An exploratory study of the relationship between diverse life events and specific personality disorders in a sample of suicide attempters

Can clinical and subclinical forms of narcissism be considered risk factors for suicide-related outcomes? A systematic review

BACKGROUND

Clinical and subclinical forms of narcissism may increase suicide risk. However, little is known and there are controversies on this topic. This systematic review aims at providing an overview of studies investigating this association.

METHODS

We used PubMed, Scopus, and PsycInfo databases and followed PRISMA. We focused on cohort, case-control, cross-sectional and case series studies. We referred to both clinical (i.e., narcissistic personality disorder (NPD) and/or NPD criteria) and subclinical forms (i.e., grandiose and vulnerable narcissistic traits) of narcissism. Moreover, we considered: Suicidal Ideation (SI), Non-Suicidal Self-Injury(s) (NSSI), Deliberate Self-Harm (DSH), Suicide Attempt(s) (SA), Suicide Risk (SR), and Capability for Suicide.

RESULTS

We included 47 studies. Lack of association between NPD diagnosis/criteria and suicide-related outcomes (SI) or mixed results (SA) were found. Higher homogeneity emerged when considering narcissistic traits. Vulnerable narcissism was associated with SI, less impulsive NSSI, and DSH. Grandiose narcissism was associated with severe NSSI and multiple SA with high intent to die, but it was protective against SI and SR. Vulnerable narcissism seemed to be associated with suicide-related outcomes characterized by low intent to die, while grandiose narcissism seemed to be a risk factor for outcomes with high planning and severity.

LIMITATIONS

Between-study heterogeneity and lack of longitudinal studies.

CONCLUSIONS

Assessing suicide risk in subjects with clinical or subclinical forms of narcissism may be useful. Moreover, considering the most vulnerable form of narcissism, and not just the grandiose one, may contribute to a more nuanced risk stratification and to the identification of distinct therapeutic approaches.

The relationship between mood disorders, personality disorder and suicidality in adolescence: does general personality disturbance play a significant role in predicting suicidal behavior?

INTRODUCTION

Current research points to the importance personality pathology and Major Depression e as relevant psycopathological risk factors for understanding suicidal risk in adolescence. Literature has mainly focused on the role of BPD, however current orientations in personality pathological functioning suggest that BPD may be the representative of a general personality disturbance, a factor of vulnerability underlying diverse psychopathological variants and aspects of maladaptive functioning. However, recent studies seem to have neglected the contributions that other specific personality disorders and personality pathology as a general factor of vulnerability for suicidality; and only marginally investigated the interaction of personality disorder (PD) as an overall diagnosis and individual PDs and major depression (MDD). In this paper, the independent and cumulative effects of MDD and DSM-IV PDs on suicidal risk are investigated in a sample of adolescents observed in a longitudinal window of observation ranging from three months preceding the assessment to a six-month follow up period of clinical monitoring.

METHODS

A sample of 118 adolescents (mean age = 15.48 ± 1.14) referred for assessment and treatment on account of suicidal ideation or behavior were administered the CSSRS, SCID II, Kiddie-SADS at admission at inpatient and outpatient Units. All subjects included in the study had reported suicidal ideation or suicide attempts at the C-SSRS; The CSSRS was applied again to all patients who reported further suicidal episodes during the six-months follow-up period of clinical monitoring. Dimensional diagnoses of PDs was obtained by summing the number of criteria met by each subject at SCID-%-PD 5, In order, to test the significance of the associations between the variables chosen as predictors (categorical and dimensional PDs and MD diagnosis), and the suicidal outcomes variables suicide attempts, number of suicide attempts and potential lethality of suicide attempt, non-parametric bivariate correlations, logistic regression models and mixed-effects Poisson regression were performed PD.

RESULTS

The categorical and dimensional diagnosis of PD showed to be a significant risk factors for suicide attempt and their recurrence, independently of BPD, that anyway was confirmed to be a specific significant risk factor for suicidal behaviors. Furthermore, PD assessed at a categorical and dimensional level and Major Depression exert an influence on suicidal behaviors and their lethality both as independent and cumulative risk factors.

LIMITATIONS

Besides incorporating dimensional thinking into our approach to assessing psychopathology, our study still relied on traditionally defined assessment of PD. Future studies should include AMPD-defined personality pathology in adolescence to truly represent dimensional thinking.

CONCLUSION

These results point to the importance of early identification of the level of severity of personality pathology at large and its co-occurrence with Major Depression for the management of suicidal risk in adolescence.

Predictors of prospective suicide attempts in a group at risk of personality disorder following self-poisoning

Background

Patients with personality disorder (PD) are at risk for suicidal behavior and are frequently admitted for this reason to emergency departments. In this context, researchers have tried to identify predictors of their suicidal acts, however, the studies have been mostly retrospective, and uncertainty remains. To prospectively explore factors associated with suicide attempts (SA) in individuals screened for PD from the ecological context of emergencies.

