Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6–12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.     

An investigation of psychopathology in nonreferred suicidal and nonsuicidal adolescents

This investigation examined self-reported psychopathology in a school-based sample of 456 suicidal and nonsuicidal adolescents. The sample consisted of four groups: three at-risk for suicidal behavior based on current suicidal ideation as assessed by the Suicidal Ideation Questionnaire (SIQ; Reynolds, 1988), past suicide attempts, or both; and one nonsuicidal comparison group. Psychopathology was examined using ten scales from the Adolescent Psychopathology Scale (APS; Reynolds, 1998a) including: Major Depression, Conduct Disorder, Substance Abuse, Schizophrenia, Adjustment Disorder, Anorexia Nervosa, Borderline Personality Disorder, Obsessive-Compulsive Personality Disorder, Schizotypal Personality Disorder, and Avoidant Personality Disorder. Analyses were conducted separately for males and females using a MANOVA design that examined psychopathology severity among the four groups. Adolescents who engaged in past or current suicidal behavior had higher psychopathology severity scores compared to their nonsuicidal peers. Males with current suicidal thoughts who had attempted suicide had the highest levels of psychopathology severity compared to males in the other three groups. Females with a past suicide attempt or current suicidal ideation had higher psychopathology severity scores compared to nonsuicidal females. Results show greater psychopathology in school-based adolescents who have engaged in past and/or current suicidal behavior. The need for clinicians and mental health professionals working with at-risk youth to focus on concurrent psychopathology along with suicidal behavior is discussed.     

Styles of problem solving in suicidal individuals

This study compared qualitative aspects of problem solving among suicide attempters, suicide ideators, and nonsuicidal patients. The subjects completed a suicidal intent scale and a problem-solving task involving three dilemmas. Problem solving was analyzed along eight qualitative categories: versatility of the various solutions, reliance on self versus others, activity versus passivity, confrontation versus avoidance, relevance of the solution to the problem, positive versus negative affect, reference to the future, and extremity of the solution. The statistical analysis yielded differences among the three groups. In general, the solutions of suicidal patients showed less versatility, more avoidance, less relevance, more negative affect, and less reference to the future than the solutions of the nonsuicidal patients. The suicide attempters and nonsuicidal patients offered more active solutions than did the suicide ideators. Our findings emphasize the importance of general coping styles, as well as energetic/motivational aspects and affective aspects of the problem-solving process. Some applications to therapy are discussed.     

Differentiating Adolescent Suicide Attempters from Ideators: Examining the Interaction between Depression Severity and Alcohol Use

Depressed mood, frequency of alcohol use, and their combination were examined to see if they differentiated nonsuicidal adolescents from those with suicidal ideation and adolescents with suicidal ideation from those who have made a suicide attempt. Hierarchical logistic regressions indicated that frequency of alcohol use did not differentiate nonsuicidal adolescents from those with current suicidal ideation, but severity of depressed mood did so. In contrast, alcohol use was a significant differentiating factor between adolescents who had attempted suicide compared to those with suicidal ideation only, with severity of depressed mood not being significant. However, there was also a significant interaction effect such that for adolescents with suicidal ideation and low levels of depression, increased frequency of alcohol use was associated with increased odds of a suicide attempt. These findings suggest that alcohol use may hasten the transition from suicidal ideation to suicide attempt in adolescents with low levels of depressed mood.     

厌恶情绪与自杀行为的关系

自杀导致人类死亡的人数与日俱增,然而自杀的心理机制却并不清楚。最近研究发现,厌恶情绪是导致自杀的主要情绪因素,个体因为自身厌恶而走向自杀。厌恶情绪是一种对自己和他人排泄物等反感的基本情绪,促进个体远离毒性和疾病,从而产生“免疫行为”。许多心理问题来自于对周围人或事物的厌恶,有自杀行为的个体对自身极其厌恶,说明他们的厌恶情绪出现了问题。如同躯体免疫攻击自身一样,自身厌恶是自杀意念的关键因素,早年创伤是其根源,生活压力和精神疾病也参与厌恶诱发自杀意念。厌恶诱发自杀意念的神经基础与HPA轴和五羟色胺系统有关。未来研究可利用神经影像和电生理等神经科学技术,检验自杀行为的神经机制,探讨厌恶情绪影响自杀行为的心理和神经机制。     

