Personality traits in attempted and completed suicide

ObjectiveThough widely used in clinical and biological studies, no investigation of the factor structure of the Karolinska Scales of Personality (KSP) has been performed in suicide attempters. There are very few studies of personality traits in suicide completers. The aim of the present study was to assess the factor structure of KSP in suicide attempters. A secondary aim was to examine whether the factor structure of the KSP was related to gender and/or to violent method of the suicide attempt or to suicide completion.MethodThe factor structure of the KSP was analysed in data from 165 suicide attempters from the Suicide Prevention Clinic at the Karolinska University Hospital using principal component analysis and orthogonal varimax rotation for the factor extraction. The effect of gender and (1) used method in the suicide attempt (violent versus nonviolent), and (2) later completed suicide on the factors was assessed in two separate series of the two-way ANOVAs.ResultA four-factor solution appeared: (1) Neuroticism, (2) Nonconformity, (3) Psychoticism and (4) Extraversion. Men who later completed suicide reported more Extroversion than male survivors.ConclusionThe obtained factor structure is comparable to a previous factor structure in a group of twins from the population-based Swedish Twin Registry indicating that no specific personality structure characterized the current sample. Differences in personality traits between suicide completers and survivors indicate that these groups may have some distinct characteristics.     

Relationships between attempted suicide, temperamental vulnerability, and violent criminality in a Swedish forensic psychiatric population.

The relationship between suicide attempts and different vulnerability factors was investigated in 61 male subjects during forensic psychiatric examination. Personality traits and psychopathy were determined by means of the Karolinska Scales of Personality (KSP) and the Psychopathy Checklist-Revised (PCL-R). Clinical diagnoses were determined by the use of Structured Clinical Interview for DSM-III-R (SCID). Platelet monoamine oxidase (MAO) activity was investigated in 58 subjects.Suicide attempters had extremely low socialization and high impulsive aggression. This was independent of a history of repeatedly criminal violence or not. They had higher PCL-R scores and lower levels of platelet MAO activity than non-attempters. No relationship was found between suicide attempts and repeated violent criminality. However, among the subjects with repeated criminal violence there was a highly significant difference between suicide attempters and non-attempters, indicating different personality profiles in violent offenders with and without suicidal behavior. Suicidal behavior was significantly associated with borderline personality disorder, but not with any other single DSM-III-R disorder. The results show a far more severe personality disturbance in suicide attempters than in other violent patients in this type of population. Suicidal behavior should therefore be evaluated and treated per se.     

High interleukin-6 and impulsivity: determining the role of endophenotypes in attempted suicide

The dysregulation of inflammation has been associated with depression and, more recently, with suicidal behaviors. The reports regarding the relationship between interleukin-6 (IL-6) and suicide attempts are inconsistent. Personality traits such as impulsivity and aggression are considered endophenotypes and important factors that underlie suicidal behaviors. The aim of the current study was to assess whether plasma and cerebrospinal fluid (CSF) levels of IL-6 are associated with personality traits among suicide attempters. We assessed the relationships among personality traits, IL-6 and violent suicide attempts. The plasma and CSF levels of IL-6 were measured in suicide attempters (plasma=58, CSF=39) using antibody-based immunoassay systems. Personality domains were assessed using the Karolinska Scale of Personality (KSP). IL-6 levels in plasma and CSF were used to predict personality domains via regression models. Plasma IL-6 was significantly and positively correlated with extraversion as well as the KSP subscales impulsivity and monotony avoidance. CSF IL-6 was positively correlated with monotony avoidance. Violent suicide attempts tended to be associated with high plasma IL-6 levels. Plasma and CSF levels of IL-6 were not significantly associated with each other. These results indicate that impulsivity and the choice of a violent suicide attempt method might be related to higher levels of IL-6 in individuals who attempt suicide. The neuroinflammation hypothesis of suicidal behavior on the basis of elevated IL-6 levels might be partly explained by the positive association between IL-6 and impulsivity, which is a key element of the suicidal phenotype.     

Temperament and character of suicide attempters

Temperamental features are strongly associated with suicidal behaviors both in general population and clinical samples. In the present study we considered the association between personality traits, measured by Temperament and Character Inventory (TCI), and suicidal behavior. We analyzed five samples: a German control sample of 1148 healthy individuals; 144 German suicide attempters affected by Mood (n=101), Schizophrenia spectrum (n=20) and Borderline Personality (n=23) Disorders; 46 Italian suicide attempters affected by Mood Disorders (UP=15; BP=31); 76 German non-suicide Mood Disorder patients; 147 Italian non-suicide Mood Disorder patients. Suicide attempters showed higher scores in Harm Avoidance (HA) and lower scores in Self-Directedness (SD) and Cooperativeness (C), when compared to controls. Nevertheless, comparing the German and the Italian suicide attempter groups with the non-suicide Mood Disorder patient groups, no differences were detected. This could be due to the effect of Mood Disorder on personality. In conclusion, the present study reveals the difficulty to disentangle the personality profile of suicide attempters from their psychopathology. Those findings may be useful for cautions in further dissecting this complex phenotype.     

