Comparison of the Suicidal Behavior of Adolescent Inpatients with Borderline Personality Disorder and Major Depression

Comparison of the Suicidal Behavior of Adolescent Inpatients with Borderline Personality Disorder and Major Depression

 

Netta Horesh, PhD,*† Israel Orbach, PhD,* Doron Gothelf, MD,† Meir Efrati, MA,* and Alan Apter, MD

*Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel; †Fein- berg Child Study Center, Schneider Children’s Medical Center of Israel, Petah-Tikva, Israel; and ‡Department of Psychiatry, Tel-Aviv Univer- sity, Ramat-Aviv, Tel-Aviv, Israel.

Reprints: Netta Horesh, PhD, Department of Psychology, Bar-Ilan Univer- sity, Ramat-Gan 52900, Israel. E-mail:  horeshn@mail.biu.ac.il

Copyright © 2003 by Lippincott Williams & Wilkins 0022-3018/03/19109-0582

DOI: 10.1097/01.nmd.0000087184.56009.61

 

 

Abstract: The objective of the study was to examine the hypothesis that some forms of suicidal behavior among adolescents are related to helplessness and depression, whereas others are related to anger and impulsivity. Sixty-five adolescents were studied. Thirty-three had borderline personality disorder (BPD), of whom 17 had made a recent suicide attempt. Thirty-two had major depressive disorder (MDD), of whom 16 had made a recent suicide attempt. Assess- ments were made with the Child Suicide Potential Scale, the Beck Depression Inventory, the Beck Hopelessness Scale, the Multidi- mensional Anger Inventory, the Overt Aggression Scale, the Impul- siveness-Control Scale, and the Suicide Intent Scale. Adolescents with BPD had more anger, aggression, and impulsiveness than those with MDD, but similar levels of depression and hopelessness. Suicidal versus nonsuicidal adolescents were more depressed, hope- less, and aggressive, but not more angry or impulsive. There were no significant differences in impulsiveness for the MDD suicidal group versus the MDD nonsuicidal group, but the suicidal BPD adoles- cents were significantly more impulsive than the nonsuicidal BPD adolescents. In the subjects with BPD, impulsiveness and aggression correlated significantly and positively with suicidal behavior. In the subjects with MDD, no such correlations were seen. In both diag- nostic groups, depression and hopelessness correlated positively and significantly with suicidal behavior. Anger did not correlate with suicidal behavior in either of the groups. The suicidal subjects with MDD had significantly higher suicidal intent scores than the suicidal adolescents with BPD. We conclude that the nature of suicidal behavior in adolescents with BPD differs from that seen in MDD with respect to the role of anger and   aggression.

(J Nerv Ment Dis 2003;191:  582–588)

Suicidal behavior in adolescence is a major public health problem and is one of the major reasons for admission to an adolescent inpatient unit in different parts of the world (Cohen et al., 1997). Although inpatient samples cannot be regarded as representative populations, adolescent psychiatric inpatients represent an important group of people for research in suicidology, for a number of reasons. First, the prevalence of suicidal behavior in this group is high (Motto, 1984; Robbins and Alessi, 1985). Many studies have suggested that the majority (as many as 90%) of young people who complete suicide and those who make serious suicide attempts have at least one diagnosable mental disorder at the time of their suicide attempt (Beautrais et al., 1998; Brent et al., 1993; Shaffer et al., 1996). Second, adolescent patients usually have a history of repeated suicide attempts (Barter et al., 1968). Finally, a high percentage of adolescents who have a history of psychiatric hospitalization go on to commit suicide (Motto, 1984; Pfeffer et al., 1988; Welner et al.,   1979).

The relationship between aggressive drives and suicidal behavior has received extensive attention in the psychoana- lytic literature (for example, Kernberg, 1978). Freud (1957/ 1917) initially recognized the relationship between aggres- sion and suicidal behavior. He envisaged suicidal acts as anger turned against the self, a notion that was elaborated by Menninger (1938) in his seminal work Man Against Himself. Menninger (1938) proposed that every suicidal act was com- posed of three basic elements: the wish to kill, the wish to die, and the wish to be killed. However, this may not be true in every suicidal act, and we attempted to determine whether, in different diagnostic groups of adolescents, the correlates of suicidal behavior might be different. Thus, in some adoles- cents, the primary associated emotion would be aggression (the wish to kill), and in others, depression (the wish to die). These ideas have received considerable empirical support from clinical (Tardiff and Sweillan, 1980), psychometric (Plutchik and van Praag, 1989), and biological research (van Praag et al., 1987). There have, however, been studies that have not found such a relationship (reviewed in Koslowsky et al., 1992; Linnoila et al., 1993). A possible explanation for these discrepancies is that aggression is related only to certain types of suicidal behavior, whereas depression is related to other forms of suicidal behavior (Apter et al.,   1995).

