Alexithymia in suicide attempters

Taiminen TJ, Saarijärvi S, Helenius H, Keskinen A, Korpilahti T. Alexithymia in suicide attempters. Acta Psychiatr Scand 1996: 93: 195–198. © Munksgaard 1996. Alexithymia seems to share some common features with psychological constriction, a phenomenon described in suicidal individuals. Fifty suicide attempters were interviewed within 24 h after arrival at a hospital, and measures of lethality of the attempt, suicidal intent, depression and alexithymia were carried out with structured instruments. Almost all the attempters were depressive, and about half of them were also alexithymic. However, alexithymia was not more prevalent in this population than in non-suicidal depressive patients. Depression and alexithymia correlated significantly with each other, but there was no correlation between alexithymia and lethality of the suicide attempt or suicidal intent. The authors conclude that alexithymia in suicide attempters seems to be associated with depression, but not with suicidality per se. Therefore, measurement of alexithymia may not yield extra information in suicide risk assessment.     

Suicide attempts and impulsivity

Impulsivity in suicidal behavior can describe the attempt (state) or the attempter (trait). There are no studies simultaneously measuring attempt impulsivity and attempter impulsivity in representative samples of suicide attempts. A one–year study of 278 suicide attempts in a general hospital tested the continuous versus dichotomous relationship between attempter impulsivity (Barratt Impulsiveness Scale) and attempt impulsivity (low scores in the planning subscale of Becks Suicidal Intent Scale). Attempter impulsivity was not a good predictor of attempt impulsivity independently of how both dimensions were measured (continuous or dichotomous ways). Impulsive attempts were associated with low lethality and lack of depression. Opportunities for prevention of suicide attempts in major depression and some personality traits may exist but require attentive monitoring of suicidal ideation and intent.     

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

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

Relationship between self-disclosure and serious suicidal behavior

The ability to predict which suicidal patient is at high risk for a serious attempt is an important clinical problem. On the basis of our clinical research, we hypothesized that self-disclosure may be an important personality variable differentiating suicide attempters and completers. We assessed 80 patients with depressive disorder, divided into four groups of 20 each: suicidal ideation only, nonserious suicide attempts, severe suicide attempts, and no suicidal behavior. Comparisons were also made with 20 healthy controls. All subjects completed Jourad's Self-Disclosure Questionnaire (JSDQ), as well as scales measuring depression/anxiety and hopelessness. The lack of willingness for self-disclosure significantly differentiated the serious attempters from the suicide ideators and mild attempters. The relationship of self-disclosure and more lethal suicide attempts did not appear to be mediated by depression, anxiety, or hopelessness. This preliminary study indicates that self-disclosure may be a promising field for assessment, therapy, and prevention in suicidal patients. Further studies are needed to investigate related variables, wider patients groups, and the use of different instruments.     

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.     

When the Pain Becomes Unbearable: Case-Control Study of Mental Pain Characteristics Among Medically Serious Suicide Attempters

The unbearable mental pain experience is recognized as a key antecedent of suicidal behavior. We aimed to examine the precise nature of the mental pain among medically serious suicide attempters (MSSAs), a population closely resembling those who died by suicide. We evaluated various factors of mental pain from the Orbach and Mikulincer Mental Pain Scale, as well as medical lethality and suicide intent. MSSAs were higher than non-MSSAs and psychiatric controls for Irreversibility of pain. Moreover, Emptiness predicted medical lethality, while Cognitive Confusion negatively predicted suicide intent level, controlling for hopelessness and depression. high sense of Irreversibility of pain as well as high Emptiness and low Cognitive Confusion are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide as well as for suicide prevention and treatment of suicidal individuals are discussed.     

Characteristics of recent suicide attempters with and without Borderline Personality Disorder.

The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.     

Characteristics of Recent Suicide Attempters with and without Borderline Personality Disorder

The present research compared recent suicide attempters with and without a diagnosis of Borderline Personality Disorder (BPD). One hundred and eighty recent suicide attempters, recruited in the Emergency Department, participated in extensive research interviews. Results showed that suicide attempters with BPD displayed greater severity of overall psychopathology, depression, hopelessness, suicidal ideation, past suicide attempts, and had poorer social problem solving skills than those without a BPD diagnosis. No differences were found between the groups regarding the intent to die or lethality associated with the index suicide attempt. These findings highlight the seriousness of BPD and the risk that individuals diagnosed with this disorder will attempt suicide.     

