Clinical Features Associated with Suicide Attempts versus Suicide Gestures in an Inpatient Sample

The objective of this study was to test whether suicide attempters and suicide gesturers can be clinically differentiated. A total of 150 subjects who had attempted suicide at least once, had made a suicide gesture, had suicidal ideation, and/or had engaged in non-suicidal self-injury were recruited from the inpatient service of the Jiménez Díaz Foundation (Madrid, Spain). A multinomial regression analysis was conducted. Histrionic and antisocial personality disorders were risk factors specific to suicide gestures. Narcissistic personality disorder was specifically associated with suicide attempts. Borderline personality disorder was associated with both suicide gestures and attempts. A high level of impulsiveness was a risk factor specific to suicide attempts. Conclusion: Suicide attempters and suicide gesturers are two distinct, although partially overlapping, populations.     

Suicide attempts in antisocial personality disorder

Previous studies that have examined suicide attempts and the diagnosis of antisocial personalities are somewhat difficult to compare because of variable diagnostic criteria. The diagnosis of antisocial personality disorder does not include past suicide attempts as a criterion.^1–4 Previous investigations have revealed antisocial personality disorder or criminal behavior to be a predictor of subsequent suicide attempts.^5,6 These findings of suicide attempts contrast to those of completed suicides.Sociopaths completed suicides infrequently when compared to patients with other psychiatric disorders.^7,8 A follow-up study of sociopaths and nonpsychiatrically ill controls revealed no difference in completed suicides.⁹Previous investigations^9,10 revealed suicide attempt rates in sociopaths of 23%–11%. Our experience has been that sociopaths frequently had past histories of nonserious suicide attempts. This investigation was undertaken to explore the incidence of previous suicide attempts in sociopaths.     

Social risk factors for borderline personality disorder: a review and hypothesis.

A number of behaviours associated with borderline personality disorder (including attempted suicide, suicide, substance abuse, and antisocial behaviour) are on the increase among the young. The common factor in these disorders is impulsiveness. Evidence is reviewed suggesting that social disintegration reduces the threshold of impulsive behaviours. It is proposed that this is the mechanism through which social risk factors effect the prevalence and morbidity of borderline personality. A number of ways of testing this hypothesis are suggested.     

Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder.

OBJECTIVE: This paper has 3 objectives. First, we review the epidemiologic evidence for the association between suicidal behaviour and suicide in individuals diagnosed with antisocial, borderline, or narcissistic personality disorder. Second, we examine whether any potentially modifiable risk factors are associated with these diagnoses, based on existing empirical evidence. Last, we discuss clinical approaches to assessing youth with antisocial, borderline, or narcissistic personality disorder presenting at risk for suicide. METHOD: We reviewed the English-language literature for the last 12 years (from January 1, 1991, to December 31, 2002), using as search terms the names of the 3 disorders, as well as the key words suicide, suicidal behaviour, youth, and adolescents. RESULTS: Patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behaviour when they demonstrate such comorbid disorders as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse. CONCLUSIONS: For patients with antisocial personality disorder, the risk of violence has to be judged in addition to the risk of suicide or self-harm. For patients with borderline personality disorder, interventions are determined by differentiating acute-on-chronic from chronic risk of suicidal behaviour. Finally, patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable.     

Psychiatric comorbidity and suicidality among intravenous drug users.

BACKGROUND: Prevalence of lifetime psychiatric comorbidity and history of attempted suicide among intravenous drug users was investigated. METHOD: One thousand sixty-two relatives of hospitalized alcoholics, felons, and control subjects were administered a structured interview that gathered data on lifetime psychiatric symptoms and psychoactive drug use. Psychiatric diagnoses were based on interview information, medical records, and family history data. Comparisons were made between 411 subjects who used no illicit drugs, 329 cannabis users, 230 subjects who had used psychoactive drugs other than cannabis more than five times but had never injected drugs, and 92 intravenous drug users. RESULTS: Any history of injecting drugs increased the odds of being diagnosed with antisocial personality disorder by a factor of 21.01, alcoholism by 4.42, and unipolar depression by 3.02. A diagnosis of antisocial personality disorder increased the odds of having injected drugs by a factor of 27.19, while diagnoses of alcoholism or unipolar depression conveyed odds for injecting drugs of 4.62 and 3.70, respectively. Intravenous drug use was associated with an 8.27-fold increase in odds for a suicide attempt compared with no drug use. CONCLUSION: Rates of alcoholism, depression, and antisocial personality disorder, but not other psychiatric disorders (other than drug dependence), are significantly elevated in intravenous drug users. Moreover, among drug users, the decision to inject is differentially made by those with antisocial personality disorder. A history of suicide attempt is common among intravenous drug users, but injecting appears to convey little additional risk above substantial but non-intravenous drug use.     

