were investigated. RESULTS: During the current episode, 39 (20%) of the patients had attempted suicide and 116 (61%) had suicidal ideation; all attempters also reported ideation. During their lifetime, 80% of patients (N = 152) had had suicidal behavior and 51% (N = 98) had attempted suicide. In nominal regression models, severity of depressive episode and hopelessness were independent risk factors for suicidal ideation, and hopelessness, comorbid personality disorder, and previous suicide attempt were independent risk factors for suicide attempts. There were no differences in prevalence of suicidal behavior between bipolar I and II disorder; the risk factors were overlapping but not identical. CONCLUSION: Over their lifetime, the vast majority (80%) of psychiatric patients with bipolar disorders have either suicidal ideation or ideation plus suicide attempts. Depression and hopelessness, comorbidity, and preceding suicidal behavior are key indicators of risk. The prevalence of suicidal behavior in bipolar I and II disorders is similar, but the risk factors for it may differ somewhat between the two.     

Suicidal Intent and the HPA-Axis Characteristics of Suicide Attempters with Major Depressive Disorder and Adjustment Disorders

The main purpose of the study was to investigate Hypothalamic-Pituitary-Adrenal (HPA) axis characteristics in relation to suicidal intent among suicide attempters with Major Depressive Disorder (MDD) and Adjustment Disorders (AD). The relationship between suicidal intent, assessed by means of the Suicidal Intent Scale (SIS), and serum cortisol after a Dexamethasone Suppression Test (DST) was investigated in 78 suicide attempters, divided into diagnostic subgroups. There was a significant negative correlation between suicidal intent and post DST cortisol in patients with MDD. Our findings may be attributed to pathophysiological processes, where a high suicidal intent is revealed during a potential chronic course of MDD, which in turnresults in a seemingly normal stress system.     

Suicidal intent and the HPA-axis characteristics of suicide attempters with major depressive disorder and adjustment disorders

The main purpose of the study was to investigate Hypothalamic-Pituitary-Adrenal (HPA) axis characteristics in relation to suicidal intent among suicide attempters with Major Depressive Disorder (MDD) and Adjustment Disorders (AD). The relationship between suicidal intent, assessed by means of the Suicidal Intent Scale (SIS), and serum cortisol after a Dexamethasone Suppression Test (DST) was investigated in 78 suicide attempters, divided into diagnostic subgroups. There was a significant negative correlation between suicidal intent and post DST cortisol in patients with MDD. Our findings may be attributed to pathophysiological processes, where a high suicidal intent is revealed during a potential chronic course of MDD, which in turn results in a seemingly normal stress system.     

Suicide attempts and personality disorder

OBJECTIVE: The purpose of the present study was to compare clinical characteristics of suicide attempters with or without personality disorders. METHOD: A systematic sample (n = 114) of patients from consecutive cases of attempted suicide referred to general hospitals in Helsinki was interviewed and diagnosed according to DSM-III-R. Forty-six subjects with DSM-III-R personality disorders were identified and divided into clusters A (n = 4), B (n = 34) and C (n = 8). These subjects were compared with 65 suicide attempters without personality disorders in terms of clinical characteristics and treatment received. RESULTS: Suicide attempters with personality disorders more often had a history of previous suicide attempts and lifetime psychiatric treatment than comparison subjects. However, suicide attempts did not differ in terms of suicide intent, hopelessness, lethality or impulsiveness between subjects with or without personality disorders. CONCLUSION: Although suicidal behaviour is a more persistent feature among those with personality disorders, their clinical characteristics at the time of a suicide attempt may not differ from those without personality disorders.     

