Are suicide attempters who self-mutilate a unique population?

OBJECTIVE: Individuals who mutilate themselves are at greater risk for suicidal behavior. Clinically, however, there is a perception that the suicide attempts of self-mutilators are motivated by the desire for attention rather than by a genuine wish to die. The purpose of this study was to determine differences between suicide attempters with and without a history of self-mutilation. METHOD: The authors examined demographic characteristics, psychopathology, objective and perceived lethality of suicide attempts, and perceptions of their suicidal behavior in 30 suicide attempters with cluster B personality disorders who had a history of self-mutilation and a matched group of 23 suicide attempters with cluster B personality disorders who had no history of self-mutilation. RESULTS: The two groups did not differ in the objective lethality of their attempts, but their perceptions of the attempts differed. Self-mutilators perceived their suicide attempts as less lethal, with a greater likelihood of rescue and with less certainty of death. In addition, suicide attempters with a history of self-mutilation had significantly higher levels of depression, hopelessness, aggression, anxiety, impulsivity, and suicide ideation. They exhibited more behaviors consistent with borderline personality disorder and were more likely to have a history of childhood abuse. Self-mutilators had more persistent suicide ideation, and their pattern for suicide was similar to their pattern for self-mutilation, which was characterized by chronic urges to injure themselves. CONCLUSIONS: Suicide attempters with cluster B personality disorders who have a history of self-mutilation tend to be more depressed, anxious, and impulsive, and they also tend to underestimate the lethality of their suicide attempts. Therefore, clinicians may be unintentionally misled in assessing the suicide risk of self-mutilators as less serious than it is.     

Comparison of the suicidal behavior of adolescent inpatients with borderline personality disorder and major depression

The objective of the study was to examine the hypothesis that some forms of suicidal behavior among adolescents are related to helplessness and depression, whereas others are related to anger and impulsivity. Sixty-five adolescents were studied. Thirty-three had borderline personality disorder (BPD), of whom 17 had made a recent suicide attempt. Thirty-two had major depressive disorder (MDD), of whom 16 had made a recent suicide attempt. Assessments were made with the Child Suicide Potential Scale, the Beck Depression Inventory, the Beck Hopelessness Scale, the Multidimensional Anger Inventory, the Overt Aggression Scale, the Impulsiveness-Control Scale, and the Suicide Intent Scale. Adolescents with BPD had more anger, aggression, and impulsiveness than those with MDD, but similar levels of depression and hopelessness. Suicidal versus nonsuicidal adolescents were more depressed, hopeless, and aggressive, but not more angry or impulsive. There were no significant differences in impulsiveness for the MDD suicidal group versus the MDD nonsuicidal group, but the suicidal BPD adolescents were significantly more impulsive than the nonsuicidal BPD adolescents. In the subjects with BPD, impulsiveness and aggression correlated significantly and positively with suicidal behavior. In the subjects with MDD, no such correlations were seen. In both diagnostic groups, depression and hopelessness correlated positively and significantly with suicidal behavior. Anger did not correlate with suicidal behavior in either of the groups. The suicidal subjects with MDD had significantly higher suicidal intent scores than the suicidal adolescents with BPD. We conclude that the nature of suicidal behavior in adolescents with BPD differs from that seen in MDD with respect to the role of anger and aggression.     

Blood platelet uptake of serotonin in episodic aggression

Blood platelet uptake of 3H-serotonin (5HT uptake), a potential marker of serotonergic function, was determined in male outpatients with episodic aggression (n = 15) and in age- and sex-matched nonaggressive controls (n = 15). Correlations with rating scales of "impulsivity" (Barratt Impulsivity Scale, 10th revision) and "anger" (Spielberger Anger Expression Scale) were performed. Mean 5HT uptake was 18% lower in patients with episodic aggression. A significant negative correlation between % difference in platelet 5HT uptake and impulsivity score was observed, but the correlation between 5HT uptake and anger was not significant. These results support the hypothesis of disturbed serotonergic function in aggression and suggest that the primary relationship is in the "control" of aggression. The blood platelet may be useful in identifying impulsive subtypes.     