The diagnosis of borderline personality disorder (BPD) is a serious risk factor for suicidal behavior. A large propor- tion of people who commit suicide (Foster et al., 1999) and those who attempt suicide (Suominen et al., 1996) suffer from some kind of personality disorder. Patients with BPD also have high repetition rates of suicidal behavior (Brodsky et al., 1997). The risk factors for suicidal behavior in adult patients with BPD are previous suicide attempts, impulsiveness, older age, antisocial personality, higher education, and depressive mood (Brodsky et al., 1997; Paris et al., 1989; Soloff et al., 1994). People with BPD are classically characterized by both aggressive and suicidal behavior (American Psychiatric As- sociation, 1994). This suicidal behavior seems to be related to emotional dysregulation and problems with aggression and impulse control (Linehan, 1993).

Among teenagers, both attempted and completed sui- cidal acts are, in the great majority of cases, preceded by depressive symptoms (Brent et al., 1994). Attempted suicide is common in the course of depressive illness. Subjective feelings of depression, hopelessness, and suicidal ideation are more common in attempters than in nonattempters (Mann et al., 1999), and 38% of attempters have been reported to suffer from major depressive disorder (MDD) (Suominen et al., 1996). A recent suicide attempt in a patient with MDD indicates a particularly high risk for suicide (Nordstrom et al., 1995). There is also evidence that both in adults and in adolescents with MDD, there is a significant and positive relationship between the severity of suicidal behavior and that of depression (Apter et al., 1995; Carlson and Cantwell, 1982; Suominen et al., 1997). The relation among depression, hopelessness, and suicidal behavior is widely accepted and based on extensive theoretical reasoning (Beck et al., 1975) and research findings (Beck et al., 1990; Robbins and Alessi, 1985). However, although depression may be an important factor in the suicidal behavior of some adolescent inpatients, it is far less important in others (Apter et al., 1995; Orbach, 1987).

To elucidate the possibility that aggressively motivated suicidal behavior is different from depressively motivated suicidal behavior, we compared suicidal behavior in patients with a diagnosis of BPD with that shown by patients with major depressive disorder MDD. More specifically, we hypothesized that adolescent inpatients diagnosed as suffering from MDD would show suicidal behavior related to de- pression and hopelessness, whereas those with BPD would show suicidal behavior related to impulsivity, anger, and aggression.

 

Population

METHODS

The sample was composed of 65 adolescents  admitted to a university-affiliated adolescent psychiatric unit. The age of the patients ranged from 13 to 18 years (mean, 15; SD, 2.3). There were 50 girls and 15 boys. All the patients came from lower-middle-class backgrounds, and all were Jewish (39 Sephardim and 26 Ashkenazim by paternal origin). Thir- ty-three subjects were diagnosed as suffering from BPD (26 girls and seven boys). Seventeen of these subjects had made  a recent (first ever) suicide attempt, and 16 had never at- tempted suicide during their lifetime. Recent was defined as being within 30 days of the assessment. Ten of the subjects with BPD also met criteria for MDD, 11 had dysthymic disorder, and three met criteria for conduct disorder. There were no differences in the distribution of comorbid diagnoses between the suicidal and nonsuicidal subjects with BPD. Thirty-two subjects (24 girls and eight boys) met DSM-IV criteria for MDD. Sixteen had made a recent (first ever) suicide attempt, and 16 had never made a suicide attempt during their lifetime. None of the patients with MDD had BPD or any other significant comorbidity. There were no significant gender or age statistical differences among any of the four cells (BPD suicidal versus nonsuicidal; MDD sui- cidal versus nonsuicidal)

Exclusion criteria were as follows: comorbid diagnosis of substance abuse (two patients in each group); mental retardation (one subject); and lack of knowledge of Hebrew (one subject in each group). In addition, two subjects with MDD and two subjects with BPD who had made suicide attempts in their remote pasts were also not studied. Other- wise, the subjects represented consecutive admissions to the adolescent unit. Three subjects refused to participate in the study.

Attempted suicide or parasuicide was defined by the criteria of the ICD-10 as “an act with nonfatal outcome, in which an individual deliberately initiates nonhabitual behav- ior that, without intervention from others, will cause self- harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences” (Schmidtke et al., 1996).

 

Assessment

Child Suicide Potential Scale

The Child Suicide Potential Scale (CSPS; Pfeffer et al., 1979) is a semistructured interview to evaluate different aspects associated with suicidal behavior in children and adolescents. It consists of nine subscales: spectrum of assaul- tive behavior, spectrum of suicidal behavior, precipitating events, affects and behaviors (recent and past), family background, concept of death, ego function, and ego defenses. In the current research, we used only the spectrum of suicidal behavior to measure the severity of suicidal behaviors occur- ring in the last 6 months and past suicidal behaviors. This scale classifies suicidal behavior along a 5-point spectrum of severity (as defined by outcome), ranging from nonsuicidal behavior (rated 1) through suicidal ideation (rated 2), suicidal threats (rated 3), and mild suicide attempts not requiring medical attention (rated 4), to serious suicide attempts requir- ing medical treatment (rated 5). Each subject’s score was determined by the most severe documented suicidal behavior (Pfeffer, 1986; Pfeffer et al., 1979; 1980; 1984; 1988). Ques- tions include, “Have you ever thought of hurting yourself?” and “Have you ever attempted to hurt   yourself?”