Methods

Patients were recruited from two emergency departments after a self-poisoning episode (n = 310). PDQ-4+ (risk of PD), TAS-20 (alexithymia), SIS (suicidal intent), H (hopelessness), BDI-13 (depression), AUDIT (alcohol consumption), and MINI (comorbidity) questionnaires were completed. SA over the subsequent two years were identified by mailed questionnaires and hospitals' active files. Logistic regression analyses were performed.

Results

Having a previous suicidal attempt was linked to a 2.7 times higher chance of recurrence after 6 months, whereas the TAS-20 showed a 1.1 times higher risk at 18 months (OR = 1.1) and the BDI at 24 months (OR = 1.2). Each one-unit increment in TAS-20 and BDI-13 scores increased the risk of SA by 9.8 and 20.4% at 18 and 24 months, respectively.

Conclusion

Some clinical features, such as alcohol dependence, suicide intent, and hopelessness, may not be reliable predictors of SA among PD patients. However, in the short term, previous SA and, in the long term, depression and alexithymia may be the most robust clinical predictors to consider in our sample of patients with self-poisoning SA.Clinical trial registration: [ClinicalTrials.gov], NCT00641498 24/03/2008 [#2006-A00450-51].

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

Predictors of Emergency Department Use for Suicidal Behaviors among Patients with Substance-Related Disorders

OBJECTIVE

This study aimed to identify predictors of emergency department (ED) use for suicide ideation or suicide attempt compared with other reasons among 14,158 patients with substance-related disorders (SRD) in Quebec (Canada).

METHODS

Longitudinal data on clinical, sociodemographic, and service use variables for patients who used addiction treatment centers in 2012-13 were extracted from Quebec administrative databases. A multinomial logistic regression was produced, comparing predictors of suicide ideation or attempts to other reasons for ED use in 2015-16.

RESULTS

Patients using ED for both suicide ideation and attempt were more likely to have bipolar or personality disorders, problems related to the social environment, 4+ previous yearly outpatient consultations with their usual psychiatrist, high prior ED use, and dropout from SRD programs in addiction treatment centers in the previous 7 years, compared with those using ED for other reasons. Patients with alcohol- or drug-related disorders other than cannabis and living in the least materially deprived areas, urban territories, and university healthcare regions made more suicide attempts than those using ED for other reasons. Patients with common mental disorders, 1-3 previous yearly outpatient consultations with their usual psychiatrist, one previous treatment episode in addiction treatment centers, and those using at least one SRD program experienced more suicide ideation than patients using ED for other reasons.

CONCLUSION

Clinical variables most strongly predicted suicidal behaviors, whereas completion of SRD programs may help to reduce them. SRD services and outreach strategies should be reinforced, particularly for patients with complex issues living in more advantaged urban areas. HIGHLIGHTSOver 10% of ED visits were for suicidal behaviors among patients with SRD.ED use for suicidal behaviors was mainly associated with clinical variables.Addiction treatment centers may help reduce ED use for suicidal behaviors.

The Psychoanalytic Study of Suicide, Part I: An Integration of Contemporary Theory and Research

Psychodynamic psychotherapy has an important role in suicide prevention. The psychoanalytic study of suicide has taught us a great deal about the human experience and the process of suicidality. There is also much to be learned from other fields of study and from empirical research that can be integrated into psychoanalytic therapies. Central to the psychoanalytic approach to suicide has been understanding the patient's internal subjective experience of unbearable emotional or psychic pain and the urgent need for relief. Emotional pain can include intense affects such as shame, humiliation, self-hate, and rage. Factors that can increase vulnerability to suicidal states include problems with early attunement, dissociation and deficits in bodily love and protection, conscious and unconscious fantasy, and certain character traits and dynamics. Empirical research has confirmed many basic psychoanalytic concepts about suicide, including escape from unbearable pain as the primary driver of suicidal behavior, the role of dissociation in increasing risk of bodily attack, and the importance of unconscious processes. Further research into implicit processes and their role in the suicidal process holds potential to improve suicide risk assessment and to enhance psychotherapy by bringing otherwise inaccessible material into the treatment.

Recent Stressful Life Events and Suicidal Ideation in Schizophrenia: A 1-Year Follow-up Study

ABSTRACT

Half of patients with schizophrenia experience suicidal ideation. Only few studies have examined the effects of recent stress on both current and emergent suicidal ideation.A cohort of 85 patients with schizophrenia spectrum disorders was assessed. The study was divided into a cross-sectional and longitudinal arms to test the effect of recent stress on suicidal ideation. Analysis was done using logistic regression models.After correcting for covariates, recent stress had no significant effect on current suicidal ideation. However, increased total stress (odds ratio [OR] = 1.099 [1.032-1.170], p = 0.003) and health-related stress (OR = 1.331 [1.074-1.650], p = 0.009) at follow-up were predictive of emergent suicidal ideation.With this sample size, we were unable to draw firm conclusions regarding the effect of specific life events on suicidal ideation. Further studies involving larger samples that investigate the interplay between several risk factors are needed.

