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     

Comorbidity of dependent personality disorder and separation anxiety disorder in addictive disorders and in healthy subjects

The aim of the study was to determine the comorbidity of dependent personality disorder (DPD) and separation anxiety disorder (SAD) in large nonclinical and clinical samples. Using a cross-sectional method, the relationship between these disorders was studied in 784 healthy subjects and in 708 subjects presenting with various addictive behaviors. DPD was significantly associated with SAD in healthy subjects, alcoholics, drug abusers and anorectic and bulimic patients. The comorbidities of SAD and DPD suggest that specific therapeutic strategies could be discussed. Moreover, longitudinal studies are required to determine if SAD constitutes a risk factor for DPD.     

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.     

Parental representation in eating disorder patients with suicide

OBJECTIVE: We examined parental, personality, and symptomatological characteristics in relation to suicide attempts among eating disorder patients. METHODS: Fifty-one eating disorder inpatients, divided into two groups according to lifetime suicide attempts, and 107 non-psychiatric subjects were compared on the following variables: Parental Bonding Instrument (PBI), Global Clinical Score (GCS), Eating Disorder Inventory-91 (EDI-91), Eating Attitudes Test-26 (EAT), clinical and personality characteristics, and family backgrounds. RESULTS: Suicidal patients reported significantly higher overprotection by both parents than non-suicidal patients and non-psychiatric subjects. Suicidal patients had a more prevalent history of child abuse, affective instability, unstable self-image, avoidance of abandonment, maladaptive perfectionism, personality disorder, and mood disorder. There were no differences in symptomatological factors or the severity of the eating disorders. CONCLUSION: The results suggest that high overprotection is associated with suicidal behaviour in eating disorder patients. The association between overprotective parenting and personality characteristics, and methods of suicide prevention are discussed briefly.     

Suicide and other causes of death in a five-year follow-up of patients treated for self-poisoning in Oslo

This 5-year follow-up study includes all patients (n = 934; 50% females) treated for self-poisoning in Oslo during 1 year. Seventeen percent were considered suicide attempts upon admission, 25% among the nonabusers and 8% among the abusers. At follow-up, 122 patients were dead (61% males). The mortality rate was highest among the abusers. The mortality rate was similar (13%) among those who were considered to be suicidal on admittance and those who were not. The causes of death were suicide (28%), opiate abuse (16%), heart disease (14%), accidents or wounds (11%), alcoholism (9%) and others (22%). The standard mortality rate was highly increased in all groups (8 times on average), highest among the female opiate abusers, whose rate was 63 times higher than expected. The increased suicide rates (87 times for females, 27 times for males), however, may be a more relevant measure of mental morbidity than the standard mortality rate. Logistic regression analysis demonstrated that male sex, age above 50 years and the lowest social group were factors on admission associated with death in the follow-up period. Age above 50 years and suicidal attempt on admission were associated with subsequent suicide. The study strongly supports the idea of self-destructiveness and slow suicide in substance abuse.     

Comorbid personality disorders in subjects with panic disorder: do personality disorders increase clinical severity?

Personality disorders are common in subjects with panic disorder. Personality disorders have been shown to affect the course of panic disorder. The purpose of this study was to examine which personality disorders affect clinical severity in subjects with panic disorder. This study included 122 adults (71 women, 41 men) who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ( DSM-IV ) criteria for panic disorder (with or without agoraphobia). Clinical assessment was conducted by using the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and the Panic and Agoraphobia Scale, Global Assessment Functioning Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Patients who had a history of sexual abuse were assessed with Sexual Abuse Severity Scale. Logistic regressions were used to identify predictors of suicide attempts, suicidal ideation, sexual abuse, and early onset of disorder. The rates of comorbid Axes I and II psychiatric disorders were 80.3% and 33.9%, respectively, in patients with panic disorder. Patients with panic disorder with comorbid personality disorders had more severe anxiety, depression, and agoraphobia symptoms, had earlier ages at onset, and had lower levels of functioning. The rates of suicidal ideation and suicide attempts were 34.8% and 9.8%, respectively, in subjects with panic disorder. The rate of patients with panic disorder and a history of childhood sexual abuse was 12.5%. The predictor of sexual abuse was borderline personality disorder. The predictors of suicide attempt were comorbid paranoid and borderline personality disorders, and the predictors of suicidal ideation were comorbid major depression and avoidant personality disorder in subjects with panic disorder. In conclusion, this study documents that comorbid personality disorders increase the clinical severity of panic disorder. Borderline personality disorder may be the predictor of a history of sexual abuse and early onset in patients with panic disorder. Paranoid and borderline personality disorders may be associated with a high frequency of suicide attempts in patients with panic disorder.     