The scale has been shown to have a high level of internal reliability and discriminant validity in suicidal chil- dren (Pfeffer et al., 1979; 1980; 1984). Interrater reliability showed 94% of agreement between two clinicians (Ofek et al., 1998). The CSPS was found by Ofek et al. (1998) to be   a reliable and valid tool among Israeli inpatient adolescents. The correlations between the CSPS suicidal behavior spec- trum scale and parallel self-report measures were statistically significant. The internal consistency was Cronbach’s alpha =

.85 for the spectrum of suicidal behavior scale. The scale has been shown to differentiate between suicidal and nonsuicidal patients (Pfeffer, 1988). The intraclass correlation coefficient between raters in this study for the spectrum of suicidal behavior scale was markedly significant  (.89).

 

Beck Depression Inventory

The well known Beck Depression Inventory (BDI; Beck and Steer, 1987) consists of 21 items related to symp- toms of depression. The scoring is based on a Likert scale, with 12 items with 4 points, eight with 5 points, and one with 6 points. Scoring is based on the average score of each item times the number of items. The range of scores is thus 21 to 94.

 

Beck Hopelessness Scale

The well known Beck Hopelessness Scale (BHS; Beck et al., 1974) measures hopelessness and has 20 items. The range is 0 to 20. Internal consistency in this study was .90.

 

Multidimensional Anger Inventory

The original form of the Multidimensional Anger In- ventory (MAI; Siegal, 1986) questionnaire was 38 items. We used a short form with 24 items. The internal consistency of the scale is reported to be .84. In this study, it was .87. A Hebrew translation of the short form was found to be psy- chometrically sound (Maoz, 1995). Answers are given on a 5-point Likert scale. The scale describes anger as a trait that usually characterizes the person. The scale consists of four factors: those related to intensity, duration, and frequency of angry feelings; those related to a range of situations that may

elicit anger; a factor called hostile outlook, and a factor related to how anger is expressed. Two subscales from this instrument were also calculated: anger in and anger out. Anger in consists of six items related to anger that remains contained. The scale measures fear of expressing anger and the tendency to block or delay expressions of anger. Anger out, six items, measures ways in which anger is directly expressed toward others. The Chronbach’s alpha of both scales is higher than 0.8 (Maoz, 1995). The scale gives a range of 24 to 120, and the mean normal value for Israeli adolescents is 38.30 (SD =  10.2).

 

Overt Aggression Scale

The Overt Aggression Scale (OAS; Yudofsky et al., 1986) is based on long-term observations of the subjects’ behavior in the unit. It measures four types of aggression: verbal aggression, aggression toward the self, aggression toward things, and aggression toward people. Each type of behavior is measured on a 4-point Likert scale. In this study, aggression toward the self was not included because we were interested to see how aggression differentiated between sui- cidal and nonsuicidal people, and including aggression against the self would have clouded this issue. Thus, the scores on this measure ranged from 0 to 12 instead of 0 to 16. In this study, internal consistency was  .85.

 

Impulsiveness-Control Scale

The Impulsiveness-Control Scale (ICS; Plutchik and van Praag, 1989) consists of 15 items scored on a 4-point Likert scale. The scores range from 0 to 45. The scale has been adapted for adolescents both in the United States (Grosz, 1991) and in Israel (Wagner, 1989). Internal consis- tency in this study was  .75.

 

Suicide Intent Scale

The widely used Suicide Intent Scale (SIS; Beck et al., 1974) has 20 items, but only the first 15 items are used for calculating the score. Scoring for each item ranges from 0  to

  1. Items 1 to 9 are concerned with the suicide act itself, 10 to 15 with the thoughts and feelings associated with the suicide act, and 16 to 20 with the subject’s thoughts and feelings about suicide in the present. The scale has been shown to have sound psychometric properties in many studies.

 

Procedure

All subjects were interviewed within 1 month of ad- mission, and all suicide attempts had been made during the month before the assessment. Diagnoses were made accord- ing to DSM-IV criteria using the Hebrew translation of the Child and Adolescent version of the Schedule for Affective Disorders and Schizophrenia. The reliability and validity of this instrument in an Israeli adolescent population were found satisfactory (Shanee et al.,  1997).

In addition, the revised version of the Diagnostic Inter- view for Borderlines (DIB-R; Zanarini et al., 1989) was administered to all patients to ensure meticulous diagnoses of BPD. This well known semistructured interview assesses the presence of 22 clinical features ascribed to the borderline condition. The various clinical characteristics are clustered in four major domains: affect, cognition, impulsiveness, and interpersonal relationships.