The Road from Pathological Narcissism to Suicidality in Adolescence: An Empirical Study

Background: Clinical and empirical research evidenced a complex link between pathological narcissism and the suicidal process in adulthood. Given the relevance of suicidality and the peculiar narcissistic vicissitudes of adolescence, the proposed research investigated the relationship between pathological narcissism analyzed from the multi-dimensional perspective of the Diagnostic Interview for Narcissism (DIN) and suicidal ideation conducted in a sample of Italian Adolescents. Methods: One hundred and three Italian male and female adolescents between 12 and 18 were administered the DIN, SCIDII, CSSRS, and Kiddie-SADS with six months follow-up. Results: The correlation, t-test, multiple regression analyses evidenced the association of narcissistic affective states and mood with both suicidal ideation and lethality of conduct. The increase in the dimension of grandiosity is associated with the passage to potentially highly lethal suicidal gestures. Conclusions: Suicidal ideation and conduct seem to serve the function of restoring a sense of control and self-esteem in narcissistic individuals experiencing a state of affective dysregulation. Narcissistic pathological functioning seems to play an important role in the adolescent suicidal process, quite like adulthood. Assessing an adolescent’s narcissistic functioning may provide useful clinical information in understanding and managing the suicidal risk in this phase of life.

Narcissistic and Borderline Personality Disorders: Relationship With Oxidative Stress

The authors hypothesized that personality disorders characterized by interpersonal hypersensitivity would be associated with an elevated concentration of 8-hydroxy-2'-deoxyguanosine (8-OH-DG), the oxidized form of guanine, and a biomarker of oxidative stress burden. One hundred ninety-five male and female adults underwent semistructured diagnostic interviews, completed questionnaire measures of social cognition and emotional attribution, and had blood drawn for determination of plasma 8-OH-DG. A hierarchical linear regression model revealed that narcissistic and borderline personality disorders predicted 8-OH-DG level independently of the effects of age, gender, recent alcohol and cigarette use, current major depression, and posttraumatic stress disorder. In all subjects, 8-OH-DG level was also correlated with the number of borderline personality disorder symptoms present. Narcissistic and borderline personality disorders predicted oxidative stress burden independently of potentially confounding factors.

Predictors of emergency department visits for suicidal ideation and suicide attempt

OBJECTIVES

This study investigated predictors of emergency department (ED) visits for suicidal ideation and suicide attempt in 2014-15 among patients at six Quebec emergency departments (ED), using administrative data.

METHODS

Participants (n = 11,778) used ED for suicidal ideation (30.4%); suicide attempt (7.0%); or other reasons (61.7%). A multinomial logistic regression was performed using variables described by the Andersen Behavioral Model.

RESULTS

The odds of ED visits for suicidal ideation or suicide attempt was high for adjustment disorders, personality disorders, and prior ED consultations for mental health (MH) reasons, but lower for schizophrenia spectrum and other psychotic disorders, illness acuity levels 3-5 (low severity), and 3+ consultations with outpatient psychiatrists. The odds of visiting ED for suicidal ideation increased in depressive disorders, and in the 12-17 year age range, but decreased in association with 1-2 outpatient psychiatrist consultations. The odds of suicide attempt also increased with alcohol use disorders and drug-induced disorders, but decreased with specific MH interventions at local community health services centers.

CONCLUSION

increasing access to ambulatory care, and care continuity in outreach programs for acute MH disorders, including substance-related disorders, may reduce ED visits for suicidal ideation and suicide attempt, while improving overall service delivery.

The Study of Motivation in the Suicidal Process: The Motivational Interview for Suicidality

Introduction: Suicide is the outcome of a process starting with the experiences of an unbearable pain or hopelessness, passing from suicidal ideation and planning, to possible para-suicidal behaviors or actual attempts. Recent studies have evidenced the necessity to integrate approaches based on the identification of psychopathological diagnoses and other variables as possible predictors of suicidal conduct with a more clinically based approach. A clinical assessment is needed that focuses on the patients' mental state with respect to thoughts concerning death and suicide. In particular, a qualitative assessment of motivations underlying the suicidal process could represent an effective guide for clinicians engaged in the difficult field of preventing adolescents' suicidal gestures. Most instruments investigating the suicidal motivation are self-report measures, possibly resulting in a lack of sufficiently valid assessment of this area. In the present work, we present the Motivational Interview for Suicidality in Adolescence (MIS-A) aiming at identifying the motivational areas sustaining suicidal ideation and gestures in this phase of development. Materials and Methods: The identification of the different areas derives from a thorough review of the empirical literature subsequently vetted by expert clinicians who selected specific reasons behind suicidal ideation and gesture. Result: The MIS is a semi-structured clinician-report interview. The interview is composed of seven areas and 14 sub-areas, evaluated on a four-point Likert scale: illness motivated attempts area, chronic presence of internal pessimistic criticism area, sense of defeat and entrapment area, relational area, external motivated crisis area, extreme and unusual cases area, and lack of control area. Conclusions: The path followed in the creation of the MIS reflects both an empirically orientated and a clinically informed approach. Creating this MIS is the first step within a wider research project that will allow one to test the reliability of the instrument.