Suicidal ideation and suicide attempts in body dysmorphic disorder

OBJECTIVE: Because suicidality in body dys-morphic disorder (BDD) has received little investigation, this study examined rates, correlates, predictors, and other aspects of suicidal ideation and suicide attempts in this disorder. METHOD: From January 2001 to June 2003, 200 subjects with DSM-IV BDD recruited from diverse sources were assessed with standard measures. RESULTS: Subjects had high rates of lifetime suicidal ideation (78.0%) and suicide attempts (27.5%). Body dysmorphic disorder was the primary reason for suicidal ideation in 70.5% of those with a history of ideation and nearly half of subjects with a past attempt. Suicidal subjects often did not reveal their BDD symptoms to their clinician. In univariate analyses, both suicidal ideation and suicide attempts were associated with lifetime functional impairment due to BDD (p < .001), current functional impairment (p < .001 to < .05), lifetime bipolar disorder (p < .05), any personality disorder (p < .05 to .001), and comorbid borderline personality disorder (p < .01 to < .001). A history of suicidal ideation (but not suicide attempts) was additionally associated with comorbid lifetime major depression (p = .001). A history of suicide attempts (but not suicidal ideation) was additionally associated with delusional appearance beliefs (p = .01) and lifetime posttraumatic stress disorder (PTSD), an eating disorder, or a substance use disorder (p < .001 to < .05). In logistic regression analyses, suicidal ideation was significantly predicted by comorbid major depression (p = .010) and greater lifetime impairment due to BDD (p = .003); suicide attempts were significantly predicted by PTSD (p = .011), a substance use disorder (p = .011), and greater lifetime impairment due to BDD (p = .005). CONCLUSION: Individuals with BDD have high rates of suicidal ideation and suicide attempts. Lifetime impairment due to BDD and certain comorbid disorders are associated with suicidality.     

Analysis of association of clinical correlates and 5-HTTLPR polymorphism with suicidal behavior among Chinese methamphetamine abusers

Substance use disorders are familial, and genetic factors explain a substantial degree of their familial aggregation. Methamphetamine (MAP) abusers are commonly noted as having psychosis, depression and suicidal behavior. The goals of the present study were (i) to investigate relations of clinical correlates, such as gender, drug use behavior, psychiatric comorbidity and psychiatry family history, with suicidal behavior among Chinese MAP abusers; and (ii) to investigate whether there is an association between a polymorphism in the promotor region of the serotonin transporter gene (5-HTTLPR) and suicidal behavior among Chinese MAP abusers. A total of 439 MAP abusers from a hospital and detention center in Taipei were interviewed with the Diagnostic Interview for Genetic Study and the Family Interview for Genetic Study. The 5-HTTLPR polymorphism was compared between 94 MAP abusers with suicide attempts and 294 MAP abusers without suicide attempts, for whom DNA data were available. The results of the present study indicate that among MAP abusers in Taiwan, suicide attempts were significantly related to female gender, history of MAP-induced psychotic disorder, history of MAP-induced depressive disorder, and family history of psychotic disorders. Among suicide attempters, the attempters with moderate to severe lethality used higher MAP doses than those with minimal to mild lethality. In the present sample the triallelic 5-HTTLPR polymorphism (S, L(G), L(A)) was not associated with MAP-induced depressive disorder, MAP-induced psychotic disorder or suicidal behavior, but studies with larger sample sizes are warranted before excluding the role of the 5-HTTLPR polymorphisms in suicidal behavior among MAP abusers.     