Several studies have shown that adult patients with BPD share clinical features commonly thought to be indica- tive of BPD with other AXIS II patients. However, some of the DIB-R diagnostic features are highly discriminating and relatively specific for BPD, and the instrument’s overall score was found useful in reliably distinguishing clinically diag- nosed borderline patients from patients with other AXIS II disorders (Zanarini et al.,  1989).

For use with an adolescent population, the interview was slightly modified along the lines suggested by Block et al. (1991).

Suicide assessment was made on the basis of an inter- view with the adolescent and the adolescent’s parents using the CSPS. Patients with values of 4 or 5, i.e., who had made  a definite recent suicide attempt, were classified as suicidal. Those with scores lower than 4 and who reported having never made a suicide attempt in their lifetime were classified as nonsuicidal. A master’s degree psychologist (M. E.) ad- ministered the questionnaires in random order during the first 2 weeks of hospitalization.

Data were analyzed by 2 X 2 multivariate analysis of variance (MANOVA) to compare diagnostic groups and to compare suicidal versus nonsuicidal groups. Simple Main Effect analysis was used to assess interactions, and Pearson coefficients were used for correlational  analysis.

 

RESULTS

Table 1 presents the comparison of adolescents diag- nosed as having BPD with those with MDD on all the measures of depression (BDI) and hopelessness (BHS) and on the measures of aggression (overt aggression as measured

by OAS, anger as measured by MAI, and impulsiveness as measured by ICS). A 2 X 2 MANOVA analysis showed a significant difference between the two diagnostic groups (Wilks’ Lambda = .54, F[3,61] = 9.81, p < .001). When the comparisons are made for each of the variables separately, it can be seen that the differences occur only in the aggression- related variables, that is, anger, aggression, and impulsive- ness. There are no significant differences between the two groups on levels of depression and hopelessness (Table   1).

The comparison of the suicidal versus nonsuicidal ad- olescents on the same variables using MANOVA also showed significant differences (Wilks’ Lambda = 50, F[3,61] = 11.47, p < .001). On comparison by each variable, it can be seen in Table 2 that here, depression and hopeless- ness are, as expected, significantly higher in the suicidal than in the nonsuicidal group. Suicidal adolescents are also more aggressive, but not more angry or impulsive, than the non- suicidal adolescents.

When interactions were analyzed, a significant interac- tion was found for impulsiveness and suicide and diagnosis (F[1,63] = 4.67, p < 0.05). Thus, there were no significant differences in impulsiveness for the depressed suicidal group versus the depressed nonsuicidal group (F[1,30] = 1.09, p > 0.05), but the suicidal BPD adolescents were significantly more impulsive than the nonsuicidal BPD adolescents (F[1,31] = 3.49, p < 0.05). None of the other variables measured (anger, aggression, depression, and hopelessness) showed significant interactions between suicidal behavior and diagnosis.

Anger in and anger out on the MAI were then compared for the suicidal versus nonsuicidal groups. Only anger out significantly differentiated suicidal from nonsuicidal adoles- cents (F[1,63] = 4.64, p < 0.05), with anger out higher (mean, 15.15; SD, 3.90) in the nonsuicidal group than in the suicidal group (mean, 13.00; SD, 4.70). Anger in did not significantly differ between the two groups, although it was higher in the suicidal than in the nonsuicidal patients. No interaction with diagnosis was found; however, as expected, the BPD group had more outward anger than the MDD group (mean,  15.58;  SD,  4.15;  versus  mean,  12.30;  SD,    3.95; F[1,63] = 13.68, p < 0.01).

Pearson correlations between scores on the CSPS and the other measures were then calculated. In the subjects with BPD, impulsiveness (ICS) and aggression (OAS) correlated significantly and positively with suicidal behavior. In the MDD subjects, no such correlations were seen. In both diagnostic groups, depression (BDI) and hopelessness (BHS) correlated positively and significantly with suicidal behavior. Anger (MAI) did not correlate with suicidal behavior in either of the groups (Table 3). A Fisher z-score analysis showed the difference in correlation to be significant  for impulsiveness (z = 2.76, p < 0.001) and for aggression (z = 1.80, p <   0.05).

On suicide intent (SIS), the suicidal subjects with MDD had significantly higher intent scores than the suicidal ado- lescents with BPD (MDD: mean, 17.5; SD, 6.45; versus BPD: mean, 12.2; SD, 4.2; t(31) = 2.79; p <   0.01).

