Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.     

Naturalistic evaluation of suicidal ideation: variability and relation to attempt status

Suicidal ideation has been thought to have a relatively stable course across weeks and months. However, daily changes in levels of ideation have not been adequately examined despite the importance of potential variability clinically and conceptually. For example, it has been suggested that variability in suicidal ideation may become less closely tied to variability in other mood symptoms (e.g., depression, hopelessness) among individuals with multiple suicide attempts. The present report had two related goals: (1) to prospectively evaluate suicidal ideation and related mood symptoms, and (2) to determine whether suicide attempt status predicted a decreased association between ideation and other mood symptoms. Non-clinical participants (N=108) with varying levels of suicidal ideation and number of previous suicide attempts completed the beck hopelessness scale (BHS), beck depression inventory (BDI), and suicide probability scale (SPS) every day for 4 weeks. Findings suggested considerable variability in suicidal ideation, especially for multiple attempters. Multiple attempt status predicted a decreased association between suicidal ideation and depression, although the results were only marginally significant. These findings have implications for conceptual models of suicide risk as well as assessment and treatment of suicidal individuals.     

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.     

Prediction of Suicide Intent in Aboriginal and Non-Aboriginal Adolescent Inpatients: A Research Note

The relationship among depressive symptoms, anxiety, hopelessness, and suicidal intent was explored in a group of 77 adolescents who had been hospitalized after attempting suicide. Regression analyses indicated that hopelessness was the only significant predictor of suicide intent in Caucasian patients, and depressed mood was the only significant predictor in the Aboriginal group. Clinicians should be aware that measures of hopelessness may be of limited value in assessing suicidal risk in Aboriginal adolescents.     

African American children's reports of depressed mood, hopelessness, and suicidal ideation and later suicide attempts

This study attempted to assess whether family demographic characteristics and child aggressive behavior are equal to or better than child self-reported depressive symptoms in predicting suicidal behavior. Participants were a community population of African Americans first recruited at age 6 and followed periodically through age 19-20. Measures included child self-reports of depressed mood, hopelessness, and suicidal ideation, teacher reported child aggression in grades 4-6, 6 th grade caregiver report of family demographic characteristics, and the participants' report at age 19-20 of suicide attempts. Depressed mood proved the most consistent predictor of adolescent/young adult attempts in our logistic regression analyses of the data from the population as a whole and among females. The relationship between depressed mood and suicide attempts in males was in the expected direction, but was not statistically significant. Teacher-reported youth aggressive behavior did prove to be a significant predictor of attempts in 4 th and 5 th grade for the population as a whole, but not in our analyses by gender. The relationships between family demographic characteristics and attempts failed to reach statistical significance, but were, generally, in the expected direction. The study revealed that African American children's self-reports of depressed mood as early as grade 4 may prove useful in predicting adolescent/young adult suicide attempts, particularly among females. Neither family demographics nor teacher-reported child aggressive behavior proved equal to child self-reported depressive symptoms in predicting later suicide attempts.     

Characteristics of suicide attempters and nonattempters with schizophrenia in a rural community

In this study, demographic and clinical characteristics of individuals with schizophrenia in a Chinese rural community who had attempted suicide at some time in their lives and those who had not made a suicide attempt were compared. Among individuals with schizophrenia, subjects with (n = 38) and without (n = 472) a lifetime history of suicide attempt were assessed with the Present State Examination. The results indicate that attempters had a significantly younger age, higher level of education, higher rate of lifetime depressed mood and hopelessness, and a larger number of positive symptoms than patients without suicide attempts. The logistic regression models also indicated that hopelessness, the number of positive symptoms and age were the most important predictors. Early interventions focusing on reducing hopelessness and controlling positive symptoms may help reduce the risk of suicide attempts among patients with schizophrenia.     

Assessment of mode of anger expression in adolescent psychiatric inpatients.

Anger can play an important role in depression and suicide risk among adolescents. The present study evaluated internalized and externalized anger in 92 adolescent psychiatric inpatients. Results indicated that adolescents who internalized their anger were more likely to be depressed and to experience feelings of hopelessness. In addition, adolescents who internalized their anger made more serious suicide attempts than did those who externalized their anger. In contrast, adolescents who externalized their anger were more likely to have alcohol-related problems. Thus, different modes of anger expression appear to be related to different manifestations of psychopathology. It was concluded that assessment of mode of anger expression in adolescents may enhance our understanding of suicide and its risk factors.     

Suicidal behavior among inpatients with schizophrenia and mood disorders in Chengdu, China

This study evaluated the characteristics of suicidal behavior (suicide attempt or suicidal ideation) among 230 consecutively admitted inpatients with schizophrenia and mood disorders in a university hospital in China. The rate of lifetime suicidal behavior was found to be significantly higher in patients with mood disorders (62.4%) than in patients with schizophrenia (38.6%). The rate of suicidal behavior was significantly higher in patients with major depressive disorder (86.8%) than those with bipolar disorders (42.6%). Patients with schizophrenia attempted suicide for the first time earlier in life than the patients with mood disorders. Mood disorder patients, especially those with major depressive disorder, had more and more serious suicide attempts than the patients with schizophrenia.     