Adolescents with suicidal and nonsuicidal self-harm: clinical characteristics and response to therapeutic assessment

Self-harm is one of the best predictors of death by suicide, but few studies directly compare adolescents with suicidal versus nonsuicidal self-harm. Seventy adolescents presenting with self-harm (71% young women, ages 12-18 years) who participated in a randomized controlled trial were divided into suicidal and nonsuicidal self-harm categories using the Columbia Classification Algorithm of Suicide Assessment. Adolescents with suicidal self-harm were more likely than those with nonsuicidal self-harm to be young women, 22/23 (96%) versus 34/47 (72%), odds ratio (OR) = 8.33, 95% confidence interval (CI) [1.03, 50.0]; had a later age of onset of self-harm, 15.4 years vs. 13.8 years, mean difference = 1.6, 95% CI [.8, 2.43]; and used self-poisoning more often, 18/23 (78%) versus 11/47 (23%), OR = 3.43, 95% CI [2.00, 5.89]. Only those with nonsuicidal self-harm had an improvement on Children's Global Assessment Scale score following a brief therapeutic intervention, mean difference = 8.20, 95% CI [.97, 15.42]. However, there was no interaction between treatment and suicidality. There are important differences between adolescents presenting with suicidal and nonsuicidal self-harm. Suicidal self-harm in adolescence may be associated with a less favorable response to therapeutic assessment.     

Characteristics of Suicidality Among Adolescents

The identification of high-risk adolescent suicide attempters in a population of depressed and suicidal adolescents is of crucial importance. This retrospective study examined characteristics of suicidality (recent and lifetime, active and passive) and psychopathology (depression, aggression, impulsivity, stressful life events, SCL-90 dimensions) among four groups of depressed adolescent outpatients: (1) suicide attempters who required medical treatment (n = 84), (2) suicide attempters who did not require medical treatment (n = 57), (3) suicidal ideators who had never made a suicide attempt (n = 40), and (4) nonsuicidal patients (n = 44). Results indicate that the nonsuicidal group could be differentiated from the three suicidal groups on the basis of suicidality and psychopathology, and that the three suicidal groups could be differentiated from one another on the basis of suicidality but not psychopathology. These findings are discussed in terms of the usefulness of certain self-report measures of suicidality for identifying suicidal adolescents and for differentiating among them. Furthermore, the findings suggest that psychopathological factors do not determine which suicidal adolescents make a medically dangerous suicide attempt and which do not.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Suicidal behavior in chemically dependent adolescents

Among 250 adolescents in a short-term residential treatment program for chemical dependency, 20% had attempted suicide in the two years prior to admission. Females, however, were found to have a higher attempt rate than did males. Suicide attempters were compared with a group of 50 nonsuicidal adolescents from the same treatment program and 50 non-chemically dependent, nonsuicidal high school students. Each adolescent was administered the Symptom Checklist 90-Revised (SCL-90-R), and a biographical history was obtained. The suicidal group was found to be more psychologically distressed than were the other two groups. Post hoc analysis revealed that there were significant differences between the chemically dependent groups (suicidal, nonsuicidal) on the Global Severity Index of the SCL-90-R, as well as the following subscales: Somatization, Depression, Anxiety, and Phobic Anxiety. It was also found that the majority of suicidal gestures or attempts had gone untreated beyond medical management. It was found that only 28% of the suicide attempters had received crisis intervention or emergency room treatment, and only 27% had received some type of follow-up treatment or counseling. These results are discussed, particularly in regard to the issue of "covert suicide."     

The impact of rock videos and music with suicidal content on thoughts and attitudes about suicide

In Experiment 1, 133 college student volunteers watched a rock music video with or without suicidal content and then completed written measures assessing mood, priming of suicide-related thoughts, perceptions of personal risk, sensitivity to suicidality in others, and attitudes/beliefs about suicide. In Experiment 2, 104 college student volunteers listened to rock music with either suicidal or neutral content and then completed measures similar to Experiment 1, with the addition of a hopelessness measure. In both experiments, participants exposed to suicidal content wrote more scenarios with suicide-related themes in a projective storytelling task than those exposed to nonsuicidal content. However, there were virtually no group differences on explicit measures of affect, attitudes, and perceptions. Music and videos with suicide content appeared to prime implicit cognitions related to suicide but did not affect variables associated with increased suicide risk.     