Cannabinoid Receptors, Mental Pain and Suicidal Behavior: a Systematic Review

PURPOSE OF REVIEW

The current serotonin-based biological model of suicidal behavior (SB) may be too simplistic. There is emerging evidence that other biomarkers and biological systems may be involved in SB pathophysiology. The literature on the endocannabinoid (EC) systems and SB is limited. The objective of the present article is to review all available information on the relationship between cannabinoid receptors (CB₁ and CB₂ receptors), and SB and/or psychological pain.

RECENT FINDINGS

Our review is limited by the small number and heterogeneity of studies identified: (1) an autopsy study describing elevated levels of CB₁ receptor activity in the prefrontal cortex and suicide in both depression and alcoholism and (2) studies supporting the involvement of both CB₁ and CB₂ receptors in the regulation of neuropathic pain and stress-induced analgesia. We conclude that cannabinoid receptors, particularly CB₁ receptors, may become promising targets for the development of novel therapeutic tools for the treatment of SB.

Pathological Narcissism and Nonsuicidal Self-Injury

Few studies have examined associations between pathological narcissism and self-harm, but those that do indicate that narcissistic vulnerability (not narcissistic grandiosity) relates to self-harm. The current study extends this literature by investigating how facets of pathological narcissism assessed by the Pathological Narcissism Inventory relate to specific nonsuicidal self-injury (NSSI) behaviors assessed by the Inventory of Statements About Self-Injury using statistical models appropriate for non-normally distributed count data. In a sample of 1,023 undergraduate students, results revealed that facets of both narcissistic vulnerability and narcissistic grandiosity were differentially related to the endorsement and frequency of specific NSSI behaviors and higher-order latent NSSI factors (repetitive and impulsive), even after accounting for levels of borderline pathology. The clinical implications of these results are discussed.

Narcissistic Personality Disorder in Clinical Health Psychology Practice: Case Studies of Comorbid Psychological Distress and Life-Limiting Illness

Narcissistic Personality Disorder (NPD) is characterized by a persistent pattern of grandiosity, fantasies of unlimited power or importance, and the need for admiration or special treatment. Individuals with NPD may experience significant psychological distress related to interpersonal conflict and functional impairment. Research suggests core features of the disorder are associated with poor prognosis in therapy, including slow progress to behavioral change, premature patient-initiated termination, and negative therapeutic alliance. The current manuscript will explore challenges of working with NPD within the context of life-limiting illness for two psychotherapy patients seen in a behavioral health clinic at a large academic health science center. The ways in which their personality disorder affected their illness-experience shared significant overlap characterized by resistance to psychotherapeutic change, inconsistent adherence to medical recommendations, and volatile relationships with providers. In this manuscript we will (1) explore the ways in which aspects of narcissistic personality disorder impacted the patients' physical health, emotional well-being, and healthcare utilization; (2) describe psychotherapeutic methods that may be useful for optimizing psychosocial, behavioral, and physical well-being in individuals with co-morbid NPD and life-limiting disease; and (3) review conceptualizations of NPD from the DSM-5 alternative model for assessing personality function via trait domains.

Positive and negative life events and reasons for living modulate suicidal ideation in a sample of patients with history of suicide attempts

BACKGROUND

The influence of life events on suicidal behavior remains inconclusive, while reasons for living (RFL) may be protective.

OBJECTIVES

To analyze the association between positive and negative life events and suicidal ideation (SI) and the interaction between life events and RFL on SI.

METHOD

Patients with history of suicide attempts (n = 338) underwent a comprehensive clinical evaluation, including SI (Beck's Suicidal Ideation scale), RFL (Reasons for Living Inventory, RFLI) and life events (family, school, student or professional, social, health and religion-related and other life events) during the last twelve months.

RESULTS

The only negative life events associated with SI were health-related events (OR = 2.01 95%CI[1.04;3.92]). Family-related positive life events and RFL were negatively associated with SI (OR = 0.73 95%CI[0.58;0.91] and OR = 0.98 95%CI[0.97;0.98], respectively). No significant interaction between the number of positive life events and RFLI total score with current SI (p = 0.57) was detected. Family-related positive life events and RFL did not have any additive effect on SI. Positive life events did not moderate the association between health-related negative life events and SI.

LIMITATIONS

This was a retrospective study, the presence of axis II disorders was not investigated and results cannot be generalized due to the sample choice (only suicide attempters).

CONCLUSIONS

Patients with history of suicide attempts could be less sensitive to negative life events, except for those related to health. Clinicians should pay more attention to somatic problems in patients at risk of suicide. Family support, positive psychology and therapies that strengthen RFL should be developed to prevent suicide.