Parental psychopathology and the risk of suicidal behavior in their offspring: results from the World Mental Health surveys

Previous research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive aggression (for example, antisocial personality) and anxiety/agitation (for example, panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55?299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (that is, time since most recent episode controlling for age of onset and time since onset) of subsequent suicidal behavior (suicide ideation, plans and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental antisocial personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt was also found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of intergenerational transmission of suicidal behavior.     

Attempted suicide in those with personality disorders

Summary From a sample of 499 patients admitted to hospitals for suicide attempts, a subsample of 182 suicide attempters who described histories of illicit activities or who were diagnosed with DSM-II antisocial, drug or alcohol personality disorders were compared with another sample of 109 suicide attempters diagnosed as having depressive disorders. The former group of unsocialized attempters obtained similar depression inventory scores as the diagnosed depressive attempters. However, the index attempts of the unsocialized group were made with less suicidal intent than those of the diagnosed depressive patients, and they made more prior suicide attempts than the diagnosed depressive patients.     

Depression spectrum disease versus pure depressive disease. Clinical, personality, and course differences

In a group of 191 women admitted to the University of Iowa Psychiatric Hospital for depression over a 45-year period and selected on the basis of alcoholism or antisocial personality, vs. depression, in a parent, 105 probands fit into the depression spectrum group (parental alcoholism or antisocial personality) and 86 into the pure depression group (parental depression). Few differences were found between the presenting clinical pictures (including precipitating factors) of the two groups; but depression spectrum patients and pure depressive patients showed study differences in the areas of personal problems and personality as well as course of illness. The depression spectrum patients were significantly less likely to have loss of interest in usual activities as a symptom at index admission. They were significantly more likely to have had a history of sexual problems, to have been divorced or separated before, to have been described as irritable, and to report having previously been depressed. They are nonetheless significantly more likely to recover completely and have no relapse of depression. The pure depression group were significantly more likely to have depressed sisters, and suicide was much more frequent in their ill parents. Thus, important personality and course differences separate depressive spectrum disease from pure depressive disease;     

Reduced hippocampus and amygdala volumes in antisocial personality disorder

In the present paper, we aimed to investigate hippocampus and amygdala volumes in a group of patients with antisocial personality disorder and hypothesized that hippocampus and amygdala volume alterations would be observed. It was measured hippocampus and amygdala volumes of twenty patients with antisocial personality disorder and those of healthy control subjects. We found that both sides of hippocampus and amygdala volumes of patients with antisocial personality disorder were statistically significantly reduced compared to those healthy control subjects, and observed statistically important correlations between the left and right and left hippocampus and left amygdala volumes, and age, some results on scale scores. Consequently, the present study suggest that hippocampus and amygdala volumes of patients with antisocial personality disorder had abnormally smaller than those of healthy control subjects, considering that these abnormalities might be associated with at least some clinical features of antisocial personality disorder. However, longitudinal studies are needed to assess causality of this relationship.     

Serum cholesterol in antisocial personality.

Serum cholesterol fasting concentrations were measured in 274 subjects with personality disorders, who had committed offences. Of these subjects, 139 were found to possess the antisocial personality (sociopathy or psychopathy). With standardized ages, the group of subjects with antisocial personality had a clearly lower mean level of serum cholesterol than the group with other personality disorders which was used as a control group. The use of a mean male population with standardized ages as a control group further emphasized the low values of the serum cholesterol of the antisocial personality group.     

Psychological autopsy of completed suicide in children and adolescents

A psychological autopsy of 20 children and adolescents aged 12-19 years who had committed suicide and a matched-pair control group revealed that 85% of the victims and 18% of the control subjects had expressed suicidal ideation. A statistically significant number of the victims had a history of suicide threats (55%), suicide attempts (40%), drug or alcohol abuse (70%), antisocial behavior (70%), or inhibited personality (65%). Suicidal behavior of parents, relatives, or friends and a parental history of emotional problems and absence or abusiveness were also significant factors for the victims.     