 

TABLE 1.  Comparison of Mean ± SD of Aggression and Depression Measures in BPD and MDD Groups of Patients

Variables BPD (N = 33) MDD (N = 32) F (1,63)
Anger 77.7 ± 14.9 62.2 ± 15.1 17.3*
Aggression 6.0 ± 3.0 2.2 ± 3.4 25.3*
Impulsiveness 38.4 ± 6.9 30.0 ± 4.8 33.7*
Depression 50.0 ± 16.4 47.3 ± 15.5 0.6
Hopelessness 8.4 ± 6.0 8.6 ± 6.0 0.1
*p < .001 (Two-tailed test).

 

TABLE 2.  Comparison of Mean ± SD of Aggression and Depression Measures in Suicidal vs. Nonsuicidal Adolescent

Variables Suicidal Adolescents (N = 33) Nonsuicidal Adolescents (N = 32) F(1,63)
Anger 69.4 ± 17.5 70.8 ± 16.3 0.2
Aggression 5.2 ± 4.1 3.0 ± 2.9 8.2*
Impulsiveness 35.0 ± 8.4 33.6 ± 6.0 0.8
Depression 57.8 ± 11.6 39.3 ± 14.3 32.0**
Hopelessness 11.6 ± 5.4 5.2 ± 4.6 26.3**
*p < .01; **p < .001 (Two-tailed test).

 

TABLE 3. Pearson Correlations Between CSPS Scores and Aggression and Depression Measures  in  BPD  and MDD

Anger Aggression Impulsiveness Depression Hopelessness
BPD -0.01 0.50** 0.40* 0.63*** 0.54**
MDD -0.08 0.08 -0.21 0.60*** 0.71**

*p < .05; **p < .01; ***p < .001 (Two-tailed test).

 

DISCUSSION

The hypothesis underlying this study was that suicidal behavior in BPD and suicidal behavior in MDD have some- what different dynamics. The former may be related to aggression, the latter to depression and hopelessness. In terms of the original theory by Menninger (1938), it may be said that suicide in BPD represents the wish to kill and that suicidal behavior in MDD represents the wish to  die. The results of the MANOVA show some support, but not unqualified support, for our hypothesis. Depression and hopelessness were equally related to suicidal behavior in both diagnostic groups. The relationship between aggression and suicidal behavior was also shown to hold, and there was no interaction among suicidal behavior, diagnosis, and aggres- sion. These results are similar to the findings of Brent et al. (1993) and may have implications for eventual suicide (Brent et al., 1994).Although suicidal adolescents with BPD are more ag- gressive than their counterparts with MDD, this difference may be related to the underlying diagnosis and not to the suicidal behavior, as shown by the lack of an interactive effect. In this sample, anger was not related at all to suicidal behavior, and indeed, anger out was higher in nonsuicidalpatients. Thus, adolescents who can express their angry feelings may have some protection from suicidal behavior. This finding is different from our findings in adults using the same measure (Apter et al., 1993) and may reflect some difference between adolescent and adult suicidal behavior. It also supports the observation that the emotion anger is not always associated with the act of aggression (Gothelf et al., 1997). An alternative explanation is that adolescents may be less aware of their angry feelings than adults. The only result supporting our hypothesis in this analysis was the finding that impulsiveness was specifically associated with suicidal be- havior in the BPD group but not in the MDD    group.The correlational analysis was more supportive of our hypothesis. Again, depression and hopelessness are highly correlated with suicidal behavior, irrespective of diagnosis. However, aggression and impulsiveness are significantly and positively correlated only with suicidal behavior among ad- olescents with BPD.The difference in results between the two statistical methods may be related to the way suicidal behavior is defined. When only the presence or absence of a suicide attempt is used to define the behavior, different severities of suicidal behavior are glossed over. Thus, the correlational analysis may be a better measure in this respect. In two previous studies (Horesh, 2001; Horesh et al., 1999), we found a relationship between impulsiveness and suicidal behavior in boys, but not in girls. This finding was most significant in boys who were not depressed. These studies did not, however, take into account diagnostic considerations. The present study addresses disorders that are more common in girls (BPD and MDD) and shows that impulsiveness can also be related to suicidal behavior in girls when they suffer from BPD. Another important finding in this respect, which will come as no surprise to clinicians working with people suffering from BPD, is the significant difference in intent to die that differentiates the two diagnostic groups. The suicide attempts in depression are perhaps more related to the wish to die (Menninger, 1938), whereas in patients with BPD, the meaning of suicide is more a communication of a cry for help (Kaplan and Saddock, 1998, p 786). This finding suggests that the meaning of suicidal behavior may be very different for adolescents with different  diagnoses.An interesting result was the high levels of depression and hopelessness that characterized our BPD adolescents. This finding must lend some credence to the notion that there is a strong relationship between BPD and affective disorder (Akiskal, 1994; Bech, 1994; Soloff et al., 1984). It has been reported that approximately 30% of depressed adolescents have BPD as a comorbid condition (Marton et al., 1989). Borderline personality disorder is a common comorbid con- dition with MDD in adults and can lead to increased suicidal behavior in such people (Friedman et al., 1983; Fyer et al., 1988). Borderline personality disorder in combination with other psychiatric disorders such as bulimia may also confer added risk for suicidal behavior (Dulit et al., 1994). This combination may also be peculiarly lethal (Cheng et al., 1997). Comorbid affective disorder may not, however, in- crease the risk for suicidal behavior in adults with BPD where comorbid antisocial behavior is a far more dangerous factor (Soloff et al., 1994).The results of this study should be compared with those of a recently published report comparing suicidal behavior in BPD and MDD in adults (Soloff et al., 2000). Here, no differences in the characteristics of the attempts were found, although once again, comorbidity seemed to be an important aggravating factor. In contradistinction to our results, the investigators found that adults with BPD had more serious planning and intent than subjects with MDD. This finding is substantially similar to findings by other researchers in adult patients (Casey, 1989; Suominen et al., 2000), and it is possible that changes could occur in BPD characteristics with age. This may explain why older patients with BPD have more serious suicidal behavior than younger subjects (Soloff et al.,   1994).It is commonly believed that impulsive violence is a characteristic of suicidal inpatient adolescents (Brent et al., 1993), but this may be an overgeneralization, and indeed, Fritsch et al. (2000) found that no personality characteristic described suicide attempters. Our findings may explain this contradiction in that suicide attempters may be a heteroge- neous population, and thus, contradictory results may be related to the diagnostic composition of the   sample.It should be stated that, because emotions may change after a suicide attempt, our findings are limited by the fact that assessment was made as long as 1 month after the suicide attempt. Yet another limitation is the cultural specificity of the sample (all Jewish, lower-middle-class adolescents in a university-affiliated inpatient unit). This may affect the general- ization of these results to the general population of  adolescents.
Clinical ImplicationsDifferent types of suicidal behavior may have a differ- ent underlying biology and therefore different treatments. Possibly some forms are related to impulsiveness and sero- tonin abnormalities, and others are more related to depression and dysfunction of the norepinephrine system (Apter et    al., 1995). Thus, for example, Verkes et al. (1998) found that paroxetine was effective in patients with recurrent suicidal behavior and Cluster B personality disorder who did not have major depression. There is room for improving the efficacy of treatment of suicide attempters (Hulten et al., 2001), and there is even some evidence that aftercare of suicide attempt- ers can worsen prognosis. Future treatment research must take into account the diagnostic background of the subjects tested.

