An empirical study of seriously disturbed suicidal patients

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.     

Treatment of suicidal patients: a risk-benefit analysis

A therapist may be held liable when a patient commits suicide if previous suicidal tendencies were observed but reasonable precautions were not taken. In order to reduce liability and enhance treatment effectiveness, therapeutic decisions can be critiqued by estimating the risks and benefits associated with different courses of action. An evaluation of risks and benefits can be used to guide decisions regarding assessment, hospitalization, medications, and discharge from the hospital. A risk-benefit analysis can help therapists utilize a broad range of treatment options while allowing patients the maximum degree of autonomy. Additionally, all aspects of treatment should be well documented, including information about the specific course of action chosen, other treatment options considered, and the therapeutic rationale for deciding which treatment plan was best suited to the patient's needs.     

Miscarriages of psychoanalytic treatment with suicidal patients2

The author describes a particularly perilous frontier on the psychoanalytic landscape‐ namely, the treatment of suicidal patients with serious personality disorders. Using a clinical example of egregious boundary violations by an analyst, he describes specific countertransference pitfalls that lead to mishandling the patients' expressions of suicidal despair. These include disidentification with the aggressor, failure of mentalization, collapse of the analytic play space, reactions to loss in the analyst's personal life, omnipotence, envy of the patient and masochistic surrender. The author emphasizes the unique vulnerabilities that accompany analytic treatment of such patients.     

Desperation and other affective states in suicidal patients

Data collected from 26 therapists who were treating patients when they died by suicide were used to identify intense affective states in such patients preceding the suicide. Eleven therapists provided comparable data on 26 patients they had treated who were seriously depressed but not suicidal. Although the two groups had similar numbers diagnosed with MDD, the suicide patients showed a significantly higher total number of intense affects in addition to depression. The acute affective state most associated with a suicide crisis was desperation. Hopelessness, rage, abandonment, self-hatred, and anxiety were also significantly more frequently evidenced in the suicide patients.     

Prevalence of suicidal ideation in patients with atopic dermatitis

The prevalence of suicidal ideation in patients with mild, moderate, and severe atopic dermatitis between the age of 15 to 49 years were 0.21%, 6%, and 19.6%, respectively. In addition, the prevalence of homicide-suicidal ideation in mothers or fathers of patients (aged 0-14 years) with mild, moderate, and severe atopic dermatitis were 0.11%, 0.35%, and 3.28%, respectively. These results indicate that patients with atopic dermatitis or even parents of patients with atopic dermatitis have high prevalence of suicidal ideation.     

Primary care providers' views regarding assessing and treating suicidal patients

Primary care providers (PCPs) usually do not explore patient suicidality during routine visits. Factors that predict PCP attitudes toward the assessment and treatment of suicidality were examined via an online survey of 195 practicing PCPs affiliated with medical schools in the United States. PCPs who perceived themselves as competent to work with suicidal patients were more willing to assess and more willing to treat suicidal patients, with the perception of competency fully explaining the relationship between training and willingness to treat. Female gender predicted lower self-perceived competency, while in-office access to professional mental health (MH) consultation predicted greater self-perceived competency. Higher self-perceived general competence predicted lower subjective valuation of access to MH consultation. Multiple linear regression analysis indicated a three-way interaction between training, gender, and valuation of MH consultation as predictors of perceived competency, with training generally being associated with greater perceived competency to treat suicidality. Relative to their male counterparts, female PCPs have lower confidence in assessing and treating suicidality. Perceived competence in risk assessment should be given more attention in medical training because of its role in PCPs' willingness to treat suicidality.     

Correlates of relative lethality and suicidal intent among deliberate self-harm patients

Conflicting findings have been reported regarding the relationship between the potential lethality of acts of deliberate self-harm (DSH) and suicidal intent, and how each relates to patient characteristics. This study examines the relationship of suicidal intent of DSH to lethality, the relationship of both to patient characteristics, and determines if intent or lethality are risk factors for repetition of DSH. Potential lethality and Suicide Intent Scale (SIS) scores for DSH episodes were examined in a representative sample of 150 patients presenting to a general hospital. Follow-up interviews were completed 12 to 20 months later. Lethality was strongly associated with high intent. Both lethality and intent were associated with male gender. Suicidal intent but not lethality was associated with the presence of psychiatric disorder and depression. Intent was significantly correlated with hopelessness scale score. Although intent was correlated with both depression and self-esteem scale scores, these correlations became nonsignificant when the effect of hopelessness was removed. Repetition of DSH during the follow-up period was related to neither lethality nor intent scores for the original episodes. Lethality and suicidal intent, although related, have somewhat different correlates. Both should be considered when assessing DSH patients, but their relationship to further suicidal behavior does not appear to be straightforward.     