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。     

Markers for vulnerability to psychopathology: temperament traits associated with platelet MAO activity

The functional linkage between platelet MAO activity and psychopathology was explored by analyzing temperamental correlates in 40 male subjects by means of scales from the Eysenck Personality Questionnaire (EPQ), the Zuckerman Sensation Seeking Inventory, and the Karolinska Scales of Personality (KSP). Linear correlations were found with two sensation seeking scales, replicating earlier findings. However, nonlinear correlations predominated. Subjects with intermediate platelet MAO activity had higher scores in conformity scales and lower scores in anxiety and hostility scales than low and high MAO subgroups. Low MAO subjects showed a pattern of higher scores in KSP Impulsiveness, EPQ Neuroticism, and KSP Somatic Anxiety and Irritability and lower scores in KSP Socialization, in line with personality profiles found in alcoholics, psychopaths, and suicide attempters who also tend to have low platelet MAO activity. High MAO subjects scored lower in sensation seeking and conformity scales and higher in KSP Psychasthenia, Muscular Tension and Suspicion scales, consistent with clinical links between high platelet MAO activity and anxiety and paranoia.     

Karolinska Scales of Personality,cognition and psychotic symptoms in patients with schizophrenia and healthy controls

Background: Studies on both personality dimensions and cognition in schizophrenia are scarce. The objective of the present study was to examine personality traits and the relation to cognitive function and psychotic symptoms in a sample of patients with schizophrenia and healthy controls. Method: In total 23 patients with schizophrenia and 14 controls were assessed with the Karolinska Scales of Personality (KSP). A broad cognitive test programme was used, including the Wechsler Adult Intelligence Scales, the Finger-Tapping Test, the Trail Making Test, the Verbal Fluency Test, the Benton Visual Retention Test, the Wisconsin Card Sorting Test and Rey Auditory Verbal Learning Test . Results: Compared with controls, the patients exhibited prominent elevations on KSP scales measuring anxiety proneness and neuroticism (P = 0.000005–0.0001), on the Detachment scale (P < 0.00009) and lower value on the Socialization scale (P < 0.0002). The patients also scored higher on the Inhibition of Aggression, Suspicion, Guilt and Irritability scales (P = 0.002–0.03) while the remaining five scales did not differ between patients and controls. KSP anxiety-related scales correlated with the Positive and Negative Symptoms Scale (PANSS) general psychopathology subscale. Cognitive test results were uniformly lower in the patient group and correlated with PANSS negative symptoms subscale. There was no association between KSP scale scores and PANSS positive or negative symptoms. Conclusion: The patients revealed a highly discriminative KSP test profile with elevated scores in neuroticism- and psychoticism-related scales as compared to controls. Results support previous findings utilizing other personality inventories in patients with schizophrenia. Cognitive test performance correlated inversely with negative symptoms.     

Autistic traits in obsessive-compulsive disorder

In contrast to other non-psychotic psychiatric populations, subjects with obsessive-compulsive disorder (OCD) are more prone to have personality disorder from cluster A (the odd and eccentric cluster). The present study aims at further investigating the relationship between these and other personality traits in OCD subjects and their relation to high functioning autism (HFA) and Asperger disorder. Sixty-four subjects with OCD were included. Personality traits were assessed with the Karolinska Scales of Personality (KSP), and personality disorders with DSM-adapted questionnaires. In addition, autistic traits were assessed in 29 videotaped subjects, by 3 independent raters. Twenty percent of the subjects with OCD were identified as also having autistic traits. These subjects scored higher on KSP scales measuring muscular tension, psychasthenia, and inhibition of aggression and lower on socialization as compared with OCD subjects without autistic traits. Additionally, subjects with autistic traits fulfilled criteria for anxious personality disorders and paranoid personality disorders significantly more often than subjects without autistic traits. We propose that OCD is often related to HFA and Asperger disorder. Self-report questionnaires may be useful in establishing the diagnosis. However, those with the most obvious autistic features seem to be less able to identify these traits in themselves.     