Alexithymia in patients with antisocial personality disorder in a military hospital setting

We investigated the prevalence of alexithymic features and other psychometric correlates in patients diagnosed with antisocial personality disorder in a military hospital setting. Forty soldiers diagnosed with antisocial personality disorder in a general military hospital and 50 normal soldiers with no known medical or psychiatric disorder were assessed by sociodemographic data form, the Toronto Alexithymia Scale (TAS)-26 items, the Beck Depression Scale, the Beck Hopelessness Scale, the Brief Symptom Inventory and the State-Trait Anxiety Inventory. Antisocial patients showed significantly higher rates of unemployment, lower educational and socioeconomic status, higher rates of self mutilation, previous suicide attempts, substance abuse, history of incarceration and broken family bonds. The patient group also displayed significantly higher scores on alexithymia, depression, hopelessness and general psychological distress measures. Alexithymia was not associated with other psychological measures but was associated with socioeconomic and educational status. The failure in the socialization process of these patients may pave the way for an inability to identify and communicate their feelings. To draw a more definitive conclusion on this issue, a study which recruits ASPD patients from the community and compares them with a sociodemographically matched patient control group is necessary.     

Antisocial personality disorder and psychopathy in cocaine-dependent women.

OBJECTIVE: The goal of this study was to examine the lifetime prevalence of antisocial personality disorder according to five diagnostic systems and the prevalence of psychopathy in a study group of women. The relationship between antisocial personality disorder and psychopathy was also examined. Finally, differences in treatment admission variables based on the presence or absence of antisocial personality disorder and/or psychopathy were evaluated. METHOD: Antisocial personality disorder was diagnosed in 137 treatment-seeking, cocaine-dependent women according to the Feighner criteria, Research Diagnostic Criteria (RDC), and DSM-III, DSM-III-R, and DSM-IV criteria. Psychopathy was assessed by the Revised Psychopathy Checklist. RESULTS: Rates of antisocial personality disorder varied from 76% according to the Feighner criteria to 11% for the RDC. Nineteen percent (N = 26) of the women scored in the moderate to high range on the Revised Psychopathy Checklist. All of these women were diagnosed with antisocial personality disorder according to DSM-III and Feighner criteria, but only 15 of the 26 were diagnosed according to DSM-III-R, 12 according to DSM-IV, and six with the RDC. Moderate levels of psychopathy were associated with a history of illegal activity at treatment admission, whereas antisocial personality disorder was not. CONCLUSIONS: There was relatively little diagnostic agreement between classification systems. This study indicates that antisocial personality disorder and psychopathy are not synonymous terms for the same disorder. Findings support a need to redefine antisocial personality disorder diagnostic criteria to make them gender neutral by including behaviors associated specifically with antisociality in women.     

Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection

OBJECTIVE: To investigate the role of parenting in the development of adult antisocial personality traits. METHOD: A total of 742 community-based subjects were assessed for adult DSM-IV antisocial personality disorder traits and for measures of parental behavior experienced as children, including by the Parental Bonding Instrument (PBI). RESULTS: Three fundamental dimensions of parental behavior - care, behavioral restrictiveness and denial of psychological autonomy - were derived by factor analysis from the PBI. These dimensions significantly correlated with measures of parental behavior considered influential in later antisocial behavior. Adult antisocial traits in males were associated with low maternal care and high maternal behavioral restrictiveness, and in females, antisocial traits were associated with low paternal care and high maternal denial of psychological autonomy. These dimensions did not, however, explain all variance parental behavior has on adult antisocial personality traits. CONCLUSION: Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection.     

Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States.

A significant difference in the prevalence of personality disorders was reported between similar studies of suicide among young people (under age 30) performed in San Diego, California (10% of 133 cases), and Göteborg, Sweden (34% of 58 cases). The difference was due entirely to the absence of borderline personality disorder (BPD) reported in the San Diego sample. In this study, we used preselected variables to reassess the suicides from the San Diego study for criteria consistent with BPD. We found that 41% met the criteria, which was now not significantly different from the Göteborg sample. Comparisons among a number of other demographic, social, and diagnostic variables revealed many similarities in the two samples, particularly Axis I comorbidity with depression and/or substance abuse and Axis II comorbidity with antisocial personality disorder. We conclude that the characteristics associated with BPD identify similar young persons who committed suicide in Sweden and the United States. Questions remain as to whether or not Axis I and II disorders are independent in relation to suicide. The comorbidity pattern described here must be considered seriously in the clinical setting for its fatal implications.     