A group approach to guilt in depressive and suicidal patients

Summary A psychiatrist and a pastoral psychologist considered the problem of guilt as a source of alienation in depressed and suicidal patients by using a four-dimensional approach in a group psychotherapy setting. This involved functioning as cotherapists representing theological and psychiatric orientations and utilizing both didactic and insight-oriented approaches to elicit and explore meaningful material related to guilt feelings. With a number of exceptions, the patients did not appear to make a sharp distinction between the cotherapists' roles. The didactic openings on guilt served to provoke ready discussion of personal conflicts involving guilt feelings, especially in the silent patients who were not easily drawn into spontaneous discussion.     

Childhood trauma and suicidal behavior in male cocaine dependent patients.

A consecutive series of 100 male cocaine dependent patients were interviewed about suicidal behavior and completed the 34-item Childhood Trauma Questionnaire (CTQ) to determine whether childhood trauma is associated with suicidal behavior in cocaine dependent men. Patients who had attempted suicide (n = 34) reported significantly higher scores for childhood emotional abuse, physical abuse, sexual abuse, and emotional and physical neglect than patients who had never attempted suicide (n = 66). In this study, various childhood traumas were found to be significantly associated withsuicidal behavior among adult male cocaine dependent patients.     

Adolescent suicidal ideation

Adolescent suicidal ideation and its relationship to other variables was tapped by a self-report questionnaire administered to 88 high school seniors. Eighteen percent responded positively to the statement "sometimes I feel suicidal." Those who reported suicidal ideation were found to differ from those who did not on a number of variables, including family relationships (quality of relationship with mother, intimacy with parents, and closeness to siblings), family history of depression (maternal depression), peer relations (quality of peer relationships, popularity, and number of friends), emotional well-being (happiness, anger, and depression), drug use (cigarettes, marijuana, and cocaine), and grade point average. Stepwise regression indicated that happiness explained 46% of the variance in suicidal ideation, and number of friends, anger, and marijuana use explained an additional 20%, for a total of 66% of the variance. While 34% of the variance remained unexplained, it is suggested that the questions used to measure these four variables be included in global screenings to identify adolescents at risk for suicidal ideation.     

The study of suicidal lives

Thirty suicides about whom book-length biographies have been written were examined in the framework of the ten statements formulated by Leenaars for each of his ten theories of suicide. Suicides who fit well with particular theories were identified, and the theories compared both for their success in describing the suicides and for their similarity with one another.     

Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder

Clinical approaches in treating and preventing suicidal behaviors in patients with borderline personality disorder (BPD) have received limited attention. To stimulate further work in this area, we present a behavioral activation treatment for depression (BATD; Lejuez, Hopko, & Hopko, 2002) that has shown promising results in treating clinically depressed patients and a theoretical conceptualization for why BATD may prove particularly useful in reducing the frequency of suicide-related behaviors and other symptoms characteristic of patients with BPD. We also present theoretical consistencies between BATD and the well-established intervention of dialectical behavior therapy (DBT; Linehan, 1993), which may allow for their practical integration, and conclude with a case study that illustrates the assimilation of these strategies in the treatment of a patient with BPD.     

Self-discrepancy and suicidal ideation

The purpose of this study was to determine whether certain self-discrepancies predicted the extent to which individuals experienced suicidal ideation. The Selves Questionnaire (an idiographic measure of self-beliefs) was administered to 152 undergraduate participants, who also completed measures of hopelessness, depression, and suicidal ideation. Three kinds of self-discrepancies were associated with suicidal ideation: actual:ideal, actual:ought, and actual:ideal:future. Covariance structure analyses indicated a best-fitting model suggesting that, actual:ideal and actual:ideal:future self-discrepancies contribute to hopelessness, which in turn contributes to depression and suicidal ideation. The findings suggest that self-discrepancy, as a form of negative self-evaluation, may contribute to an individual's risk for suicidal ideation. Moreover, the findings point to an integration of self-discrepancy theory with hopelessness theory.     

Dementia and suicidal behavior

Behavioral and psychological symptoms of dementia, including depression, might complicate the course of the disorder additionally. Dementia is more frequent in older people and suicide rates are higher in later life than in any other age group. To explore the phenomenology of suicidal behavior in patients with dementia, we searched electronic databases and key journals for original research and review articles on suicide in demented patients using the search terms “suicide, suicidal behavior, dementia, Alzheimer disease, and old age”. Although cognitive impairment could result in a diminishing ability to think flexibly and to solve problems or to cope with conflict, in the early stage of dementia such impairments are absent or mild, and suicidal behavior might be expected, especially following diagnosis. In addition, personality changes based on declining cognitive capacity and the neurochemical imbalances described in late-life depression and in dementia may predispose patients to aggressive or impulsive acts, such as suicide attempt. The literature on suicidal behavior and dementia highlights the need for further research in this area.