CSF 5-HIAA levels are lower in impulsive as compared to nonimpulsive violent suicide attempters and control subjects.

BACKGROUND: We studied CSF 5-HIAA and HVA concentrations in violent suicide attempters and examined their relationship with depression, anxiety, and impulsivity. METHODS: CSF 5-HIAA and HVA concentrations were determined very shortly after hospital admission and compared to those of a matched control population. Clinical evaluation was performed concomitantly; the level impulsivity was evaluated by the Impulsivity Rating Scale (IRS). RESULTS: Twenty-three patients and 23 control subjects were included. According to the IRS, 14 patients were classified as impulsive, including all patients suffering from personality disorders, and 9 as nonimpulsive, with a main DSM-IIIR diagnosis of melancholia. CSF 5-HIAA concentrations in the suicide group were significantly lower than in control subjects. This difference was entirely due to the impulsive suicide attempters. There was an inverse correlation between the IRS score and CSF 5-HIAA (r = -.47, p = .02) and only a trend for HVA (r = -.41, p = .078) levels in the suicide group. CONCLUSIONS: This study of a group of violent suicide attempters distinguished a subgroup of patients diagnosed with personality disorder with high impulsivity scores and a subgroup of patients with the main diagnosis of severe depression. CSF 5-HIAA was significantly lower in impulsive violent attempters than in nonimpulsive violent attempters, therefore desintangling violence from impulsivity and linking this biologic abnormality to impulsivity.     

Inter-relationship between different platelet measures of 5-HT and their relationship to aggression in human subjects

The objective of this study was to explore the inter-relationship of three platelet measures of serotonergic function (5-HT): 5-HT Transporter Binding, 5-HT-2 Receptor Binding and 5-HT Content and to explore their inter-relationship with measures of aggression and impulsivity. 58 male subjects with personality disorder were studied. Numbers of platelet 5-HT Transporter and 5-HT-2 Receptor sites were assessed by examining the Bmax of ³H-Paroxetine Binding and the Bmax of ¹²⁵I-LSD Binding to the blood platelet; 5-HT Content was assessed by measuring the amount of 5-HT in the platelet material. Life history of aggression was assessed by Life History of Aggression. Impulsivity was assessed by the Impulsivity Scale of the Eysenck Personality Questionnaire-II. Platelet 5-HT Transporter Binding correlated with both 5-HT-2 Receptor Binding and 5-HT Content; the latter two variables did not correlate with each other. Only Platelet 5-HT Transporter binding correlated significantly with LHA Aggression. These data suggest that while Platelet 5-HT Transporter binding correlates with both 5-HT-2 Receptor Binding and with 5-HT Content, that only 5-HT Transporter Binding represents a correlate of aggression in male personality disordered subjects.     

History of suicide attempt in male substance-dependent inpatients and relationship to borderline personality features, anger, hostility and aggression

The aim of this study was to investigate the relationship between severity of borderline personality features and history of suicide attempt (HSA) in male substance-dependent inpatients and the effect of anger, hostility and aggression on this relationship. Further, the effect of some variables that may be related to suicide and/or borderline personality, such as age at inception of regular substance use, substance of dependence (alcohol/drug), depression, and both state and trait anxiety, were controlled. Participants were 200 consecutively admitted male substance-dependent inpatients. Patients were investigated with the Borderline Personality Inventory (BPI), the Buss-Perry Aggression Questionnaire (AQ), the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI). Among substance-dependent inpatients, 33.0% (n = 66) were identified as the group with HSA. Mean scores employment status, marital status and duration of education did not differ between groups, whereas current age and age at onset of regular substance use were lower in group with HSA. Mean scores of BPI, AQ and its subscales (anger, hostility and physical/verbal aggression), BDI and STAI were higher in the HSA group. In addition, the rates of drug dependency and borderline personality disorder were higher in this group. The severity of borderline personality symptoms was highly correlated with subscales of the AQ, depression and anxiety, whereas it was negatively correlated with age at onset of regular substance use. The severity of anger and borderline personality features predicted HSA in the logistic regression model. Results suggest that, to reduce the risk of suicide attempt among substance-dependent patients, the feeling of anger must be the target of evaluation and treatment among those with borderline personality features.     

