Reducing Suicide A National Imperative (2002) / Chapter Skim
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3 Psychiatric and Psychological Factors
3 Psychiatric and Psychological Factors
Pages 69-118
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From page 69... ...
Determining who among those with mental disorders will attempt suicide is paramount for individual intervention and prevention. It is important to note that mental illness and substance abuse are not always the greatest risk factors for suicide.
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From page 70... ...
PSYCHIATRIC/SUBSTANCE USE DISORDERS AND SUICIDE RISK Almost all psychiatric disorders, including alcohol and substance disorders, are associated with an increased risk of suicide. Depressive disorders are found in 30-90 percent of those who complete suicide, including the approximately 5 percent with bipolar disorder (Lonnqvist, 2000~.
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From page 71... ...
Borderline personality and antisocial personality disorders are those most frequently associated with suicide. Mood Disorders Suicides in many nations including the United States are most commonly associated with a diagnosis of a mood disorder in adults (Lonnqvist, 2000)
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From page 72... ...
A major depressive episode and borderline personality disorder are the only diagnostic entities in the DSM-IV system that include suicidality as a symptom. Dysthymic disorder is diagnosed when an individual is depressed and sad more days than not for at least 2 years, but does not have symptoms that meet criteria for a major depressive disorder.
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From page 73... ...
No suicides were observed in those being treated on an outpatient basis without medication (Simon and Von Korff, 1998~. Other studies suggest a disconnect between the response of depressive symptoms and suicidal behavior (Brent et al., 1997; Lerner and Clum, 1990~.
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From page 74... ...
Bipolar II disorder is frequently misdiagnosed as major depression (Goodwin and lamison, 1990~. Whereas much is known about variables associated with increased risk for all of those with mood disorders, few studies have examined bipolar disorder separately.
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From page 75... ...
A recent study using the National Comorbidity Survey data (Molnar et al., 2001) found that for all anxiety disorders including PTSD, the population attributable risk for serious suicide attempts is almost 60 percent for females, and 43 percent for males.
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From page 76... ...
It predicts subsequent first onset of a suicide attempt with an odds ratio of 6, as compared to other anxiety disorders with an odds ratio of 3, and mood disorders at 12.9 times the increased risk (Kessler et al., 1999~. Furthermore, PTSD appears to have an equal or greater odds ratio than mood disorders or other anxiety disorders for making a suicide plan and for making impulsive suicide attempts (Kessler et al., 1999~.
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From page 77... ...
Using time series analysis, Kessler (2000) found that current PTSD significantly predicts subsequent first onset of all other anxiety disorders, substance use disorders, major depression, and dysthymia for males and females.
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From page 78... ...
Approximately 50 percent of those who complete suicide had made prior attempts (Drake et al., 1985; Heila et al., 1997; 1998~. This is markedly lower than the 65 percent rate of prior attempts among people who complete suicide with borderline personality disorder, which likely reflects in part the high lethality of suicidal behavior in those with schizophrenia.
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From page 79... ...
In fact BED is one of only two diagnoses in the DSM system for which suicidal behavior is listed as a symptom, with depressive episode as the other (APA, 1994~. Borderline personality disorder is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior, which seriously interferes with functioning.
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From page 80... ...
Approximately 40-90 percent of those with personality disorders have attempted suicide (Ahrens and Hang, 1996; Bornstein et al., 1988; Corbitt et al., 1996; Garvey and Spoden, 1980; Modestin et al., 1997~. A large, psychological autopsy study of completed suicides in Finland found that personality disorder and major depressive disorder were diagnosed in equal percentages (31 percent)
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From page 81... ...
Alcohol use, particularly heavy use and alcohol dependence, is highly associated with suicide in three ways: · Alcohol through its disinhibiting effects is related to suicide attempts and completions · Individuals with alcohol use disorders are at an increased risk of suicide as compared to the population at large · At the population level (nationally and internationally) alcohol consumption is correlated with suicide rate Impulsivity, Relationship Loss, and Hopelessness Acute alcohol intoxication acts as a disinhibitor in impulsive, angry suicides, often precipitated by loss of a relationship (Mayfield and Montgomery, 1972~.
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82 do JO be o V)
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From page 83... ...
PSYCHIATRIC AND PSYCHOLOGICAL FACTORS 83 lion studied (Ford et al., 1979; Hayward et al., 1992) and in suicides that occur at night and on weekends (Smith et al., 1989; Welte et al., 1988~.
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From page 84... ...
Lifetime risk of suicide has been estimated at 3.4 percent for those with severe alcohol abuse disorders requiring hospitalization (Murphy, 1992~. Alcohol dependent individuals who complete suicide are most frequently male, white, middle-aged, unmarried, with hospitalization in the past year, and with a history of previous attempts (Roy and Linnoila, 1986~.
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From page 85... ...
Substance abuse prevalence is increasing among younger cohorts (Kessler et al., 1994~. Abuse of illicit substances, like alcohol abuse, is associated with increased risk for suicide and suicide attempts.
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From page 86... ...
The relationship of substance abuse disorders and comorbid psychiatric diagnoses to suicidal behavior is complex, since it is often unclear in what order the conditions arose, what causal links exist, and whether other characteristics of psychology, biology or social circumstance may mediate the relationships. The same suicide risk factors are found in substance abusers as in other populations: family psychopathology (especially maternal depression)
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From page 87... ...
, although some studies find conduct disorder more strongly associated with suicide attempts in adolescents (Borst and Noam,1989~. In four studies, between 40 and 53 percent of the youth suicides were diagnosed with a personality disorder (Brent et al., 1994; Lesage et al., 1994; Rich and Runeson, 1992; Rich et al., 1986~.
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From page 88... ...