Shame-proneness in attempted suicide patients

ABSTRACT: BACKGROUND: It has been suggested that shame may be an important feature in suicidal behaviors. The disposition to react with shame, "shame-proneness", has previously not been investigated in groups of attempted suicide patients. We examined shame-proneness in two groups of attempted suicide patients, one group of non-suicidal patients and one group of healthy controls. We hypothesized that the attempted suicide patients would be more shame-prone than non-suicidal patients and healthy controls. METHOD: The Test of Self-Conscious Affect (TOSCA), which is the most used measure of shame-proneness, was completed by attempted suicide patients (n = 175: 105 women and 3 men with borderline personality disorder [BPD], 45 women and 22 men without BPD), non-suicidal psychiatric patients (n = 162), and healthy controls (n = 161). The participants were convenience samples, with patients from three clinical research projects and healthy controls from a fourth research project. The relationship between shame-proneness and attempted suicide was studied with group comparisons and multiple regressions. Men and women were analyzed separately. RESULTS: Women were generally more shame-prone than men of the same participant group. Female suicide attempters with BPD were significantly more shame-prone than both female suicide attempters without BPD and female non-suicidal patients and controls. Male suicide attempters without BPD were significantly less shame-prone than non-suicidal male patients. In multiple regressions, shame-proneness was predicted by level of depression and BPD (but not by attempted suicide) in female patients, and level of depression and non-suicidality in male patients. CONCLUSION: Contrary to our hypothesis and related previous research, there was no general relationship between shame-proneness and attempted suicide. Shame-proneness was differentially related to attempted suicide in different groups of suicide attempters, with significantly high shame-proneness among female suicide attempters with BPD and a negative relationship between shame-proneness and attempted suicide among male patients. More research on state and trait shame in different groups of suicidal individuals seems clinically relevant.     

Anxiety disorders in suicidal youth.

OBJECTIVE: To test the hypothesis that anxiety disorders are associated with suicidal ideation and suicide attempts in a child and adolescent sample referred to a clinic. METHOD: The sample comprised 1979 patients aged 5 to 19 years who were assessed using the Schedule for Affective Disorders and Schizophrenia for School Aged Children--Present Episode (K-SADS-P) at an outpatient mood and anxiety disorders clinic. Subjects were stratified by age and categorized into mutually exclusive groups as being nonsuicidal (n = 817), having suicidal ideation (n = 768), or having attempted suicide (n = 394) in the current episode. Psychiatric diagnoses based on DSM-IV criteria were compared to determine if anxiety disorders were a risk factor for suicidal ideation and suicide attempts. Logistic regression was used to control for significant demographic characteristics and comorbid disorders. RESULTS: After stratifying by age, we found no differences across the 3 groups (ideators, attempters, and nonsuicidal youth) in rates of an anxiety disorder in general or in specific rates of panic disorder, agoraphobia, social phobia, simple phobia, and obsessive-compulsive disorder. Two salient findings involving anxiety disorders were noted with regression analysis. In younger children (age < or = 15 years), attempters had a significantly lower prevalence of separation anxiety disorder (SAD), compared with ideators (OR = 0.30; 95%CI, 0.11 to 0.80; P = 0.006) and nonsuicidal youngsters (OR = 0.14; 95%CI, 0.05 to 0.39; P < 0.0001). In older children (age > 15 years), generalized anxiety disorder (GAD) was more prevalent in ideators (OR = 1.65; 95%CI, 1.03 to 2.66; P = 0.03) than in nonsuicidal patients. CONCLUSIONS: Based on this clinical sample, the relation between pediatric anxiety disorder and suicidal ideation and suicide attempts is not straightforward. However, further studies in nonreferred samples are warranted.     

Childhood trauma as a correlative factor of suicidal behavior – via aggression traits. Similar results in an Italian and in a French sample

Background and objectiveChildhood trauma and aggressive traits are considered risk factors for suicidal behavior. The hypothesis we aimed to test in this study was the existence of an association between childhood trauma and aggression in two distinct samples of Italian and French suicide attempters.MethodStudy participants comprise 587 subjects with different psychiatric diagnoses according to DSM-IV-TR criteria. Three different samples were analyzed and compared: a group of French suicide attempters (N = 396; mean age 40.47 SD = 13.52; M/F: 110/286); a group of Italian suicide attempters (N = 103; mean age 38.60 SD = 12.04; M/F 27/76) and an Italian psychiatric comparison group (N = 88; mean age: 41.49 SD = 12.05; M/F; 37/51). Patients were interviewed with the Brown–Goodwin Assessment for Lifetime History of Aggression (BGLHA) and the Childhood Trauma Questionnaire (CTQ) 34-items for Italian data and 28-items for French data.ResultsWhen compared with the comparison group, Italian suicide attempters had significantly higher scores on the BGLHA scale and reported higher scores on the CTQ scores for physical abuse, sexual abuse and emotional abuse. Significant correlations between childhood trauma and aggression were found in both groups, Italian and French, of suicide attempters.ConclusionThe hypothesis tested was supported as psychiatric patients who had attempted suicide reported significantly more childhood trauma and aggression. Significant correlations were found between aggressive behavior, and childhood trauma in suicidal patients. This finding was replicated in two independently recruited samples in two countries with different prevalence of suicidal behavior.     