Association of aggressive behavior with altered serotonergic function in patients who are not suicidal

OBJECTIVE: The purpose of this study was to determine whether aggression and serotonergic dysfunction are related in the absence of a history of suicidal behavior. Although serotonergic dysfunction has been implicated in aggressive and impulsive behavior, most studies of such behavior have included individuals with a history of suicide attempts. Low concentrations of CSF 5-hydroxyindoleacetic acid (5-HIAA) have been consistently associated with suicidal behavior, presenting a potential confound in the link between aggression and serotonergic dysfunction. METHOD: The authors examined the association between aggression and CSF 5-HIAA concentrations in a group of 64 patients who had different DSM-III-R axis I diagnoses and no past suicidal behavior. Aggressive (N=35) and nonaggressive (N=29) groups were defined by a median split on a six-item history of adulthood aggressive behavior. RESULTS: The aggressive group had significantly lower CSF 5-HIAA concentrations than the nonaggressive group. Aggressive individuals also scored significantly higher on self-report measures of hostility, impulsiveness, and sensation seeking. CSF 5-HIAA concentrations, however, did not correlate with self-reported hostility and impulsivity. CONCLUSIONS: There is an association between aggressive behavior and serotonergic dysfunction independent of suicidal behavior in patients with axis I disorders who exhibit relatively milder forms of aggressive behavior. Analogous to findings with suicidal behavior, a low concentration of CSF 5-HIAA is related to aggressive behavior but does not show the same relationship to the continuum of aggressive feelings and thoughts.     

Alexithymia in parents of daughters with eating disorders: its relationships with psychopathological and personality variables

OBJECTIVES: The purpose of this research was to investigate alexithymia among parents of a daughter with eating disorders (EDs) and to relate alexithymia to personality and psychopathology characteristics. METHODS: Parents of 73 women with ED (20 with anorexia nervosa, restrictive subtype (ANR), 23 with anorexia nervosa, bulimic subtype (ANB) and 30 with bulimia nervosa (BN)) and parents of 72 normal women were evaluated with the Toronto Alexithymia Scale (TAS-20), the Eysenck Personality Questionnaire, the Beck Depression Inventory and the Self-Rating Anxiety Scale. RESULTS: The parents of daughters with ED show higher scores in the TAS-20 and its factors than the controls. TAS-20 scores of parents are associated with neuroticism, anxiety and depression. CONCLUSIONS: Alexithymia in parents of daughters with an ED could be a trait of personality, but it could also be a state due to distress. Alexithymia should be taken into account in order to help these parents express emotions.     

Serotonergic interhemispheric asymmetry: gender difference in the orbital cortex

The asymmetry of tritiated imipramine (IMI) binding sites (which are associated with serotonergic mechanisms) were investigated in the orbital frontal cortex in 6 women and men who died of natural causes, and who did not have a history of mental disorders. There was significant interhemispheric asymmetry in both sexes, higher Bmax on the right side compared with the left. The Bmax values of IMI binding in the right orbital cortex in women were significantly higher than in men. Our preliminary findings--gender difference of serotonergic mechanisms in some area of the human brain--are in accordance with the observed gender differences in a variety of serotonin-regulated behaviors (sexual behavior, aggression and impulse control), and serotonergic mental disorders (eating disorders, suicidal behavior, anxiety disorders and depression).     

Self-mutilative behaviors in male substance-dependent inpatients and relationship with anger and aggression: mediator effect of childhood trauma