Teenage suicide victims who use firearms to complete suicide are 4.9 times more likely to have been drinking than those who used other methods. Substance abuse among youth is another of the most significant risk factors for suicidal behavior (for review, see Brent and Kolko, 1990~.
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From page 89... ...
Comorbidity of Psychiatric Disorders Comorbidity of psychiatric disorders with other psychiatric illnesses including substance use disorders or with somatic disorders increases risk of suicide (Lonnqvist, 2000~. Co-occurrence of mental disorders and substance abuse disorders increases the risk of suicide beyond that for each of these disorders singly (Suominen et al., 1996~.
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From page 90... ...
· Memory and Cognitive Distortions · Hopelessness and Hope · Self-Efficacy · Locus of Control · Coping Style and Affect Regulation Memory and Cognitive Distortions Individuals with mental disorders, especially those with depression, often display cognitive distortions such as rigid or dichotomous thinking, overgeneralization, exaggeration or minimization of events, drawing conclusions based on insufficient/contradictory evidence or selectively attending to relevant information, and falsely attributing causality to themselves (for review, see Weishaar and Beck, 1990~. Unlike self-reports of high depression, which predict depression remission after treatment, high levels of cognitive distortion appear difficult to modify and may predict continued depression (Brent et al., 1998~.
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From page 91... ...
predicted 91-94 percent of suicides in both inpatients and outpatients over 5-10 years. Hopelessness appears trait-like, exhibiting stability and chronicity over the course of mental illness and remaining even after remission of major depression (Brent et al., 1998; Minkoff et al., 1973; Rifai et al., 1994~.
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From page 92... ...
Reductions in suicidal ideation and attempt have also been reported (see Chapter 7) , but there are no published findings on the specific effect of reducing hopelessness on rates of suicidality.
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From page 93... ...
Positive self-efficacy beliefs further increase the establishment and use of protective factors such as social support and active coping strategies (e.g., Bandura, 1982; 1988; 1992; Benight et al., 1999a; Green and Rodgers, 2001~. Although some studies show coping efficacy beliefs buffering suicidality, very little research exists on modifying suicidality via increasing self-efficacy.
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From page 94... ...
; for others, especially those with personality disorders or alcoholism, these skills deficits are characteristics or traits of the individual (Linehan et al., 1987; Weishaar and Beck, 1990~. Many psychotherapeutic interventions target coping and emotion regulation skills (see Chapter 7~.
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From page 95... ...
As described in Chapter 8, recent suicide prevention programs across the world have incorporated skills training and efficacy enhancement into their efforts, and evaluation of such interventions should yield critical information about the relationship between these variables and suicide. Temperament and Personality Research shows that mental health and the experience of stress is confounded with aspects of temperament and personality individuals higher in emotionality report more negative life events and daily stresses than individuals lower in emotionality (Aldwin et al., 1989~.
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From page 96... ...
High neuroticism was found linked with increased suicide attempts in a 21-year, prospective, study of 1265 children in New Zealand (Fergusson et al., 2000~. Like those individuals at risk for suicide with the irritable/aggressive traits, those with high neuroticism who attempted suicide were also more likely to have experienced childhood trauma, including abuse and inadequate relationships with caretakers (see Chapter 5~.
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From page 97... ...
Youth with psychological problems or psychiatric disorders are at greater risk for behavior-dependent adverse life events, thereby increasing exposure to stressors and trauma, which in turn affects personality development, thus creating a cyclical pathway of greater psychopathology (Ge and Conger, 1999; Sandberg et al., 1998~. Temperament and personality emerge early in life and remain relatively stable over the life-course, and thus may be less easily modifiable than other psychological variables.
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From page 98... ...
Suicidal ideation and attempts in depressed patients are highly correlated with affective factors such as sadness and crying spells and with cognitive factors like self-hate, and not as strongly with somatic symptoms of depression (Beck and Lester, 1973; Beck et al., 1973; Lester and Beck, 1977~. Furthermore, suicidal behavior among those with borderline personality disorder, for example, often represents a strategy to regulate psychic pain (see Catanzaro, 2000~.
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From page 99... ...
· Suicide most commonly is associated with a diagnosis of depression. Recent research has increasingly established anxiety disorders and borderline personality disorder as significantly elevating suicide risk.
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From page 100... ...
1996. Suicidality in hospitalized patients with a primary diagnosis of personality disorder.
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1994. Prevalence of personality disorders in community-living elderly.
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2001. Treatment utilization by patients with personality disorders.
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1994. Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents.
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From page 104... ...
1996. Suicidal behavior in patients with major depression and comorbid personality disorders.
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1997. Childhood antecedents of self-destructiveness in borderline personality disorder.
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From page 106... ...
1988. Suicide attempts in patients with borderline personality disorder.
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From page 107... ...
1988. Personality disorders in panic patients: Response to termination of antipanic medication.
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From page 108... ...
1996. Suicide among subjects with personality disorders.
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1999. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey.
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From page 110... ...
2000. Psychiatric aspects of suicidal behavior: Personality disorders.
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1997. Possible correlates of DSM-III-R personality disorders.
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1984. The implications of DSM-III personality disorders for patients with major depression.
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From page 113... ...
1988. DSM-III personality disorders and the outcome of treated panic disorder.
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From page 114... ...
1997. Risk factors for suicide in patients with schizophrenia: nested case-control study.
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From page 115... ...
1994a. Risk factors for suicidal behavior in borderline personality disorder.
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From page 116... ...
1998. Comorbidity of personality disorders with bipolar mood disorders.
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From page 117... ...
Journal of Personality Disorders, Supplement, Spring: 44-62. Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S
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From page 118... ...
What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately iJentifiable pain, like that of a broken limb.
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