Frequency of Suicidal Thought and Self-Destructive Behavior among Females

ABSTRACT: The focus of the present investigation was to examine the importance of a control group in suicide research and to develop an instrument to disguish between levels of suicidal thought among subjects who had a history of attempted suicide and among a comparison group of nonsuicidal individuals. The sample was comprised of female university students ranging in age from 18 to 25 years. A 31-item questionnaire designed by the investigator was given to 199 students, 20 of whom were found to have histories of one or more previous suicide attempts. The remaining 179 nonsuicidal subjects were divided into two categories based on the frequency of expressed suicidal thought. Fifty individuals were randomly selected from each of these two groups. The three groups (individuals who had attempted suicide, individuals who had not attempted suicide but who thought about suicide on a frequent basis, and individuals who had not attempted suicide and who thought about suicide on an infrequent basis) were compared on the variables of motivation for suicidal thoughts, history of self-destructive behaviors, probability of a future suicide attempt, and age of first suicidal considerations. A chi-square analysis was performed on each of these items in order to assess the extent to which the items discriminated among the three comparison groups. The differences among the three groups on each of the items were found to be statistically significant at less than the .01 level. The results of the study have provided support for the necessity of a distinction between groups within a nonsuicidal comparison population and for the suggestion that there may be a quantitative relationship between the frequency of suicidal thought and the likelihood of attempted suicide.     

Suicidal behavior in adolescent and young adult gay men

The relationship of homosexuality to suicidal behavior was explored by questionnaire responses from 52 men in gay-and-lesbian college organizations and 56 men in gay rap groups. A family background of alcoholism and physical abuse, social supports perceived as rejecting of homosexuality, and no religious affiliation were associated with a history of suicidal ideation, reported by 55% of the participants. Racial/ethnic minorities tended to be overrepresented among suicidal as compared to nonsuicidal gay men. Suicide attempts, reported by 20% of the sample, were most often associated with intrapersonal distress, and occurred most often while individuals were "closeted" and/or in the context of recent rejection for being homosexual. Nearly all attempters were aware of their homosexual feelings, but had not yet established a "positive gay identity" at the time of their first suicide attempt. Suicidal behavior in gay youths may be the product both of familial factors that predispose youths to suicidal behavior, and for social and intrapersonal stressors involved in coming to terms with an emerging homosexual identity.     

Social skills and depression in adolescent suicide attempters

The relationship among depression, social skills, and suicidal behavior was examined in a sample of 41 adolescents hospitalized in a general medical setting following a suicide attempt. These subjects were compared to 40 nonsuicidal psychiatrically hospitalized adolescents. Level of depression, assessed using the Children's Depression Inventory (CDI), and social skills, assessed via the Matson Evaluation of Social Skills with Youngsters (MESSY), were evaluated for all subjects. The suicide attempters and psychiatrically hospitalized patients were not found to differ on either the CDI or MESSY. However, multiple regression analyses revealed the factor scores of the MESSY to be related to depression in both patient groups. The data provide support for the relationship between social skills and depression. Results are also discussed in terms of the similarities between adolescent suicide attempters and nonsuicidal psychiatrically disturbed adolescents.     

Adolescent suicide and defensive style.

This empirical study investigated the relation between ego defense mechanisms, diagnoses, and suicidality among 200 adolescent psychiatric patients ages 12 to 16 years. Based on a structured diagnostic interview, adolescents were divided into three groups: suicide attempters, suicidal ideators, and nonsuicidal patients. Using the Defense Mechanisms Inventory (DMI), suicidal adolescents scored higher on the defense of turning-against-self and lower on reversal, as compared to nonsuicidal adolescents. Although suicide was significantly more common among adolescents with an affective disorder, turning-against-self remained significantly associated with suicide attempt even when diagnosis was controlled for. Results demonstrate the importance of defense mechanisms in understanding adolescent suicidal behavior.     