Relationship Between Religious Coping and Suicidal Behaviors Among African American Adolescents

This study investigated whether hopelessness and depression were risk factors for suicidal thoughts and behaviors in African American adolescents and looked at whether religious participation and religious coping protected these students from suicidality. Participants were 212 African American high school students (133 females, 79 males). The results of multiple and logistic regression analyses found that hopelessness and depression were risk factors for suicidal ideation and attempts. Religious coping style was significantly related to suicidal behaviors: Self-directed coping was related to increased hopelessness, depression, and suicide attempts, and collaborative coping was related to increased reasons for living. Gender differences were found in symptoms of depression, religious coping style and religious participation. Results provide additional support for suicide interventions to target hopelessness and depressive symptoms and highlight the importance of examining the role of culturally salient variables, such as religious participation and religious coping style, when developing intervention programs for suicide.     

Examining the impact of psychiatric diagnosis and comorbidity on the medical lethality of adolescent suicide attempts

Specific psychiatric diagnoses and comorbidity patterns were examined to determine if they were related to the medical lethality of suicide attempts among adolescents presenting to an urban general hospital (N=375). Bivariate analysis showed that attempters with substance abuse disorders had higher levels of lethality than attempters without substance abuse. Regression results indicated having depression comorbid with any other diagnosis was not associated with medical lethality. However, having a substance abuse disorder was associated with higher suicide attempt lethality, highlighting the importance of substance abuse as a risk factor for lethal suicide attempts in adolescents. This finding stimulates critical thinking around the understanding of suicidal behavior in youth and the development and implementation of treatment strategies for suicidal adolescents with substance abuse disorders.     

Emotional Dynamics in the Development of Early Adolescent Psychopathology: A One-Year Longitudinal Study

This study examined the role of the level and variability of happiness, anger, anxiety, and sadness in the development of adolescent-reported anxiety disorder symptoms, depressive symptoms, and aggressive behavior in 452 adolescents (250 male) followed from age 13 to 14. Level and between-day variability of emotions were assessed through adolescent report at 3-month intervals across a 1 year period. Level and variability of the four emotions contributed to changes in anxiety disorder and depressive symptoms more consistently than to changes in aggressive behavior. All four emotions were predictive of changes in internalizing problems, while anger played the most prominent role in the development of aggressive behavior. Variability of emotions contributed to changes in anxiety disorder symptoms, while heightened levels of negative emotions and diminished happiness contributed to changes in depression. Results suggested somewhat stronger effects of negative affect on aggressive behavior for females than for males. Results underscore the role of emotion dysregulation in the development of psychopathology.     

Childhood diagnoses and later risk for multiple suicide attempts

The relationship between childhood diagnosis, personality psychopathology and suicidal behavior in young adulthood was explored in a sample of 327 suicide ideators, single attempters, and multiple attempters. Of the total sample, 174 received at least one childhood diagnosis; the 153 without a diagnosis provided a comparison group. Results suggest that a childhood history of an anxiety disorder or major depression predispose a person to both later multiple suicide attempts and personality psychopathology. Gender was found to play a significant role, with females being predisposed to multiple attempts in young adulthood but only as a function of childhood anxiety, not major depression. Additionally, childhood anxiety disorders were found to predispose to multiple attempts as a function of personality psychopathology, with distinctly different paths for males and females. Implications are discussed in terms of etiology, prevention, and treatment.     

Suicidality as a function of impulsivity, callous-unemotional traits, and depressive symptoms in youth

Suicidality represents one of the most important areas of risk for adolescents, with both internalizing (e.g., depression, anxiety) and externalizing-antisocial (e.g., substance use, conduct) disorders conferring risk for suicidal ideation and attempts (e.g., Bridge, Goldstein, & Brent, 2006). However, no study has attended to gender differences in relationships between suicidality and different facets of psychopathic tendencies in youth. Further, very little research has focused on disentangling the multiple manifestations of suicide risk in the same study, including behaviors (suicide attempts with intent to die, self-injurious behavior) and general suicide risk marked by suicidal ideation and plans. To better understand these relationships, we recruited 184 adolescents from the community and in treatment. As predicted, psychopathic traits and depressive symptoms in youth showed differential associations with components of suicidality. Specifically, impulsive traits uniquely contributed to suicide attempts and self-injurious behaviors, above the influence of depression. Indeed, once psychopathic tendencies were entered in the model, depressive symptoms only explained general suicide risk marked by ideation or plans but not behaviors. Further, callous-unemotional traits conferred protection from suicide attempts selectively in girls. These findings have important implications for developing integrative models that incorporate differential relationships between (a) depressed mood and (b) personality risk factors (i.e., impulsivity and callous-unemotional traits) for suicidality in youth.     

Adolescent Suicide Attempters: What Predicts Future Suicidal Acts?