Alexithymia and suicidal behavior

A number of factors including hopelessness have been identified as amplifying suicide risk. Alexithymia has recently been investigated as a predictor of suicidal behavior. The prevalence of the personality trait alexithymia in suicide attempters as well as other predictors of suicidal behavior were investigated in this study. One hundred suicide attempters were compared to 60 healthy controls on the measures of hopelessness, alexithymia, depression and suicidal ideation. First-timers and repetitive suicide attempters, males and females, married and unmarried suicide attempters were compared to each other in the suicide attempter group. The correlations of hopelessness, depression and alexithymia with suicidal intent and suicide lethality were investigated. The suicide attempter group did not display significantly higher scores on the alexithymia measure, compared to healthy controls. Alexithymia neither seemed to be a prevalent personality trait in suicide attempters nor a sensitive predictor of suicidality. The subscales of Toronto Alexithymia Scale measuring difficulty in identification and expression of feelings also did not reveal a significant difference between the two groups. Suicide attempters were more depressive, more hopeless and displayed greater suicidal ideation than healthy controls. Severity of depression was a stronger predictor of suicidal intent than hopelessness in the suicide attempter group. The lethality of the suicide attempt did not correlate with any of the psychometric measures. These findings propose that difficulty in the identification and articulation of feelings does not comprise a risk factor for suicidal behavior.     

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

Objectives:  Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.
Methods:  Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.
Results:  The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.
Conclusions:  Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.     

Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior

OBJECTIVE: The authors sought to determine 1) whether the risk for familial transmission of suicidal behavior is greater with increased family loading for suicide attempts, and 2) whether the transmission of suicidal behavior is mediated by impulsive aggression. METHOD: A reanalysis of a high-risk study compared the offspring of three mood disorder proband groups: suicide attempters with a sibling who also attempted suicide (N=19), suicide attempters whose siblings never made a suicide attempt (N=73), and nonsuicidal probands whose siblings also never engaged in suicidal behavior (N=73). Probands and offspring were assessed with respect to psychopathology, suicide attempt history, impulsive aggression, and exposure to familial adversity. RESULTS: Offspring of suicide attempters with siblings concordant for suicidal behavior showed a higher risk of suicide attempt than did offspring of nonsuicidal probands and had an earlier age at onset of suicidal behavior than offspring of suicide attempters with siblings discordant for suicidal behavior. Probands from sibling pairs concordant for suicidal behavior and their offspring reported greater lifetime impulsive aggression compared with each of the other two proband/offspring groups. In the offspring, impulsive aggression was the most powerful predictor of early age at first suicide attempt. CONCLUSIONS: Familial loading for suicide attempts may affect rates of transmission as well as age at onset of suicidal behavior, and its effect may be mediated by the familial transmission of impulsive aggression.     

Personality and suicidal behavior in depressed patients

The relationship between personality and suicidal behavior was evaluated in 53 patients with primary major depressive disorder. Mean borderline personality scale scores on the Millon Clinical Multiaxial Inventory (MCMI) differed between suicide attempters and non-attempters. The frequency of personality disorder diagnoses, especially borderline personality disorder, was not higher in the suicide attempters. Clinical and theoretical implications of these findings are discussed.     