Predictors and Outcomes of Psychiatric Hospitalization in Youth Presenting to the Emergency Department with Suicidality

Youth suicide attempters presenting to the emergency department (ED) are frequently admitted to psychiatric inpatient hospitals, yet little is known about how clinicians decide which youths to admit versus discharge to outpatient care. We examine predictors of inpatient hospitalization and describe service use outcomes associated with hospitalization in 181 youths drawn from consecutive ED admissions for suicidality. Predictors of hospitalization include ED site, suicide plan, and parent report of problems. Hospitalization was associated with improved linkage to outpatient treatment and more intensive service use. Future research is needed to understand the best service delivery and treatments for these high-risk youth.

Narcissistic Personality Disorder and suicidal behavior in mood disorders

The relationship of Narcissistic Personality Disorder (NPD) to suicidal behavior is understudied. The modest body of existing research suggests that NPD is protective against low-lethality suicide attempts, but is associated with high lethality attempts. Mood-disordered patients (N = 657) received structured interviews including Axis I and II diagnosis and standardized clinical measures. Following chi-square and t-tests, a logistical regression model was constructed to identify predictors of suicide attempt. While there was no bivariate relationship of NPD on suicide attempt, in the logistic regression patients with NPD were 2.4 times less likely to make a suicide attempt (OR = 0.41; 95% CI = 0.19 - 0.88; p < 0.05), compared with non-NPD patients and controlling for possible confounding variables. NPD was not associated with attempt lethality. NPD patients were more likely to be male, to have a substance use disorder, and to have high aggression and hostility scores. Limitations include that the sample consists of only mood-disordered patients, a modest sample size of NPD, and the data are cross-sectional. The multivariate protective effect of NPD on suicide attempt is consistent with most previous research. The lower impulsivity of NPD patients and less severe personality pathology relative to other personality disorders may contribute to this effect. No relationship of NPD to attempt lethality was found, contradicting other research, but perhaps reflecting differences between study samples. Future studies should oversample NPD patients and include suicide death as an outcome. Clinical implications include discussion of individualized suicide risk assessment with NPD patients.

Suicide attempts in bipolar I patients: impact of comorbid personality disorders

Objective

To evaluate the association between personality disorders (PDs) and suicide attempts (SAs) in euthymic patients with type I bipolar disorder (BD).

Methods

One-hundred twenty patients with type I BD, with and without history of SA, were evaluated during euthymia. The assessment included a clinical and sociodemographic questionnaire, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Barratt Impulsiveness Scale, and Structured Clinical Interviews for DSM-IV Axis I and II Disorders. Logistic regression was employed to determine associations between history of SA and patient characteristics.

Results

History of SA was significantly associated with comorbid axis I disorder, rapid cycling, high impulsivity (attentional, motor, non-planning, and total), having any PD, and cluster B and C PDs. Only cluster B PDs, high attentional impulsivity, and lack of paid occupation remained significant after multivariate analysis.

Conclusions

Cluster B PDs were significantly associated with SA in patients with type I BD. High attentional impulsivity and lack of gainful employment were also associated with SA, which suggests that some cluster B clinical and social characteristics may exacerbate suicidal behavior in this population. This finding offers alternatives for new therapeutic interventions.

Personality and life events in a personality disorder sample

Individuals with a personality disorder (PD) tend to experience more negative life events (NLEs) than positive life events (PLEs). In community samples, the Five Factor Model of personality (FFM) predicts both positive and negative life events. The present research examined whether FFM normal personality traits were associated with positive and negative life events among individuals with 1 of 4 PDs: avoidant, borderline, schizotypal, and obsessive-compulsive, and tested whether associations between the FFM of personality and PLEs and NLEs were similar across the 4 PD groups and a control group. Among aggregated PDs, neuroticism was positively associated with NLEs, whereas extraversion, openness to experience, and conscientiousness were positively associated with PLEs. Comparisons of each PD group to a control group of individuals with a major depressive disorder indicated that the FFM traits operated similarly across clinical samples with and without PD. Our findings indicate that normal personality traits can be used to help understand the lives of individuals with PD. (PsycINFO Database Record

Patterns of Comorbidity of Suicide Attempters: An Update

Between 10 and 20 million people attempt suicide every year worldwide, and suicide attempts represent a major economic burden. Suicide attempters suffer from high rates of comorbidity, and comorbidity is the rule in suicide re-attempters. Comorbidity complicates treatment and prognosis and causes a more protracted course. In the present narrative review, we included these patterns of comorbidity: intra-Axis I disorders, intra-Axis II disorders, Axis I with Axis II disorders, and psychiatric with physical illnesses. We also briefly reviewed the patterns of comorbidity in suicide re-attempters. We concluded that comorbidity at different levels appears to be the rule in suicide attempters, particularly in those who re-attempt. However, several issues deserve further research regarding the patterns of comorbidity in suicide attempters.