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.     

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.     

Psychiatric comorbidity and gender difference among treatment-seeking heroin abusers in Taiwan

The objectives of the present study were to estimate the psychiatric comorbidity of Taiwanese heroin users seeking treatment and to identify the gender differences in psychiatric comorbidity and drug use behavior. Subjects were interviewed using a structured questionnaire on drug use behavior and the Mini International Neuropsychiatric Interview for psychiatric disorders. Of the subjects, 58.5% of the male and 62.5% of the female subjects had at least one non-substance-use axis I psychiatric disorder or antisocial personality disorder. Compared to male subjects, female subjects were younger, were less educated, had higher rates of unemployment and had earlier onset of illicit drug use. Female subjects were 11-fold more likely than male subjects to exhibit suicidal behavior. Among heroin abusers in the present study, female subjects were more widely exposed to unfavorable social factors and had substantially higher incidence of suicidal behavior than male subjects. Drug treatment centers should be aware of these gender differences and pay particular attention to comorbid depressive disorders and suicidal behavior of female heroin abusers.     

Gender differences in suicide attempts from adolescence to young adulthood

OBJECTIVE: To examine associations of age, gender, and psychosocial factors during adolescence with risk of suicide attempt between ages 19 and 23 years. METHOD: Initial assessments were conducted with 1,709 adolescents (aged 14-18) in western Oregon between 1987 and 1989. One year later, 1,507 participants returned for a second assessment. A subset of participants (n = 941; 57.2% women) had a third diagnostic assessment after turning 24 (between 1993 and 1999). Information on suicidal behavior, psychosocial risk factors, and lifetime DSM-III-R psychiatric diagnosis was collected at each assessment. RESULTS: The suicide attempt hazard rate for female adolescents was significantly higher than for male adolescents (Wilcoxon chi 2(1)[n = 941] = 12.69, p < .001). By age 19, the attempt hazard rate for female adolescents dropped to a level comparable with that of male adolescents. Disappearance of the gender difference for suicide attempts by young adulthood was not paralleled by a decrease in the gender difference for major depression. Adolescent suicidal behavior predicted suicide attempt during young adulthood for female, but not male, participants. Adolescent psychosocial risk factors for suicide attempt during young adulthood were identified separately for girls and boys. CONCLUSIONS: Unlike depression, the elevated incidence rate of suicide attempts by adolescent girls is not maintained into young adulthood. Screening and prevention implications are discussed.     

Temperament and character personality profile in relation to suicide attempts in patients with schizophrenia

Introduction

Schizophrenia is associated with a significant risk of suicide, and suicide still remains one of the main causes of death in schizophrenic patients. Beside classic risk factors for suicidality, temperament and character traits have been researched and considered as risk factors for suicidal behavior in recent years.

Method

Subjects were 94 patients with schizophrenia who were under treatment. All patients were in a stable phase of the illness. Patients with lifetime suicide attempt (n = 46) and without suicidal attempt (n = 48) were compared with each other in terms of temperament and character traits by using the Temperament and Character Inventory.

Results

Harm avoidance and persistence scores were higher in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. The scores of self-directedness and cooperativeness were lower in suicidal schizophrenic patients compared with nonsuicidal schizophrenic patients. These 4 variables remained significant predictors of lifetime suicidal attempts in a logistic regression model.

Conclusion

To the best of our knowledge, the present study is the first that specifically compares schizophrenic patients with and without suicidal behavior by the Cloninger temperament and character model. Our data indicate that schizophrenic patients will show a greater risk for suicide according to certain personality configurations. However, to establish causal relationships between personality and suicidality in schizophrenia, longitudinal studies are warranted within a multifactorial interactive framework of biologic and clinical variables.     