 

REFERENCES

Akiskal HS (1994) The temperamental borders of affective disorders. Acta Psychiatr Scand. 89:32–37.

American Psychiatric Association (1994) Diagnostic and statistical manual for mental disorders (4th ed). Washington,  DC.

Apter A, Gothelf D, Orbach I, Har-Even D, Weizman R, Tyano S (1995) Correlation of suicidal and violent behavior in different diagnostic cate- gories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry. 34:912–918.

Apter A, Plutchik R, van Praag HM (1993) Anxiety, impulsivity and depressed mood in relation to suicidal and violent behavior. Acta Psychi- atr Scand. 87:1–5.

Barter JT, Swaback DO, Todd D (1968) Adolescent suicide attempts: A follow-up study of hospitalized patients. Arch Gen Psychiatry. 19:523– 527.

Beautrais AL, Joyce PR, Mulder RT (1998) Psychiatric contacts among youth aged 13 through 24 years who have made serious suicide attempts. J Am Acad Child Adolesc Psychiatry.  37:504 –511.

Bech P (1994) The borderline syndromes of depression, mania and schizo- phrenia: The coaxial or temperamental approach. Acta Psychiatr Scand. 89:45– 49.

Beck AT, Brown G, Berchick RJ, Stewart BL, Steer RA (1990) Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. Am J Psychiatry. 147:190 –195.

Beck AT, Kovacs M, Weissman A (1975) Hopelessness and suicidal behav- ior: An overview. JAMA. 234:1146 –1149.

Beck AT, Schuyler D, Herman I (1974a) Development of suicide intent scales. In AT Beck, HL Resnik, DJ Lettieri (Eds), The prediction of suicide (pp 45– 46). Bowie, MD: Charles  Press.

Beck AT, Steer RA (1987) Manual for the revised Beck Depression Inven- tory. San Antonio, TX: Psychological  Corp.

Beck AT, Weissman A, Lester D, Trexler L (1974b) The measurement of pessimism: The Hopelessness Scale. J Consult Clin Psychol. 42:861– 865. Block MJ, Westen D, Ludolph P, Wixom J, Jackson A (1991) Distinguishing female borderline adolescents from other disturbed female adolescents. Psychiatry. 54:89 –103.

Brent DA, Johnson B, Bartle S, Bridges J, Rather C, Matta J, Constantine DJ, Connolly J (1993) Personality disorder, personality traits, impulsive vio- lence and repeated suicide in adolescents. J Am Acad Child Adolesc Psychiatry. 33:1080 –1086.