Loudness dependence of auditory evoked potentials (LDAEP) in clinical monitoring of suicidal patients with major depression in comparison with non-suicidal depressed patients and healthy volunteers: A follow-up-study

Differences in central serotonergic function due to affective disorders and due to extraordinary situations like suicidality may be visualized using the loudness dependence of auditory evoked potentials (LDAEP). Twenty patients (mean age 43.25 ± 10.85, age range 20-61, 11 male) suffering from a major depressive episode who had either acutely attempted suicide or who had suicidal plans and behavior, which are reflected by item 3 of Hamilton Depression Rating Scale ≥ 3 (suicidality), were included in the study. Furthermore, we intended to compare their LDAEP to those of non-suicidal depressed patients as well as to healthy volunteers, each matched according to age and gender. LDAEP measurement and psychometric tests took place about 2, 5, 9, 16 and 30 days after acute suicidal action or suicide attempts. In contrast to previous results, significant differences in LDAEP could not have been shown in between the suicidal group, or by comparing results of suicidal patients to non-suicidal depressed patients or to healthy volunteers. However, when the LDAEP of non-suicidal depressed patients were compared to healthy volunteers, there was a trend for a higher LDAEP in the healthy volunteers. Further studies are necessary to detect and describe further influences on serotonergic function and confounding factors like medication, smoking, age, gender, comorbidities and methods of suicidal attempts.

Personality disorder risk factors for suicide attempts over 10 years of follow-up

Identifying personality disorder (PD) risk factors for suicide attempts is an important consideration for research and clinical care alike. However, most prior research has focused on single PDs or categorical PD diagnoses without considering unique influences of different PDs or of severity (sum) of PD criteria on the risk for suicide-related outcomes. This has usually been done with cross-sectional or retrospective assessment methods. Rarely are dimensional models of PDs examined in longitudinal, naturalistic prospective designs. In addition, it is important to consider divergent risk factors in predicting the risk of ever making a suicide attempt versus the risk of making an increasing number of attempts within the same model. This study examined 431 participants who were followed for 10 years in the Collaborative Longitudinal Personality Disorders Study. Baseline assessments of personality disorder criteria were summed as dimensional counts of personality pathology and examined as predictors of suicide attempts reported at annual interviews throughout the 10-year follow-up period. We used univariate and multivariate zero-inflated Poisson regression models to simultaneously evaluate PD risk factors for ever attempting suicide and for increasing numbers of attempts among attempters. Consistent with prior research, borderline PD was uniquely associated with ever attempting. However, only narcissistic PD was uniquely associated with an increasing number of attempts. These findings highlight the relevance of both borderline and narcissistic personality pathology as unique contributors to suicide-related outcomes.

Life events: a complex role in the timing of suicidal behavior among depressed patients

Suicidal behavior is often conceptualized as a response to overwhelming stress. Our model posits that given a propensity for acting on suicidal urges, stressors such as life events or major depressive episodes (MDEs) determine the timing of suicidal acts. Depressed patients (n=415) were assessed prospectively for suicide attempts and suicide, life events and MDE over 2 years. Longitudinal data were divided into 1-month intervals characterized by MDE (yes/no), suicidal behavior (yes/no) and life event scores. Marginal logistic regression models were fit, with suicidal behavior as the response variable and MDE and life event score in either the same or previous month, respectively, as time-varying covariates. Among 7843 person-months, 33% had MDE and 73% had life events. MDE increased the risk for suicidal behavior (odds ratio (OR)=4.83, P⩽0.0001). Life event scores were unrelated to the timing of suicidal behavior (OR=1.06 per 100 point increase, P=0.32), even during a MDE (OR=1.12, P=0.15). However, among those without borderline personality disorder (BPD), both health- and work-related life events were key precipitants, as was recurrent MDE, with a 13-fold effect. The relationship of life events to suicidal behavior among those with BPD was more complex. Recurrent MDE was a robust precipitant for suicidal behavior, regardless of BPD comorbidity. The specific nature of life events is key to understanding the timing of suicidal behavior. Given unanticipated results regarding the role of BPD and study limitations, these findings require replication. Of note, that MDE, a treatable risk factor, strongly predicts suicidal behaviors is cause for hope.

Neither too much, nor too little. The dilemma of identifying personality disorders in adolescents patients with self-reports

The study aimed to compare methods of identification of Personality Disorders (PD) in adolescent patients with psychiatric disorders. A sample of 120 Spanish adolescents with clinical disorders was assessed using the International Personality Disorder Examination (IPDE) interview, its Screening Questionnaires (IPDE-SQ) comprising the ICD-10 and DSM-IV modules, and also the Temperament Character Inventory (TCI) to identify risk of PD. The IPDE-SQ identified a risk of PD around 92-97% of the sample; 61.7% when adjusting the stricter cut-off points. The TCI showed a PD risk of 20%, whereas the prevalence of PD identified by the IPDE clinical interview was around 36-38%. The differences between the IPDE, IPDE-SQ and TCI were significant, and a low agreement among instruments was obtained. Large discrepancy between self-report instruments in identifying PD with regard to the clinical interview raises several questions concerning the use of these instruments in clinical settings on adolescents with psychiatric disorders.