Interpersonal dependency in suicide attempters

BACKGROUND: A high level of interpersonal dependency (IPD) has been reported in suicide attempters, which might be explained by depression levels as well as the high rate of female suicide attempters. METHODS: 63 suicide attempters and 63 non-suicide attempters were recruited from a nonpsychiatric sample. The control subjects were individually matched to the patients for gender, age and educational status. The subjects filled out the Beck Depression Inventory and the Interpersonal Dependency Inventory (IDI). Analysis of covariance was performed to control the depression level. RESULTS: Suicide attempters had significantly higher scores on the IDI than non-suicide attempters. CONCLUSION: A high level of IPD is related to suicide risk independently of depression. Limitation: only a prospective study could test the hypothesis that a high level of IPD predisposes an individual to commit suicide. Clinical relevance: IPD must be detected in subjects at risk of suicide.     

A pilot study on differences in aggression in New York City and Madrid, Spain, and their possible impact on suicidal behavior

OBJECTIVE: Published results from a U.S. study of depressed suicide attempters and a Madrid, Spain, study including all consecutively admitted suicide attempters suggested that aggression scores were higher in U.S. attempters. This observation led us to compare depressed attempters and controls from both suicide research centers and explore whether New York City (NYC) patients carry out suicidal acts of greater lethality than patients in Madrid. The study goals were (1) to compare aggression scores in attempters and healthy volunteers between the 2 cities and (2) to determine whether higher aggression scores are associated with greater medical lethality of suicide attempts. METHOD: The respective samples from NYC and Madrid included attempters with a DSM-IV diagnosis of major depressive disorder (N = 117 and N = 133) and healthy controls (N = 90 and N = 317). Aggression scores, measured by the Brown-Goodwin Scale, in attempters and healthy volunteers from both sites were compared using an analysis of variance model. The relationship between lethality of suicidal acts and aggression scores in attempters was assessed using logistic regression analyses. NYC subjects were recruited from 1998 to 2001, and Madrid subjects were selected from consecutive admissions in 1999. RESULTS: Depressed suicide attempters from NYC made attempts of greater lethality and reported more lifetime aggressive behavior than depressed attempters in Madrid. NYC healthy volunteers also reported more aggression than their Madrid counterparts. CONCLUSIONS: This pilot study suggests that the greater lethality of suicidal behavior in NYC compared to Madrid is related to higher aggression levels, although the data have limitations. Cross-cultural studies are needed to verify whether aggression and higher lethality suicide attempts share a common diathesis explaining the higher suicide rates in NYC.     

P11 (S100A10) as a potential biomarker of psychiatric patients at risk of suicide

Although suicide represents 1.8% of the global burden of disease, there are few objective assays for suicide risk. Being associated with depressive disorders, which have a high risk of suicide, the proteins P11, P2RX7, and S100β may be biomarkers for a suicidal disposition. We measured levels of p11 and P2RX7 mRNA in peripheral blood mononuclear cells (PBMCs) of 26 psychiatric patients (11 suicide attempters, 15 suicide non-attempters) with post-traumatic stress disorder (PTSD) and major depressive disorder (MDD), and 14 normal controls, using quantitative real-time PCR. We also conducted a meta-analysis of microarray data of p11, P2RX7 and S100β from post-mortem prefrontal cortex (PFC) of patients who committed suicide (n = 56) and non-suicide controls (n = 61). We found that PBMC p11 mRNA levels were significantly lower in suicide attempters and higher in suicide non-attempters, when compared to normal controls. The PFC p11 mRNA levels in suicide completers were also lower than non-suicide controls (adjusted p = 0.007). Unlike p11, PBMC P2RX7 mRNA levels were significantly lower than normal controls in all patients including suicide attempters, suicide non-attempters, and suicide completers. In addition, levels of S100β in PFC did not differ between suicide completers and non-suicide controls. These results suggest that PBMC p11 mRNA levels may be a potential adjunctive biomarker for the assessment of suicide risk in mental disorders and warrants a larger translational study to determine its clinical utility.     