Personality Characteristics of Adolescent Suicide Attempters

Objective: The purpose of this study was to explore both the personality characteristics and the symptoms of personality disorder of adolescent suicide attempters, as well as the relationship between personality variables and hopelessness in this population. Method: Two sample populations were used in this study. First, 102 adolescent suicide attempters between 13 and 18 years of age completed the Millon Adolescent Personality Inventory (MAPI) and the Hopelessness Scale for Children (HSC). A second group of 35 adolescent suicide attempters were administered the HSC and the revised Diagnostic Interview for Borderlines (DIB). Results: No distinctive personality characteristics or symptoms of personality disorders were found. However, affective distress seemed to be the most prominent feature in the presentation of these adolescents. Additionally, high scores on the HSC were associated with elevated scores on the Personality Style scales of the MAPI and higher (more dysfunctional) scores on Affect Regulation on the DIB. Conclusions: The results suggest that clinicians should focus most on the personality characteristic of sensitivity and on affect regulation when assessing adolescent suicide attempters. In addition, hopelessness is important to systematically assess because it appears to be related to a variety of dysfunctional personality characteristics that may affect follow-up outcome.     

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.     

Serotonin transporter gene polymorphisms: effect on serotonin transporter availability in the brain of suicide attempters

The efficacy of serotonin reuptake inhibitors in depression and anxiety disorders suggests the gene coding for the serotonin transporter (5-HTT), SLC6A4, as a candidate of importance for these conditions. Positive findings regarding associations between polymorphisms in SLC6A4 have been reported, indicating that these polymorphisms may influence anxiety-related personality traits, as well as the risk of developing depression and suicidality. Serotonin 5-HTT availability was assessed with single photon emission computed tomography (SPECT), using (123)I-beta-CIT as ligand, in a population of unmedicated male suicide attempters (n=9) and in matched controls (n=9). Two polymorphisms in SLC6A4 were assessed, including the 5-HTTLPR located in the promoter region and a variable number of tandem repeats (VNTR) polymorphism in intron 2 (STin2). In suicide attempters, but not in controls, low 5-HTT availability was associated with the S allele of 5-HTTLPR and with the 12 repeat allele of STin2. Data suggest that polymorphisms in SLC6A4 may influence the expression of the brain serotonin transporter in suicide attempters.     

Low CSF oxytocin reflects high intent in suicide attempters

Data from animal studies suggest that oxytocin is an important modulating neuropeptide in regulation of social interaction. One human study has reported a negative correlation between CSF oxytocin levels, life history of aggression and suicidal behaviour. We hypothesized that CSF oxytocin levels would be related to suicidal behaviour, suicide intent, lifetime interpersonal violence and suicide risk. 28 medication free suicide attempters and 19 healthy volunteers participated in this cross sectional and longitudinal study. CSF and plasma morning basal levels of oxytocin were assessed with specific radio-immunoassays. The Beck Suicide Intent Scale (SIS), the Freeman scale and the Karolinska Interpersonal Violence Scale (KIVS) were used to assess suicide intent and lifetime violent behaviour. All patients were followed up for cause of death. The mean follow-up was 21 years. Suicide attempters had lower CSF oxytocin levels compared to healthy volunteers p=0.077. In suicide attempters CSF oxytocin showed a significant negative correlation with the planning subscale of SIS. CSF oxytocin showed a significant negative correlation with suicide intent, the planning subscale of SIS and Freeman interruption probability in male suicide attempters. Correlations between plasma oxytocin levels and the planning subscale of SIS and Freeman interruption probability were significant in male suicide attempters. Lifetime violent behaviour showed a trend to negative correlation with CSF oxytocin. In the regression analysis suicide intent remained a significant predictor of CSF oxytocin corrected for age and gender whereas lifetime violent behaviour showed a trend to be a predictor of CSF oxytocin. Oxytocin levels did not differ significantly in suicide victims compared to survivors. CSF oxytocin may be an important modulator of suicide intent and interpersonal violence in suicide attempters.     

Temperament traits in male suicide attempters and violent offenders.

With the purpose of comparing temperament traits in subjects who have been violent towards others and with subjects who have shown self-directed violence, 34 male suicide attempters and 34 male violent offenders were matched for age and psychiatric diagnosis. Violent offenders with a history of suicide attempts were excluded. Temperament traits were assessed by means of the Karolinska Scales of Personality. The temperament profiles of suicide attempters and violent offenders were very similar, with high trait anxiety and very low socialization. Violent offenders displayed significantly higher social desirability (P < 0.001). Suicide attempters tended to have higher indirect aggression and monotony avoidance. Impulsiveness, verbal aggression, and inhibition of aggression were within the normal range in both groups. There were substantial temperamental similarities between suicide attempters and violent offenders. In order to disentangle the differential mechanisms behind aggression towards self and others, we probably need to consider historical as well as current situation factors in a systematic way.     