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.

Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison

BACKGROUND

Whether suicide attempters and completers represent the same population evaluated at different points along a progression towards suicide death, overlapping populations, or completely different populations is a problem still unresolved.

METHODS

446 Adult suicide attempters and knowledgeable collateral informants for 190 adult suicide probands were interviewed. Sociodemographic and clinical data was collected for both groups using semi-structured interviews and structured assessments. Univariate analyses and logistic regression models were conducted to explore the similarities and differences between suicide attempters and completers.

RESULTS

Univariate analyses yielded significant differences in sociodemographics, recent life events, impulsivity, suicide intent, and distribution of Axis I and II disorders. A logistic regression model aimed at distinguishing suicide completers from attempters properly classified 90% of subjects. The most significant variables that distinguished suicide from attempted suicide were the presence of narcissistic personality disorder (OR=21.4; 95% CI=6.8-67.7), health problems (OR=20.6; 95% CI=5.6-75.9), male sex (OR=9.6; 95% CI=4.42-20.9), and alcohol abuse (OR=5.5; 95% CI=2.3-14.2).

LIMITATIONS

Our study shares the limitations of studies comparing suicide attempters and completers, namely that information from attempters can be obtained from the subject himself, whereas the assessment of completers depends on information from close family or friends. Furthermore, different semi-structured instruments assessed Axis I and Axis II disorders in suicide attempters and completers. Finally, we have no data on inter-rater reliability data.

CONCLUSIONS

Suicide completers are more likely to be male and suffer from alcohol abuse, health problems (e.g. somatic illness), and narcissistic personality disorder. The findings emphasize the importance of implementing suicide prevention programs tailored to suicide attempters and completers.

Early childhood sexual abuse increases suicidal intent

Childhood sexual abuse has been consistently associated with suicidal behavior. We studied suicide attempt features in depressed individuals sexually abused as children. On average, sexual abuse started before age 9. It frequently coexisted with physical abuse. Suicide attempters more often had personality disorders and had endured abuse for longer, but did not differ in terms of other clinical characteristics from non-attempters. Earlier onset of sexual abuse and its duration were associated with more suicide attempts. However, when personality disorders were included in the regression model, only these disorders predicted number of attempts. The severity of sexual abuse and the coexistence of physical abuse were correlated with age at first suicide attempt. However, only severity of sexual abuse was marginally associated with age at first suicide attempt in the regression model. Finally, the earlier the age of onset of sexual abuse, the higher the intent, even after controlling for age, sex and personality disorders. This suggests that the characteristics of childhood sexual abuse, especially age of onset, should be considered when studying the risk for suicidal behavior in abused populations.

Literature-based recommendations for suicide assessment in the emergency department: a review

BACKGROUND

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

OBJECTIVES

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

METHODS

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

RESULTS

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

CONCLUSION

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.

Combining scales to assess suicide risk

OBJECTIVES

A major interest in the assessment of suicide risk is to develop an accurate instrument, which could be easily adopted by clinicians. This article aims at identifying the most discriminative items from a collection of scales usually employed in the assessment of suicidal behavior.

METHODS

The answers to the Barrat Impulsiveness Scale, International Personality Disorder Evaluation Screening Questionnaire, Brown-Goodwin Lifetime History of Aggression, and Holmes & Rahe Social Readjustment Rating Scale provided by a group of 687 subjects (249 suicide attempters, 81 non-suicidal psychiatric inpatients, and 357 healthy controls) were used by the Lars-en algorithm to select the most discriminative items.

RESULTS

We achieved an average accuracy of 86.4%, a specificity of 89.6%, and a sensitivity of 80.8% in classifying suicide attempters using 27 out of the 154 items from the original scales.

CONCLUSIONS

The 27 items reported here should be considered a preliminary step in the development of a new scale evaluating suicidal risk in settings where time is scarce.

Genetic epistasis in female suicide attempters

BACKGROUND

Complex behaviors such as suicidal behavior likely exhibit gene-gene interactions. The main aim of this study is to explore potential single nucleotide polymorphisms combinations with epistatic effect in suicidal behavior using a data mining tool (Multifactor Dimensionality Reduction).

METHODS

Genomic DNA from peripheral blood samples was analyzed using SNPlex Technology. Multifactor Dimensionality Reduction was used to detect epistatic interactions between single nucleotide polymorphisms from the main central nervous system (CNS) neurotransmitters (dopamine: 9; noradrenaline: 19; serotonin: 23; inhibitory neurotransmitters: 60) in 889 individuals (417 men and 472 women) aged 18 years or older (585 psychiatric controls without a history of suicide attempts, and 304 patients with a history of suicide attempts). Individual analysis of association between single nucleotide polymorphisms and suicide attempts was estimated using logistic regression models.