Multiple attempters of suicide presenting at an emergency department

As part of a study involving seven hundred and forty-seven (747) consecutive cases of self-injury presenting at the emergency department of an inner city hospital, data pertaining to a multiple attempt group of ninety-nine subjects were compared with the data pertaining to first attempters. All subjects were rated on Beck's Lethality Scales, Intent Scale and Hopelessness Scale. In addition, a standard interview was conducted to provide psychosocial information. Of the total suicide attempt population, 14% can be considered chronic. The multiple attempters were found to show more chronicity in their symptomatology, poorer coping histories, a positive family history of suicidal behaviour and a positive history of alcohol and drug abuse, all at a statistically significant level compared with first-time attempters. The multiple attempters also tend to show higher lethality and depression ratings, less impulsiveness and are significantly more often admitted to the in-patient unit following the attempt, than first attempters. Their intent scores were significantly related to their sense of hopelessness, which may be a reflection of their basic feelings of inadequacy. It was concluded that the multiple or "chronic" attempter differed sufficiently from the first-time attempter to warrant special intervention strategies.     

Attempted suicide in older depressed patients: effect of cognitive functioning.

The authors explored cognitive functioning and suicidal behavior in older depressed patients. Inpatients age 50 years or older (N=103) with major depression, 45 of whom had attempted suicide, were evaluated within 1 week of their hospital admission. Measures of suicidal behavior included suicide attempter status, the Suicide Intent Scale (SIS), ratings of method used (violent/nonviolent), and seriousness of injuries sustained (lethality). The Mini-Mental State Exam (MMSE) score measured cognitive impairment; covariates were age, gender, and living arrangement. The MMSE score was not associated with suicide attempter status, but for attempters, MMSE score showed a positive association with SIS score, but not method or lethality. Findings suggest that although cognitive disturbance may be associated with less-deliberate acts among older depressed suicide attempters, it does not appear to influence the potential lethality of their behavior.     

Protective factors against suicidal behavior in depressed adults reporting childhood abuse

Most previous studies compared suicidal behavior in subjects with and without a history of childhood abuse, whereas less attention was paid to the comparison of suicide attempters and nonattempters among subjects reporting childhood abuse. To identify risk and protective factors against suicidal behavior, we compared suicide attempters with nonattempters among the sample of 119 depressed inpatients who reported childhood abuse. Compared with nonattempters, suicide attempters were younger, had more self-rated depression severity and suicidal ideation, higher trait aggression and more cluster B personality disorder comorbidity, less coping potential, and fewer moral objections to suicide (MOS)/religious beliefs. Logistic regression showed that more severe suicidal ideation and fewer MOS/religious beliefs were associated with suicidal acts in subjects with reported childhood abuse. Furthermore, suicidal ideation and MOS/religious beliefs were significantly inversely correlated. The results of this clinical study add support to previous reports that religious/spiritual coping could serve as an additional resource in prevention of suicidal behavior for subjects with reported childhood abuse.     

Aggression–impulsivity,mental pain,and communication difficulties in medically serious and medically non-serious suicide attempters

Background

Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt.

Objectives

To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters.

Method

The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression–impulsivity, mental pain, and communication difficulties.

Results

The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p < .001 for all) and on anger-in, anger-out, violence, and impulsivity (p < .05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p < .05) and more schizoid tendencies (p < .001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p < .05). Analysis of aggression–impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone.

Conclusions

Aggression–impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.     

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

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

Self-Rated Depression Severity Relative to Clinician-Rated Depression Severity: Trait Stability and Potential Role in Familial Transmission of Suicidal Behavior

Self-rated depression and hopelessness severity are predictors of suicide attempt in major depression. This study evaluated whether: (1) greater self-rated distress relative to severity of clinician-rated depression is a trait; (2) that trait is familial; and (3) that trait is linked to familial transmission of suicidal behavior. A total of 285 mood disorder probands and 457 offspring were assessed twice, at least 1 year apart. Family and subject intra-class correlations for self-report depression and hopelessness, controlling for clinician-rated depression severity, were computed. Mixed general linear models determined offspring-proband correlations. Within-individual intra-class correlation (ICC) for depression-hopelessness was 37.8% (bootstrap 95% CI: 31.0–46.3%). Parent-offspring ICC was 10.7% (bootstrap 95% CI: 3.5–17.8%). Suicide attempt concordant parent-offspring correlation for subjective depression was positive, but negative for attempter parent and nonattempter offspring (p = .0213 for slope interaction). Pessimism was greater in proband or offspring attempters than proband or offspring nonattempters (p < .05). Self-reported hopelessness is partly trait-dependent, and there is modest familial transmission of self-reported depression linked to suicidal behavior that may partly explain familial transmission of suicidal behavior.     

The correlates of planning in adolescent suicide attempts

Adolescent suicide attempts are often impulsive. It has been suggested that individuals who make nonimpulsive (premeditated) attempts have greater suicidal intent and are more hopeless than the impulsive attempters. Eighty-six adolescent suicide attempters were categorized according to the degree of premeditation of their attempt, as measured by two items of the Suicide Intent Scale. Sex, age, method of attempt, and the number of prior attempts were not useful discriminators between these groups. The nonimpulsive attempters were significantly more depressed and more hopeless than the impulsive attempters, as measured by several standardized scales. Measures of depression, hopelessness, and suicidal ideation were highly correlated in both groups. Anger turned inward and hopelessness were strongly correlated only in the premeditated group, suggesting that the nonimpulsive attempter's distress may bear a strong relationship to self anger.     