The construct validity of rule-breaking and aggression in an adult clinical sample

Previous research has demonstrated that aggression (AGG) and non-aggressive rule-breaking (RB) represent elements of antisocial behavior with different etiological mechanisms and associations to personality and psychopathology. However, these constructs have not been investigated in an adult clinical sample. In the current study, interview and self-report derived AGG and RB were associated with personality traits and disorders as well as functioning across several domains, family history, concurrent psychopathology, and prospective behaviors. Both AGG and RB were similarly related to disagreeableness. RB was uniquely related to low conscientiousness, cluster B personality disorders, functioning, problems in childhood, suicide risk, arrests, and substance use disorders. AGG (+) and RB (−) were differentially related to obsessive-compulsive personality disorder and conscientiousness. Gender moderation effects were limited. It was concluded that AGG and RB represent separable components of antisocial behavior with differential and clinically meaningful correlates in an adult clinical sample.     

Alcoholism and antisocial personality.

The picture of alcoholism in criminals with an antisocial personality was compared with criminals with other personality disorders. Fewer of those who had an antisocial personality were physically dependent on alcohol than those with other personality disorders. They considered their alcoholism to be a problem and behaved as if it were only rare. However, they had a strong tendency to behave abnormally under the influence of alcohol over and over again. In these respects the situation among those who were below the age of 20 was similar. To a great extent, the fathers of those who had an antisocial personality had also had a tendency towards abnormal behavior under the influence of alcohol. This was not so often found in the control group.     

Mental disorders among alcoholics. Relationship to age of onset and cerebrospinal fluid neuropeptides.

Eighty-one percent of 339 alcoholics participating in a research program were found to have associated mental disorders. Alcoholics with onset of heavy drinking before 20 years of age had significantly more antisocial personality traits, drug abuse, bipolar disorder, panic disorder, suicide attempts, and paternal alcoholism than alcoholics with onset after age 20 years. Alcoholics with onset before and after 20 years of age also differed significantly from each other for cerebrospinal fluid concentrations of diazepam-binding inhibitor and somatostatin. These results support the notion that age of onset may delineate subgroups of alcoholics with significant clinical and neurochemical differences.     

Impulsivity and aggression as predictors of suicide attempts in alcoholics

Introduction: The aim of this study was to assess the potential role of impulsive and aggressive behavior in the pathogenesis of suicide attempts in alcoholics. Impulsive and aggressive behavior as well as a psychiatric comorbidity with depressive conditions and personality disorders have been reported to be significant risk factors for suicide attempts in alcoholics. We hypothesized that alcoholics with a history of violent suicide attempts show an increased level of impulsive and aggressive behavior. Furthermore, the potential influence of concurrent personality disorders and depressive conditions were assessed. Material and methods: 182 detoxified alcohol-dependent subjects were enrolled into the study. Impulsive and aggressive traits were assessed using the Buss-Durkee Hostility Inventory and the Brown-Goodwin Assessment for Lifetime History of Aggression, personality disorders using the SCID II. Characteristics of alcohol dependence and suicide attempts were evaluated using the Semi-Structured Assessment on Genetics in Alcoholism (SSAGA). Results: Alcohol-dependent subjects with a history of suicidal behavior show a profile with higher impulsive and aggressive behavior. No significant association between these traits and concurrent borderline and antisocial personality disorder was found. Subjects with suicide attempts tended to have a significantly higher rate of depressive disorders. Discussion: These results suggest that impulsive and aggressive traits might contribute significantly to the risk of suicide attempts in alcoholics. Received: 14 December 2001 / Accepted: 3 April 2002     

Diagnosing personality disorders in the community. A comparison of self-report and interview measures

The rapidly expanding empirical study of personality disorders is the result of the publication of operational diagnostic criteria in DSM-III and the development of instruments to assess these criteria. Few researchers have examined the comparability of measures of personality disorders, and to our knowledge there are no studies of the factors associated with discordance between measures. In the present study, 697 relatives of psychiatric patients and healthy controls were interviewed with the Structured Interview for Personality Disorders (SIDP) and completed the Personality Disorders Questionnaire (PDQ). Significantly more individuals had a personality disorder according to the SIDP; however, multiple personality disorders were more frequently diagnosed on the PDQ. Schizotypal, compulsive, dependent, and borderline personality disorders were significantly more frequently diagnosed by the PDQ, whereas the SIDP more frequently diagnosed antisocial and passive-aggressive personality disorder. The corresponding dimensional scores of the two measures were all significantly correlated; however, the concordance for categorical diagnoses was poor. Discrepancies between the PDQ and the SIPD dimensional scores were significantly associated with current level of depressive symptoms and PDQ lie scale scores.