RESULTS

Multifactor Dimensionality Reduction showed significant epistatic interactions involving four single nucleotide polymorphisms in female suicide attempters with a classification test accuracy of 60.7% (59.1%-62.4%, 95% CI): rs1522296, phenylalanine hydroxylase gene (PAH); rs7655090, dopamine receptor D5 gene (DRD5); rs11888528, chromosome 2 open reading frame 76, close to diazepam binding inhibitor gene (DBI); and rs2376481, GABA-A receptor subunit γ3 gene (GABRG3). The multivariate logistic regression model confirmed the relevance of the epistatic interaction [OR(95% CI)=7.74(4.60-13.37)] in females.

CONCLUSIONS

Our results suggest an epistatic interaction between genes of all monoamines and GABA in female suicide attempters.

Age of first suicide attempt in men and women: an admixture analysis

OBJECTIVES

To define different subgroups of suicide attempters according to age at onset of suicide attempts.

METHODS

Participants were 229 suicide attempters (147 females; 82 males) admitted to a general hospital in Madrid, Spain. We used admixture analysis to determine the best-fitting model for the age at onset of suicide attempts separated by sex.

RESULTS

The best fitted model for the age at onset of suicide attempts was a mixture of two gaussian distributions. Females showed an earlier age at onset of suicide attempts in both Gaussian distributions (mean ± S.D.) (26.98 ± 5.69 and 47.98 ± 14.13) than males (32.77 ± 8.11 and 61.31 ± 14.61). Early-onset female attempters were more likely to show borderline personality disorder than late-onset female attempters (OR = 11.11; 95% CI = 2.43-50.0).

CONCLUSIONS

Age at onset of suicide attempts characterizes different subpopulations of suicide attempters.

[Recommendations for the prevention and management of suicidal behaviour]

INTRODUCTION

Suicidal behaviour is a major public health issue. Suicidal behaviour is one of the main causes of years of life lost and it is the third leading cause of death among young adults. This project was initiated by the Spanish Society of Psychiatry and the Spanish Society of Biological Psychiatry with the aim of providing a document containing the main recommendations on the prevention and management of suicidal behaviour; these recommendations should be based on the best available evidence and the experts' opinion.

MATERIAL AND METHODS

In this article we summarize the review of the available evidence on the epidemiology and impact of suicidal behaviour, risk and protective factors, evaluation tools for the assessment of suicide risk, international and local preventive protocols, educational interventions for health professionals, and potential interventions for at risk populations.

RESULTS

Based on this review, a panel of psychiatrists summarized and agreed a set of recommendations about the impact, prevention and management of suicidal behaviour.

CONCLUSION

The recommendations on the prevention and management of suicidal behaviour were summarized in the ten conclusions reported in this article.

Debates on the narcissism conundrum: trait, domain, dimension, type, or disorder?

The clinical implications of the term narcissism are a matter of continuous debate. This article critically examines pertinent literature of the last 12 years using a set of validators and attempting to identify narcissism as a trait, a domain, a dimension, or a personality disorder/type. Narcissistic personality disorder (NPD)-specific literature (particularly in epidemiological, developmental, and laboratory-testing areas) is scarce when compared with other personality disorders. A tendency to ideologically dominated clinical reports is observed with individual cases or small samples of nonclinical populations. Clinical descriptions of the condition vary within a wide range of descriptors, superficial or ambiguous conceptualizations, different subtypes, and inconclusive meta-analytical findings. Comorbidity with many Axes I and II conditions and the presence of narcissistic behavioral and emotional manifestations in other DSM conditions were frequent findings. The reintroduction of NPD in the personality disorders DSM-5 proposal seems to be related to nonclinical or heuristic considerations. It is concluded that NPD as such shows nosological inconsistency and that its consideration as a trait domain with needed further research would be strongly beneficial to the field.

Can the Holmes-Rahe Social Readjustment Rating Scale (SRRS) be used as a suicide risk scale? An exploratory study

The objective of this research was to examine whether the Holmes-Rahe Social Readjustment Rating Scale, a life event scale, can be used to identify suicide attempters. The Holmes-Rahe Social Readjustment Rating Scale's ability to identify suicide attempters was tested in 1183 subjects (478 suicide attempters, 197 psychiatric inpatients, and 508 healthy controls) using the Fisher Linear Discriminant Analysis and traditional psychometric methods. The Fisher Linear Discriminant Analysis outperformed traditional psychometric approaches (area under the curve: 0.85 vs. 0.78; p < 0.05) and indicated that this scale may be used to identify suicide attempters. The life events that better characterized suicide attempters were change in frequency of arguments, marital separation, and personal injury. The Holmes-Rahe Social Readjustment Rating Scale may help identify suicide attempters.