The aim of this study was to investigate the relationship of self-mutilation (SM) with anger and aggression in male substance-dependent inpatients. Also, we wanted to evaluate the mediator effect of childhood trauma on these relationships while controlling variables such as age, substance of dependence (alcohol/drug), and negative effect. Participants were consecutively admitted 200 male substance-dependent inpatients. Patients were investigated with the Self-mutilative Behaviour Questionnaire, the Childhood Trauma Reports, the Buss-Perry's Aggression Questionnaire, the State-Trait Anger Expression Inventory, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Rate of being married, current age, and age onset of regular substance use were lower, whereas being unemployed and history of childhood trauma (HCT) were higher in group with SM (n = 124, or 62.0%). Higher mean scale scores were found in SM group. Predictors of SM were being younger, impaired anger control, and physical aggression in logistic regression model. Being younger and the outward expression of anger (anger-out) predicted SM in the subgroup of patients without HCT, whereas being younger, severity of anger, and the inward expression of anger (anger-in) predicted SM in the subgroup of patients with HCT. Thus, to reduce self-mutilative behavior among substance-dependent patients, clinicians must improve anger control, particularly in younger patients. Type of strategy for coping with anger, which must be worked on, may differ in different subgroup patients, that is, focusing anger toward self among those with HCT, whereas anger toward others among those without.     

Defense mechanisms, negative emotions, and psychopathology in adolescent inpatients

Ego defense mechanisms were compared in adolescent psychiatric inpatients and healthy adolescents to determine their relationship to specific diagnoses and to negative emotions. Seventy-one patients with schizophrenia, 28 with major depressive disorder, and 24 with obsessive-compulsive disorder (OCD) and 87 normal adolescents were assessed for defense mechanisms by the Life Style Index (LSI) and Ego Defense Scale (EDS). The Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Multidimensional Anger Inventory (MAI) were used to assess depression, anxiety, and anger. Several defenses distinguished all psychiatric patients from controls, and a few defenses characterized different patient groups, especially those with OCD. Projection (on the LSI), displacement, and regression correlated significantly with anger; displacement, reaction formation, and undoing on the EDS correlated with anxiety, and denial was negatively correlated with depression. These findings have some relevance for the evaluation of Plutchik's psychoevolutionary theory of emotions and for the further empirical study of defenses in psychopathology.     

Cerebrospinal fluid 5-hydroxyindolacetic acid and homovanillic acid: reciprocal relationships with impulsive aggression in human subjects

While the relationship between cerebrospinal fluid 5-HIAA (CSF 5-HIAA) and aggression is typically reported as inverse, studies of some groups of aggressive individuals demonstrate a positive (or no) relationship, between these two variables. It is possible that simultaneous examination of both CSF 5-HIAA and CSF homovanillic acid (HVA), which co-vary in human subjects may clarify differences in reported findings in different groups of aggressive individuals. CSF 5-HIAA and CSF HVA concentrations were simultaneously examined in 60 healthy human subjects (40 with personality disorder and 20 healthy controls) and were correlated with measures of aggression and impulsivity. CSF 5-HIAA concentrations correlated positively, and CSF HVA concentrations correlated inversely, with a composite measure of impulsive aggression in all subjects as well as in the personality disordered subjects. The CSF 5-HIAA findings are consistent with those demonstrating reduced post-synaptic 5-HT receptor responsiveness to 5-HT agent challenge and suggest differences in the pathophysiology between different groups of subjects with aggressive behavior, particularly with regard to severity of aggressive behavior.     

Preliminary evidence of improvement of depressive symptoms but not impulsivity in cluster B personality disorder patients treated with quetiapine: an open label trial

INTRODUCTION: Atypical antipsychotics might become a new treatment option for patients with an impaired impulse regulation as seen in cluster B personality disorders (PD). The aim of the present study is to investigate the efficacy and tolerability of quetiapine in patients with cluster B PD. METHODS: Fifteen in-patients with a DSM-IV diagnosis of borderline, histrionic, or narcissistic PD were treated for 8 weeks with quetiapine at a dose of 400 mg/day in an open-label fashion. Effects on impulsivity (Barratt Impulsiveness Scale, BIS), depressive symptoms (Hamilton Depression Scale, HAMD, and Beck Depression Inventory, BDI) and side effects (Dosage Record and Treatment Emergent Symptom Scale, DOTES) were assessed. RESULTS: Twelve patients completed the study. No positive effect on impulsivity (BIS) was found, but a significant improvement on depression scores (HAM-D and BDI) was noted. Adverse effects that might have been due to study medication were mainly anticholinergic and mild-to-moderate. DISCUSSION: The data of our preliminary open-label study do not argue for a general recommendation of quetiapine for the treatment of impulsivity in cluster B PD, but indicate positive effects on depressive symptoms.     