Female psychoactive substance-dependent suicide victims differ from male--results from a nationwide psychological autopsy study

Suicides involving alcohol or other substance dependence have been studied in male-dominated populations. We studied male and female suicide victims with DSM-III-R psychoactive substance dependence (PSD) separately in a nationwide psychological autopsy study in Finland. The subjects were substance-dependent males from a systematic random sample and all substance-dependent female suicide victims from the total population of suicides committed over a 1-year period in Finland. Comparisons by sex and age were made, and two logistic models were created predicting sex. Females were more likely to have abused or been dependent on prescribed medication. Female victims aged 40 years or less had a relatively high frequency of borderline personality disorder (BPD), frequent previous suicide attempts, and suicidal communication, whereas older females were more like older males. The onset of a comorbid axis I disorder preceded substance dependence more often among females. Male and female substance-dependent suicide victims differ in a number of characteristics, including previous suicidality, age-related variation in personality disorders, and type of substance used. Findings from studies of predominantly male substance-dependent suicide victims cannot necessarily be generalized to females.     

大中学生自杀意念及相关心理变量研究

目的:探讨大中学生自杀意念与相关心理变量的关系。方法:采用分层取样法,对某市初二到硕士研究生一年级828名被试进行自杀意念量表(SSI)等量表测试。结果:①随年龄增长,大中学生自杀意念、企图呈下降趋势。女生自杀意念比男生多,而男生自杀行为能力比女生强;②有无自杀意念者在临床症状、人格因素、应对风格及生活满意度上差异均有统计学意义;③自杀意念与症状自评量表(SCL-90)各分量表、艾森克个性问卷(EPQ)神经质、精神质、应对检查表(COPE)诸多应对风格显著相关。结论:大中学生自杀意念与临床症状、应对方式、人格和生活满意度存在相关。     

Personality trait risk factors for attempted suicide among young women with eating disorders.

OBJECTIVE: - Clinical observations and a review of the literature led us to hypothesize that certain personality and character traits could provide improved understanding, and thus improved prevention, of suicidal behaviour among young women with eating disorders. METHOD: - The clinical group consisted of 152 women aged between 18 and 24 years, with DSM-IV anorexia nervosa/restrictive type (AN-R = 66), anorexia nervosa/purging type (AN-P = 37), bulimia nervosa/non-purging type (BN-NP = 9), or bulimia nervosa/purging type (BN-P = 40). The control group consisted of 140 subjects. The assessment measures were the Minnesota Multiphasic Personality Inventory-second version (MMPI-2) scales and subscales, the Beck Depression Inventory (BDI) used to control for current depressive symptoms, plus a specific questionnaire concerning suicide attempts. RESULTS: - Suicide attempts were most frequent in subjects with purging behaviour (30.0% for BN-P and 29.7% for AN-P). Those attempting suicide among subjects with eating disorders were mostly students (67.8%). For women with AN-R the scales for 'Depression' and 'Antisocial practices' represented significant suicidal risk, for women with AN-P the scales for 'Hysteria', 'Psychopathic deviate', 'Shyness/Self-consciousness', 'Antisocial Practices', 'Obsessiveness' and 'Low self-esteem' were risk indicators and for women with BN-P the 'Psychasthenia', 'Anger' and 'Fears' scales were risk indicators. CONCLUSION: - This study provides interesting results concerning the personality traits of young women with both eating disorders and suicidal behaviour. Students and those with purging behaviour are most at risk. Young women should be given more attention with regard to the risk of suicide attempts if they: (a). have AN-R with a tendency to self-punishment and antisocial conduct, (b). have AN-P with multiple physical complaints, are not at ease in social situations and have antisocial behaviour, or (c). if they have BN-P and tend to be easily angered with obsessive behaviour and phobic worries. The MMPI-2 is an interesting assessment method for the study of traits indicating a risk of suicidal behaviour in young subjects, after controlling for current depressive pathology.     