Brent DA, Johnson B, Perper J, Connolly J, Bridges J, Bartle S, Rather C (1994) Personality disorder, tendency to impulsive violence and com- pleted suicide in adolescents. J Am Acad Child Adolesc Psychiatry. 33:1080 –1086.

Brodsky BS, Malone KM, Ellis SP, Dulit RA, Mann JJ (1997) Characteris- tics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry. 154:1715–1719.

Carlson CA, Cantwell DP (1982) Suicidal behavior and depression in children and adolescents. J Am Acad Child Adolesc Psychiatry.   21:361–368.

Casey PR (1989) Personality disorder and suicide intent. Acta Psychiatr Scand. 79:290 –295.

Cheng AT, Mann AH, Chan KA (1997) Personality and suicide: A case control study. Br J Psychiatry.  170:441– 446.

Cohen Y, Spirito A, Apter A, Saini S (1997) A cross-cultural comparison of behavior disturbance and suicidal behavior among psychiatrically hospi- talized adolescents in Israel and the United States. Child Psychiatry Hum Dev. 28:89 –102.

Dulit RA, Fyer MR, Leon AC, Brodsky BS, Frances AJ (1994) Clinical correlates of self-mutilation in borderline personality. Am J Psychiatry. 151:1305–1311.

Foster T, Gillespie K, McClelland R, Patterson C (1999) Risk factors for suicide independent of DSM-III-R AXIS I disorder: Case-control psycho- logical autopsy. Br J Psychiatry  175:175–179.

Freud S (1957/1917) Mourning and melancholia. In J Strachey (Ed and Trans), The standard edition of the complete psychological works of Sigmund Freud (Vol XIV, pp 289 –300). London: Hogarth   Press.

Friedman RC, Aronoff MS, Clarkin JF, Corn R, Hurt SW (1983) History of suicidal behavior in depressed borderline patients. Am J Psychiatry. 140:1023–1026.

Fritsch S, Donaldson D, Spirito A, Plummer B (2000) Personality charac- teristics of adolescent suicide attempters. Child Psychiatry Hum Dev. 30:219 –235.

Fyer MR, Frances AJ, Sullivan T, Hurt SW, Clarkin J (1988) Suicide attempts in patients with borderline personality disorder. Am J Psychiatry. 145:737–739.

Gothelf D, Apter A, van Praag HM (1997) Measurement of aggression in psychiatric patients. Psychiatry Res.  71:83–95.

Grosz  D  (1991)  Correlates  of  suicide  risk  among  suicidal   adolescents. Presented at the 24th Annual Suicide Meeting, Boston,   MA.

Horesh N (2001) Self-report versus computerized measures of impulsivity as a correlate of suicidal behavior in adolescent psychiatric inpatients. Crisis. 22:27–31.

Horesh N, Gothelf D, Ofek H, Apter A (1999) Impulsivity and adolescent suicide. Crisis. 20:8 –14.

Hulten A, Jiang GX, Wasserman D, Hawton K, Hjelmeland H, de Leo D, Ostamo A, Salander-Renberg E, Schmidtke A (2001) Repetition of at- tempted suicide among teenagers in Europe: Frequency, timing and risk factors. Eur Child Adolesc Psychiatry.  10:161–169.

Kaplan HI, Saddock BJ (Eds) (1998) Borderline personality disorder. In Synopsis of psychiatry. Baltimore, MD: Williams &   Wilkins.

Kernberg O (1978) The diagnosis of borderline conditions in adolescence. Adolesc Psychiatry. 6:36 – 49.

Koslowsky M, Bleich A, Apter A, Solomon Z, Wagner B, Greenspoon A (1992) Structural equation modelling of some of the determinants of suicide risk. Br J Med Psychol.  65:157–165.

Linehan M (1993) Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford  Press.

Linnoila M, Vinkkunen M, George T, Higley D (1993) Impulse control disorders. International Scientific Symposium: Depression-OCD-Anxiety. Intl Clin Psychopharmacol. 8:53–56.

Mann JJ, Waternaux C, Naas GI, Malone K (1999) Towards a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry.   156:181–189.

Maoz G (1995) The effect of propanol on reducing anger, hostility and aggression. Haifa, Israel: University of Haifa, Department of Psychology. Marton P, Korenblum M, Kutcher S, Stein B, Kennedy B, Parkes J (1989) Personality dysfunction in depressed adolescents. Can J Psychiatry.    34: 810 – 813.

Menninger K (1938) Man against himself. New York: Harcourt Brace. Motto JA (1984) Suicide in male adolescents. In HS Sudack, AB Ford,   NB

Rushforth (Eds), Suicide in the young (pp 227–244). Boston, MA: John Wright.

Nordstrom P, Asberg M, Berg-Wistedt A, Nordin C (1995) Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatr Scand. 92:345–350.