Clinical correlates of self-mutilation in Turkish male substance-dependent inpatients

OBJECTIVE: The aim of this study was to evaluate the prevalence of self-mutilation (SM) in male substance-dependent inpatients, and to investigate the relationship of SM with childhood abuse and neglect, axis I disorders and personality disorders. METHODS: Participants were 112 consecutively admitted male substance dependents (56 alcohol and 56 drug). Substance dependence was diagnosed by means of the Structured Clinical Interview for DSM-IV (SCID-I, Turkish version). Patients were evaluated by the Childhood Abuse and Neglect Questionnaire, SCID-I, SCID-II, Beck Depression Inventory and Beck Anxiety Inventory. RESULTS: Among substance-dependent patients, SM was found to be present in 33% (SM group). Mean age and educational status were lower in the SM group. Moreover rates of being single, history of childhood physical and emotional abuse and neglect, suicide attempt history and personality disorder were higher. Mean depression and anxiety scores were also higher in the SM group. Personality disorder, physical abuse, suicide attempt history and drug dependency were predictors for SM. CONCLUSIONS: SM is more common in drug dependents than alcohol dependents. Also results of this study suggest that among Turkish substance dependents SM might be related to the presence of personality disorder and childhood physical abuse and suicide attempts.     

Is focal hand dystonia associated with psychopathology?

The purpose of this study was to determine if patients with focal hand dystonia have any significant psychopathology. We studied 20 patients with hand cramps who were participating in a therapeutic trial of botulinum toxin injections. Patients were interviewed and administered the Minnesota Multiphasic Personality Inventory (MMPI). Beck Depression Inventory, Spielberger State-Trait Anxiety Scale, a finger tapping test, and a choice serial reaction time test. Behavioral ratings were also obtained. Group statistics indicated that all personality scale scores and performances on motor tasks were within normal limits. Four out of 20 patients demonstrated mild depression. Trait anxiety scores were higher than state anxiety scores, suggesting that receiving medical treatment had a beneficial effect on mood. The number of depressive symptoms endorsed on the MMPI was correlated with reaction time speed but not finger dexterity. None of the 20 patients reported a remarkable psychiatric history. These results indicate that hand cramps are not associated with serious psychopathology.     

CSF metabolites in borderline personality disorder compared with normal controls.

Cerebrospinal metabolites were measured in 17 patients with borderline personality disorder and 17 normal controls. There were no significant differences between the two groups in levels of 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), or 3-methoxy-4-hydroxyphenylglycol (MHPG). Within the borderline group, lower levels of CSF 5-HIAA were significantly associated with a history of genuine suicide attempts, but were not associated with violence, self-mutilation, or with the presence of major depression. Thus, CSF 5-HIAA levels are not distinctively low in a diagnostic group characterized by impulsivity and suicidal behavior, but within that group may be associated with genuine suicide attempts.     

Personality and attempted suicide. Analysis of anger, aggression and impulsivity

Suicide is one of the leading causes of death worldwide, mortality from suicide being approximately 2%. Attempted suicide appears to be a major risk factor for suicide completion. Anger, aggression and impulsivity are personality traits associated with suicide attempt. In this study we analysed a part of a previously reported sample in order to test anger, impulsivity and temperament/character scales as predictors of aggression and self-aggression in suicide attempters and to compare anger- and aggression-related traits between impulsive and premeditated suicide attempts as well as between violent and non-violent suicide methods.One-hundred-eleven consecutively admitted inpatients with a lifetime history of attempted suicide were assessed for anger (State-Trait Anger Expression Inventory, STAXI), aggression (Questionnaire for Measuring Factors of Aggression, FAF) and temperament/character (Temperament and Character Inventory, TCI).Higher aggression scores, as measured by FAF, were predicted by being male, meeting criteria for borderline personality disorder and having higher angry temperament scores as assessed by STAXI; low cooperativeness was also associated with aggression but not after controlling for STAXI scales. TCI dimensions associated with self-aggression were high harm avoidance, high impulsivity and low self-directedness; state anger, inwardly directed anger and inhibition of aggression were also predictors of self-aggression.In conclusion, impulsivity and harm avoidance have emerged as temperament dimensions independently associated with self-aggressive tendencies in personality. Such interactions could explain the correlation between temperament and suicidality but further research is needed. Anger and self-directedness appear to have some effects on suicide attempt.     