Male-specific association between the 5-HTTLPR S allele and suicide attempts in alcohol-dependent subjects

Changes in serotoninergic neurotransmission have been implicated in the pathogenesis of suicidal behavior and alcohol dependence. Previous studies have demonstrated an association between suicide attempts and the 5-HTTLPR S allele in alcohol-dependent subjects. We investigated the frequency of the S allele of 5-HTTLPR in a sample of 100 French Caucasian alcohol-dependent inpatients (48 men and 52 women) with and without a history of suicide attempts. The frequencies of 5-HTTLPR genotypes did not differ significantly between men and women. A history of at least one suicide attempt was more frequent in women than in men (57.5% versus 31.3%, respectively, p=0.008). Logistic regression analysis showed that the presence of the S allele of 5-HTTLPR was related to a life-time risk of suicide attempts, but only in male subjects (p=0.05). There seems to be an allelic association between the 5-HTTLPR S allele and suicidal behavior in alcohol-dependent subjects, but this relationship is restricted to male subjects.     

A comparison of life events between suicidal adolescents with major depression and borderline personality disorder

The current study compared the correlations of different types of stressful life events (SLE) between suicidal adolescents with major depressive disorder (MDD) and suicidal adolescents with borderline personality disorder (BPD). Both groups were referred following an attempted suicide. Twenty adolescents with MDD and 20 adolescents with BPD who were consecutively referred to an outpatient clinic following a suicide attempt were evaluated. A community control group of adolescents with no lifetime history of suicidal behavior was also assessed. The following measurements were employed: the Suicide Risk Scale (SRS) Beck Depression Inventory (BDI), the Life Events Checklist (LEC), and the Childhood Sexual Abuse Questionnaire (CSEQ). Both groups of suicidal subjects reported more SLE in general and more physical abuse than community controls in the 12 months before the suicide attempt. The MDD adolescents had more lifetime death-related SLE than the BPD and control groups, while the BPD adolescents reported more lifetime sex abuse-related SLE than the other two groups. Thus, suicidal behavior in general may be related to the amount of SLE. However, different disease-specific life events may precipitate suicide attempts in adolescents with MDD and BPD.     

Characteristics of out-patient adolescents with suicidal tendencies

Suicidal adolescent out-patients were compared with non-suicidal subjects with respect to background factors, psychopathology and treatment received. Data for suicidal ideation, suicide attempts, psychiatric diagnoses (DSM-III-R) and other patient-related factors were collected prospectively during treatment of 122 male and 138 female out-patients aged 12–22 years. In total, 42% of subjects displayed suicidal tendencies, and 18% had attempted suicide. According to polychotomous regression, mood disorder, previous psychiatric treatment arid low level of psychosocial functioning at treatment entry were associated with suicide attempts and with suicidal ideation for both sexes. Suicidal patients were more often receiving psychotropic medication and had more total appointments (mean number 15 vs. 9) than non-suicidal patients. Suicidal and non-suicidal patients kept their scheduled appointments to the same extent (66% vs. 65%). Treatments which meet the needs of disordered suicidal adolescents need to be developed.     

Relationship between attempted suicide,serum cholesterol level and novelty seeking in psychiatric in-patients

This study sought to compare the serum cholesterol levels of psychiatric in-patients, with and without recent suicidal behavior. The hypothesis was that the temperament dimension novelty seeking (NS) would be an intermediary variable, correlated with both serum cholesterol level and suicidal behavior. The study included 155 psychiatric in-patients, 21.9% (n=34) of whom had recently attempted suicide. Their cholesterol level was compared to that of patients with no suicide attempt. The NS dimension was explored with the aid of Cloninger's Temperament and Character Inventory. Significantly lower average cholesterol levels were found in women who had attempted suicide before hospitalization than for the others (4.71 mmol/l+/-0.83 vs. 5.52 mmol/l+/-1.36). Similar results were not found for men. However, the average NS scores did not differ according to suicide attempts in women or in men, and the scores of NS were not correlated with cholesterol level. This study confirms an association between low cholesterol and suicidal behavior in women only, but this association seems independent from the NS personality dimension. The absence of a correlation between serum cholesterol levels and suicidal behavior in men could be linked to the small number of men included in the study.