Parent of origin effect and allelic expression imbalance of the serotonin transporter in bipolar disorder and suicidal behaviour

Suicide and suicidal behaviour are a major health concern worldwide particularly in patients with mood disorders. Family, adoption and twin studies show that genetics influences suicidal behaviour. The serotonin transporter (5HTT) plays an important role in the pathophysiology of mood disorders and may also be involved in suicidal behaviour since 5HTT binding is decreased in the brain of suicide completers. Because the effect of genomic imprinting in the 5HTT gene on suicidal behaviour has not been investigated, we analysed the parent-of-origin effect (POE) of four 5HTT markers and the differential expression of the 5HTT G2651T (rs1042173) alleles in suicide attempters affected by bipolar disorder. We performed a family based association study and ETDT/QTDT analyses of the rs25531, HTTLPR, VNTR-2 and G2651T polymorphisms in 312 nuclear families with at least one subject affected by bipolar disorder. The main outcomes investigated in this study are bipolar disorder diagnosis, suicide attempts, suicidal behaviour severity and age at onset of bipolar disorder. We also compared the allele-specific mRNA levels in lymphoblastoid cells from 13 bipolar suicide attempters and 8 bipolar non-suicide attempters. Allele 2651T was transmitted significantly more often to bipolar patients (P = 0.042). There was no significant difference between maternal and paternal transmission ratios. Furthermore, there was no significant difference in the ratio of T/G-specific mRNA expression between bipolar attempters and non-attempters. These data do not support a role for differential allelic expression of 5HTT for suicidal behaviour in bipolar disorder. Small sample size and the fact that RNA was obtained from lymphoblastoid cell lines were some of the limitations of this study.     

Beyond the mental pain: A case-control study on the contribution of schizoid personality disorder symptoms to medically serious suicide attempts

BackgroundClinical and research findings have highlighted the role of interpersonal factors in suicidal behavior with high levels of intent and lethality. Schizoid personality disorder (SPD) is at the extreme end of interpersonal difficulties. Thus, we aimed to understand the contribution of SPD symptoms to suicide behavior and specifically to more lethal suicide attempts.MethodFour groups were investigated (N = 338): medically serious suicide attempters, medically non-serious suicide attempters, psychiatric and healthy controls. SPD symptoms, mental pain variants, and clinical characteristics were assessed.ResultsOverall, attempters were characterized by higher levels of most SPD symptoms. Solitary lifestyle and emotional detachment were higher among medically serious suicide attempters relative to less-serious attempters. Emotional detachment doubled the risk for high lethality, beyond mental pain variables.ConclusionsSPD symptoms of interpersonal difficulties and low levels of emotional expressions are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide are discussed.     

伴人格障碍自杀未遂者临床特点研究

目的：探讨伴人格障碍自杀未遂者的临床特点。方法：对108名自杀未遂急诊入院的患者按CCMD-2-R进行人格障碍的诊断，分为伴人格障碍组和不伴人格障碍组，对两组的社会人口学资料和临床资料进行统计，并进行自杀意图量表及自杀企图冲动性和致死性的测定，将有关项目作对比分析。结果：有40（37.04％）名自杀未遂者伴发人格障碍，伴人格障碍自杀未遂者与不伴人格障碍自杀未遂者，有较多的既往自杀未遂史和精神科治疗史，自杀意图和自杀企图致死性较低，冲动性较高。结论：对伴人格障碍自杀未遂者应给予特别对待和积极治疗。     

What are the characteristics of adolescent hospitalized suicide attempters?

AIM: To study the specificity of hospitalized adolescent suicide attempters. METHOD: Among a national sample of students (n = 11,718, mean age = 16.6 years) studied in 1999, 9.2% (n = 1078) made at least one suicide attempt during their life (SA); 21.9% (n = 234) of them were hospitalized (HSA). We identified the risk factors (family, school, behavioral and psychological) of SA and HSA by comparing (by gender) a) suicide attempters to non-suicide attempters and b) hospitalized suicide attempters to non-hospitalized suicide attempters. RESULTS: Both for girls and boys, the risk factors for SA varied. However, certain risk factors, particularly depressive mood, low self-esteem and poor parent-child relationships, were not associated with hospitalization. Hospitalized suicide attempters had more personal and social problems. But there is an important difference according to gender: in boys, hospitalization is related to physical fighting (OR = 2.2) and offences (OR = 3.4), in girls to running away (OR = 1.7), consumption of illegal drugs other than cannabis (OR = 2.0), having a living standard outside average (OR = 2.0) and going to a private school (OR = 1.7). CONCLUSION: Suicide attempters with problem behavior are more at risk of being hospitalized than others. However, the difference between hospitalized and non-hospitalized subjects was smaller than expected.