Ofek H, Weizman T, Apter A (1998) The child suicide potential scale: Interrater reliability and validity in Israeli inpatient adolescents. Isr J Psy- chiatry Relat Sci. 35:253–261.

Orbach I (1987) Children who don’t want to live. Ramat-Gan, Israel: Bar-Ilan University Press.

Paris J, Nowlis D, Brown R (1989) Predictors of suicidal behavior in borderline personality disorder. Can J Psychiatry.  34:8 –9.

Pfeffer CR (1986) The suicidal child. New York: Guilford   Press.

Pfeffer CR, Conte HR, Plutchik R, Jerrett I (1979) Suicidal behavior in latency-age children: An empirical study. J Am Acad Child Adolesc Psychiatry. 18:679 – 692.

Pfeffer CR, Conte HR, Plutchik R, Jerrett I (1980) Suicidal behavior in latency-age children: An outpatient population. J Am Acad Child Adolesc Psychiatry. 19:703–710.

Pfeffer CR, Newcorn J, Kaplan G (1988) Suicidal behavior in adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry. 26:256 –261. Pfeffer CR, Zuckerman S, Plutchik R, Mizruchi MS (1984) Suicidal behavior in normal school children: A comparison of child psychiatric inpatients. J Am Acad Child Psychiatry. 23:416 – 423.

Plutchik R, van Praag H (1989) The measurement of suicidality, aggressivity and impulsivity. Clin Neuropharmacol. 9(suppl):380 –382.

Robbins DA, Alessi NE (1985) Depressive symptoms and suicidal behavior in adolescents. Am J Psychiatry.  142:588 –592.

Schmidtke A, Bille-Brahe U, DeLeo D, Kerkhof A, Bjerke T, Crepet P, Haring C, Hawton K, Lonnqvist J, Michel K, Pommereau X, Querejeta I, Phillipe I, Salander-Renberg E, Temesvary B, Wasserman D, Fricke S, Weinacker B, Sampaio-Faria JG (1996) Attempted suicide in Europe: Rates, trends and sociodemographic characteristics of suicide attempters during the period 1989 –1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatr Scand.  93:327–338.

Shaffer D, Gould M, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M (1996) Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry. 53:339 –348.

Shanee N, Apter A, Weizman A (1997) Psychometric properties of the K-SADS-PI in an Israeli adolescent clinical population. Isr J Psychiatry Relat Sci. 34:179 –186.

Siegal JM (1986) The Multidimensional Anger Inventory. J Pers Soc Psychol. 51:191–200.

Soloff PH, George A, Nathan RS, Schulz PM (1984) Characterizing depres- sion in borderline patients. J Clin Psychiatry.   48:155–157.

Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R (1994) Risk factors for suicidal behavior in borderline personality. Am J Psychiatry. 151:1316 – 1323.

Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ (2000) Character- istics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. Am J Psychiatry. 1:601– 608.

Suominen KH, Hendriksson MM, Isometsa ET, Ostamo A, Lonquist J (1996) Mental disorders and co-morbidity in attempted suicide. Acta Psychiatr Scand. 94:234 –240.

Suominen K, Isometsa E, Henriksson M, Ostamo A, Lonquist J (1997) Hope- lessness, impulsiveness and intent among suicide attempters with major depression, alcohol dependence, or both. Acta Psychiatr Scand. 96:142–149. Suominen KH, Isometsa ET, Henriksson MM, Ostamo A, Lonquist J (2000) Suicide  attempts  and  personality  disorder.  Acta  Psychiatr  Scand. 102: 118 –225.

Tardiff K, Swiellan A (1980) Assault, suicide and mental illness. Arch Gen Psychiatry. 37:164 –169.

van Praag HM, Kahn RS, Asnis GM, Wetzler S, Brown SL, Bleich A, Korn ML (1987) Denosologization of biological psychiatry or the specificity of 5-HT disturbances in psychiatric disorders. J Affect Disord.   13:1– 8.

Verkes RJ, van der Mast RC, Hengeveld MW, Tuyl JP, Zwinderm P, Kampen JM (1998) Reduction by paroxetine of suicidal patients with recurrent suicide attempts but not major depression. Am J Psychiatry. 155:543–547.

Wagner B (1989) Correlates of suicidal behavior in the Israel Defense Forces. Scientific Council Research  Report.

Welner A, Welner Z, Fishman R (1979) Psychiatric adolescent inpatients: Eight- to ten-year follow-up. Arch Gen Psychiatry.  36:698 –700.

Yudofsky SC, Silver JM, Jackson W (1986) The Overt Aggression Scale: An operationalized rating scale for verbal and physical aggression. Am J Psychiatry. 143:35–39.

Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL (1989) The revised diagnostic interview for borderlines: Discriminating borderline from other AXIS II disorders. J Pers Disord.   3:10 –18.

 

 

Comments are closed.