Adolescent/Adult Differences in Suicidal Behavior and Outcome

A comprehensive literature review compared the patterns of suicide and suicidal behavior for adolescents and adults to identify age-related similarities and differences. Particular attention was given to follow-up rates of suicide by psychiatrically treated persons in these age groups. The major findings were that (1) adults and adolescent suicide completers were similar with respect to their gender ratio, use of guns in the attempt, completion of the initial attempt, and serious psychopathology; (2) adolescents differed from adults in suicidal behavior in their greater attempt rate, higher attempt/completion ratio, and lower rates of short and intermediate completion following psychiatric treatment; (3) the suicide outcome following psychiatric hospitalization is eightfold greater in adults than in youths during the first 3.5 years post-discharge; and (4) the 5:1 male/female ratio is the same for both adolescent attempters who later suicide and for all U.S. 15–19-year-old suicide completers. The frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions.     

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.

     

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.     

Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit

BACKGROUND: Although gender differences have been noted in the risk factors for suicide and attempted suicide, comparative studies to date have used only 2 groups and a limited number of measures. The present study compared the effect of gender on suicide among 4 groups of psychiatrically hospitalized adolescents using a cross-sectional design. METHODS: The study sample consisted of 404 patients, aged between 12 and 21, who were divided into 4 groups: 76 male suicide attempters, 103 male nonattempters, 143 female suicide attempters, and 82 female nonattempters. Patients were tested for life events, affective disorders, aggression, impulsivity, ego defense mechanisms, and death perception with the Child Suicide Potential Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, Overt Aggression Scale, Multidimensional Anger Inventory, Impulsivity Control Scale, and Life Style Index. Findings were analyzed by multivariate regression with stepwise logistic models. RESULTS: Depression and anxiety were more prevalent in female nonattempters than in male nonattempters; there were no such gender differences among the attempters. Antisocial behavior was more prevalent in male attempters than in female attempters; there were no gender differences on this aspect among the nonattempters. There were gender differences for defense mechanisms in the attempters. Logistic regression models for men and women separately revealed that antisocial behavior and anxiety were common predictors of suicide attempt, that destructiveness was a predictor in women only, and that depression was associated with suicide attempt in men only. CONCLUSIONS: Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a gender-specific behavior must raise suspicion of a risk of attempted suicide.     

Personality and attempted suicide in depressed adults 50 years of age and older: a facet level analysis

We examined the contribution of personality traits to attempted suicide, the number of suicidal attempts, and suicidal ideation in a sample of depressed inpatients. Personality was assessed via the Revised NEO Personality Inventory (NEO-PI-R). Bivariate analyses showed that suicide attempters were more self-conscious, self-effacing, impulsive, and vulnerable to stress, and less warm, gregarious, and inclined to experience positive emotions. Multivariate regression analyses controlling for age, gender, severity of depression, and psychiatric comorbidity showed that patients with a lifetime history of attempted suicide were less inclined to experience positive emotions and be more self-effacing. Patients with more severe suicidal ideation were less warm and more self-effacing. Results indicated that specific personality traits confer risk for suicidal behaviors in middle age and older adults. Interventions tailored to specific personality profiles in this high-risk group should be developed, and their efficacy examined.     

Electrodermal reactivity in male and female depressive patients who later died by suicide

On the basis of earlier studies on electrodermal responsiveness in patients with suicide attempts, an investigation on electrodermal activity (EDA) in former depressive inpatients was carried out. Male and female depressive inpatients who died of suicide later and participated in an habituation experiment during their inpatient treatment were identified retrospectively and compared (strictly matched by age and sex) to depressive suicide attempters with violent or nonviolent methods, suicide ideators and a nonsuicidal depressive group. In the first part of the study only male depressives (n= 12) who had committed suicide after or during inpatient treatment were compared with their controls. The hypothesis of a expected low electrodermal responsiveness and a fast habituation as an peripheral expression of a central impulse or violence control disturbance could not be confirmed. This was done in the second part of this study. We came to the following results: 1) a tendency to a faster habituation in the violent suicides compared with nonsuicidal depressives and violent suicide attempters plus violent suicide group in male depressives compared to suicide attempters (SA), nonviolent suicide ideators and nonsuicidal depressives. 2) A significant difference with faster habituation rates in a male and female violent suicide group compared with nonsuicidal depressives and again comparing a group of male and female violent suicides and SA with nonviolent SA, suicide ideator and nonsuicidal depressive controls. These results may reflect a dysregulation of violence and impulsivity control mechanism as an underlying disorder or personality trait.     

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.