The Mood Spectrum Self-Report: validation and adaptation into Spanish

This study explores the psychometric properties of the Spanish adaptation of the Mood Spectrum Self-Report (MOODS-SR), an instrument designed to assess a broad range of manifestations of mood psychopathology. A total of 71 Spanish subjects participated: 49 outpatients who met criteria for a mood disorder or generalized anxiety disorder, and 22 normal controls. The instrument proved to have good internal consistency and test-retest reliability. Significant positive correlations were found between the depressive subdomains of the questionnaire and the Beck Depression Inventory, as well as between the manic-hypomanic subdomains and the Clinician-Administered Rating Scale for Mania. Clinical subjects displayed higher mean scores than normal subjects in all domains, and patients with bipolar disorder displayed higher scores than patients with unipolar disorder in the Manic component, particularly in the Energy and the Cognition subdomains. Differences between patients with generalized anxiety and mood disorders were small. The former, however, did not differ from normal controls in several subdomains, whereas patients with mood disorders did.     

Psychologic correlates of eating attitudes in Turkish female college students

OBJECTIVE: The purpose of this study is to determine the frequency and correlates of disordered eating attitudes in a university-sample Turkish female population and to evaluate the contribution of maternal psychopathologic symptoms and family functioning. METHOD: Female students (n = 267; mean age, 21.21 +/- 1.88 years) completed the Eating Attitude Test, Beck Depression Inventory, 20-item Toronto Alexithymia Scale, Symptom Check List 90-R, and Family Assessment Device. Mothers (n = 96; mean age = 46.41 +/- 5.31 years) completed the Beck Depression Inventory, 20-item Toronto Alexithymia Scale, and Symptom Check List 90-R. RESULTS: Twelve percent of the female college students had abnormal eating attitudes. Disordered eating attitudes were positively correlated with depression, obsessive-compulsive symptoms, and phobic anxiety. Eating attitude of the student sample was positively correlated with the mothers' obsessive-compulsive symptoms, phobic anxiety, and general psychopathology and "affective involvement" in family functioning. CONCLUSIONS: It is necessary to pay attention to the levels of depression, alexithymia, anxiety, and obsession-compulsions, as well as family functioning and maternal psychopathology.     

The relationship of Internet addiction severity with Attention Deficit Hyperactivity Disorder symptoms in Turkish University students; impact of personality traits,depression and anxiety

Aim

The aim of this study was to investigate the relationship of Internet addiction (IA) with Attention Deficit Hyperactivity Disorder (ADHD) symptoms while controlling the effect of personality traits, depression and anxiety symptoms in Turkish university students.

Methods

A total of 271 university students participated in the present study. The students were assessed through the Internet Addiction Scale (IAS), the Wender Utah Rating Short Scale (WURS-25), the Turkish version of the Adult ADHD Self-Report Scale (ASRS), the Eysenck Personality Questionnaire Revised Abbreviated Form (EPQR-A), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI).

Results

According to IAS, participants were separated into three groups, namely, moderate/high, mild and without IA groups. The rates of groups were 19.9% (n = 54), 38.7% (n = 105) and 41.3% (n = 112), respectively. Correlation analyses revealed that the severity of IAS is positively correlated with WURS-25, ASRS (total, inattention and hyperactivity/impulsivity subscales), neuroticism personality trait, depression and anxiety scores, whereas it is negatively correlated with extraversion personality trait. Hierarchical regression analysis indicated that depression and anxiety symptoms, introversion and neuroticism personality traits and the severity of ADHD symptoms (particularly hyperactivity/impulsivity symptoms) are the predictors for IAS score, respectively.

Conclusions

The severity of ADHD symptoms has predicted the severity of IA even after controlling the effect of personality traits, depression and anxiety symptoms among Turkish university students. University students with severe ADHD symptoms, particularly hyperactivity/impulsivity symptoms may be considered as a risk group for IA.