Predictors for repetition of suicide attempts were evaluated among 92 adolescent suicide attempters 9 years after an index suicide attempt (90% females). Five were dead, two by suicide. Thirty-one (42%) of 73 had repeated a suicide attempt. In multiple Cox regression analysis, four factors had an independent predictive effect: comorbid disorders, hopelessness, having ever received treatment for mental or behavior problems, and having a father exerting control without affection. Prediction on an individual level was difficult. Since almost half repeated a suicidal act, the best strategy is to evaluate all adolescent suicide attempters thoroughly and provide treatment as needed.     

Single and multiple suicide attempts and associated health risk factors in New Hampshire adolescents

In this study we examined self-reported suicide attempts and their relationship to other health risk factors in a community sample of 16,644 adolescents. Fifteen percent endorsed suicide attempts (10% single; 5% multiple attempts) We hypothesized that multiple attempters would show higher prevalence of comorbid health risks than single or non-attempters. The three groups showed significant differences in ten health risk domains, on factors such as depressed mood, sexual assault, weight problems, and drug and alcohol use (ORs: 3.26-13.57). Repeated suicide attempts appear to be related to increased vulnerability and likelihood of harm in multiple domains of health risk.     

Positive and Negative Expectations of Hopelessness as Longitudinal Predictors of Depression,Suicidal Ideation,and Suicidal Behavior in High‐Risk Adolescents

The relationship between hopelessness and depression in predicting suicide‐related outcomes varies based on the anticipation of positive versus negative events. In this prospective study of adolescents at elevated risk for suicide, we used two Beck Hopelessness Scale subscales to assess the impact of positive and negative expectations in predicting depression, suicidal ideation, and suicidal behavior over a 2‐ to 4‐year period. In multivariate regressions controlling for depression, suicidal ideation, and negative‐expectation hopelessness, positive‐expectation hopelessness was the only significant predictor of depressive symptoms and suicidal behavior. Clinical interventions may benefit from bolstering positive expectations and building optimism.     

Predictors of Multiple Suicide Attempts among Suicidal Black Adolescents

Psychopathology, social support, and interpersonal orientation were studied in relation to suicide attempt status in acutely suicidal, psychiatrically hospitalized Black adolescents and a matched sample of White adolescents. In the total sample, multiple attempters were differentiated by lower perceived support. Within the Black youth subsample, social comparison and positive stimulation from others differentiated multiple attempters from single attempters/ideators. Only suicidal ideation predicted multiple attempts among White youth and only higher interpersonal orientation predicted multiple suicide attempts within Black adolescents.     

Visual-motor problems of adolescents who attempt suicide.

Using the Canter Background Interference Procedure with the Bender-Gestalt Test, a group of 18 adolescent suicide attempters earned test scores indicating they had significantly more problems with visual-motor coordination than did a control group of 21 adolescents. There were also a greater number of school failures and behavior problems among these suicide attempters. The findings suggest that learning disabilities may be an unrecognized factor which increases the risk of suicide attempts by adolescents.     

Life Stress,Social Support,and Problem-Solving Skills Predictive of Depressive Symptoms,Hopelessness, and Suicide Ideation in an Asian Student Population: A Test of a Model

The present study tested both a stress-problem-solving model and a stress-social support model in the etiology of depressive symptoms, hopelessness, and suicide ideation for a group of Asian international students in the United States. Problem-solving skills and social support were hypothesized as two mediators between life stress and depressive symptoms, hopelessness, and suicide ideation. The results from a series of stepwise regression analyses and a path analysis support the hypotheses, indicating that these models generalized to a sample of Asian international students. The roles of social support and problem-solving skills in depressive symptoms and hopelessness are discussed. The results also suggest that hopelessness may serve as a cognitive factor directly affecting depressive symptoms and indirectly affecting suicide ideation.     

Social problem solving in adolescents with suicidal behavior: a systematic review

There is an increasing focus on deficiencies in problem solving as a vulnerability factor for suicidal behavior in general and hence a target for treatment in suicide attempters. In view of the uncertainty of evidence for this in adolescents we conducted a systematic review of the international research literature examining the possible relationship between deficiencies in social problem-solving skills and suicidal behavior in this population. This was based on searching two electronic databases: Medline 1966 to September 2003 and PsychInfo 1887 to September 2003. Twenty-two studies of social problem-solving skills in adolescents with suicidal behavior were found. Most of these studies, which compared adolescent patients with suicide attempts versus either nonsuicidal psychiatric or normal controls, found evidence for problem-solving deficits in the attempters; however, few of the differences remain after controlling for depression and/or hopelessness. Because most of the studies are cross-sectional, it is difficult to differentiate between the possibilities that deficiencies in problem-solving skills lead to depression when adolescents are faced by adversity and hence to suicidal behavior, or whether depression is the main factor which undermines problem-solving skills. Future research, preferably with longitudinal research designs, is required to determine the nature of the association between problem-solving skills and suicidal behavior in adolescents. This has important implications for therapeutic interventions.