Physiological Reactions to a Suicide Film: Suicide Attempters,Suicide Ideators,and Nonsuicidal Patients

A film about two teenagers who commit suicide was shown to three groups of psychiatric inpatients: 17 who had attempted suicide, 20 who had expressed suicidal thoughts, and 10 who were not suicidal. Anxiety before and after the film was evaluated with psychometric (anxiety rating scale) and physiological tools (heart and respiration rate, blood pressure, electromyogram). Values noted before and after screening, and the degree of change in these values, were compared. In addition, psychomotor agitation was rated at several points during the film. Most results were negative. The suicide attempters had significantly lower postscreening heart rates and a significantly lesser change in heart and respiration rates than the other two groups. The suicide attempters revealed an increase in psychomotor agitation until the discovery of the suicide and a decrease thereafter, whereas the agitation of the nonsuicidal patients continued to increase from the start to the end of the film. The study suggests that on some parameters, suicide attempters reveal less anxiety than nonsuicidal psychiatric patients following exposure to a simulated suicide. The reaction of suicide ideators falls somewhere between the two groups.     

Impairment in risk-sensitive decision-making in older suicide attempters with depression

Suicidal behavior is a potentially lethal complication of late-life depression. In younger adults, suicide has been linked to abnormal decision-making ability. Given that there are substantial age-related decreases in decision-making ability, and that older adults experience environmental stressors that require effective decision-making, we reasoned that impaired decision-making may be particularly relevant to suicidal behavior in the elderly. We thus compared performance on a probabilistic decision-making task that does not involve working memory ("Cambridge Gamble Task") in four groups of older adults: (1) individuals with major depression and a history of suicide attempt (n = 25), (2) individuals with major depression with active suicidal ideation but no suicide attempt (n = 13), (3) individuals with major depression without suicidality (n = 35), and (4) nondepressed control subjects (n = 22). There was a significant effect of group on quality of decision-making, whereby the suicide attempters exhibited poorer ability to choose the likely outcome, compared with the nonsuicidal depressed and nondepressed comparison subjects. There were no group differences in betting behavior. The suicide attempters differed in several aspects of social problem-solving on a self-report scale. Quality of decision-making was negatively correlated with the score on the impulsive/careless problem-solving subscale. These data suggest that older suicide attempters have a deficit in risk-sensitive decision-making, extending observations in younger adults. More specifically, older suicide attempters seem to neglect outcome probability and make poor choices. These impairments may precipitate and perpetuate suicidal crisis in depressed elders. Identification of decision-making impairment in suicidal elders may help with designing effective interventions.     

Future Well-Being Among U.S. Youth Who Attempted Suicide and Survived

To what extent does a suicide attempt impair a person’s future well-being? We estimated the prevalence of future well-being (FWB) among suicide attempt survivors using a nationally representative sample of 15,170 youths. Suicide attempt survivors were classified as having high FWB if they reported (a) a suicide attempt at Wave I, (b) no suicidal ideation or attempts over the past year at Wave III (7 years after), and (c) a well-being profile at or above the top quartile of nonsuicidal peers. Seventy-five of 574 suicide attempt survivors (∼13%) met criteria for FWB at Wave III, compared to 26% of nonsuicidal peers. Wave I well-being levels, not depressive symptoms, predicted the likelihood of FWB at Wave III (OR = 1.23, 95% CI [1.05, 1.44], p < .05). In conclusion, a nonfatal suicide attempt reduced but did not preclude FWB in a large national sample. The observation that a segment of the population of suicide attempt survivors achieves FWB carries implications for the prognosis of suicidal behavior and the value of incorporating well-being into investigations of suicide-related phenomena.     

Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.     

A Comparison of Suicidal and Nonsuicidal Elders Referred to a Community Mental Health Center Program

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.     

Common problems and coping strategies II: Findings with adolescent suicide attempters

This study investigated the most common precipitants of adolescent suicide attempts and the strategies used to cope with such problems. Adolescent suicide attempters were compared with both distressed and nondistressed nonsuicidal adolescents on problems reported and coping strategies utilized. All three groups reported four problems as occurring most frequently: school, parents, friends, or boyfriend/girlfriend. The suicide attempters and distressed controls reported problems with parents more frequently than did nondistressed controls, while this latter group reported problems at school more frequently than did suicide attempters or distressed controls. Suicide attempters used social withdrawal, problem solving, and emotional regulation more than did nondistressed controls, but not more frequently than distressed controls. Distressed controls used wishful thinking and resignation more than did suicide atempters. Results are discussed in terms of the similarities between suicide attempters and nonsuicidal distressed adolescents and the need to more closely investigate specific subgroups of suicide attempters.