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。     

Time to emergence of severe suicidal ideation among psychiatric patients as a function of suicide attempt history

BACKGROUND: Little is known about the emergence of suicidal ideation among psychiatric inpatients with histories of no, single, or multiple suicide attempts. We investigated differences in time to reemergence of severe suicidal ideation among psychiatric patients as a function of their suicide attempt histories. METHOD: One hundred seventeen individuals meeting criteria for a major depressive disorder who were recently discharged from a psychiatric hospital and participating in a larger study of treatments for depression were included in the current study. Suicidal ideation, depressive symptoms, hopelessness, and depressogenic cognitions were assessed at baseline, and suicidal ideation was assessed at 3-, 6-, 12-, and 18-month follow-up, as well as inpatient readmission if applicable. Time to the reemergence of severe suicidal ideation was analyzed using survival analysis. RESULTS: Twenty-two percent of our sample reported the occurrence of severe suicidal ideation over an 18-month period. Severe suicidal ideation emerged earlier among patients who had a history of prior suicide attempts than those who did not, but single and multiple suicide attempters did not differ significantly in time to severe suicidal ideation. Suicide attempt history remained a significant predictor of time to severe suicidal ideation when statistically controlling for hopelessness, depressive symptoms, depressogenic cognitions, and suicidal ideation at admission and initial treatment group assignment, especially between single attempters and nonattempters. CONCLUSIONS: Although nearly a quarter of participants endorsed severe, clinically significant suicidal ideation within 18 months of discharge, those with suicide attempt histories reported the occurrence of severe suicidal ideation significantly earlier than those without suicide attempt histories.     

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.     

Assessing varying degrees of lethality in depressed adolescent suicide attempters.

OBJECTIVE: Understanding the lethality of suicide attempts and its relation to other psychological variables may improve clinical judgement with regard to suicide risk. METHOD: The lethality of suicidal behaviour was examined in 60 hospitalized adolescent in-patients who had recently attempted suicide. Subjects were divided into non-lethal, low-lethal and high-lethal groups based on the qualities of their suicidal acts. RESULTS: The groups did not differ in terms of hopelessness, depression, substance abuse or self-esteem. Moreover, they did not differ significantly in diagnoses of major depression, adjustment disorder, substance abuse and bipolar disorder. The group of high-lethal attempters was the only group with several individuals diagnosed with a major depressive episode and comorbid attention deficit disorder. The high-lethal group also reported the strongest desire to end their lives. CONCLUSION: Based on lethality of suicide attempts, adolescent suicide attempters can be differentiated in terms of the wish to die as well as some instances of diagnostic comorbidity. However, they may not be differentiated in terms of severity of depression or hopelessness, demographic variables and other aspects of suicidal behaviour.     

Early maladaptive processes, depression and alexithymia in suicidal hospitalized adolescents

Alexithymia characterizes people having important difficulties in putting their feelings and moods into words. Adolescents' depression shows some peculiarities: one of them, which is often observed, is the equal difficulty of imparting one's feelings to others. This research concerns adolescents who attempted suicide. We study classical factors: depression and hopelessness. But our main objective is at first to study the relationship between attempted suicide, depression, hopelessness and alexithymia. The second objective of our study deals with the the prominent part of early schematas in this complex inter-relation. Maladaptative early schematas are no doubt involved in dysfunctional schematas found in depression and hopelessness. As a consequence, we would like to verify the following hypothesis: maladaptative early schematas are very numerous and specific among adolescents who attempted suicide. These schematas are the core of the complex inter-relation between attempted suicide, depression, hopelessness, suicide risk, suicide relapse and alexithymia. We have compared a group of normal subjects (who did not try to take their owns lives) and a group of people who did. First, we have found that the latter are more prone to alexithymia: a large majority of these subjects exceeds by far the accepted norm of the Toronto Alexithymia Scale. We have proved that the subjects who have attempted suicide also accumulate maladaptative early schematas. The qualitative analyse of these schematas leads to a possible explanation of the tendency to self destruction. Moreover there are apparently important differences between subjects who, in the past-experienced or did not experience a major depressive episode. The analysis of the relationships between the various factors of our study brings us to the conclusion that there is an unmistakable causal link between maladaptative early schematas and the interactive set (depression-hopelessness-major depressive episode-alexithymia) all these being part of attempted suicide and forming an integrant part of a whole which is the vulnerability to the suicide. Studying the various steps of early schematas seems to be quite promising as far as depression and suicide are concerned.