Personality and attempted suicide. Analysis of anger, aggression and impulsivity
Introduction
Suicide accounts for almost 2% of the world’s death (World Health Organization, 2005). Suicide has emerged as one of the leading causes of death among individuals aged 15–34 years in all countries which provided information on suicidality to the World Health Organization (World Health Organization, 2005). Epidemiological research shows that close to 90% of individuals who complete suicide have diagnosable psychiatric disorders at the time of death (Moscicki, 1997). Attempted suicide, that occurs 10–20 times more frequently than completed suicide, is currently regarded as the most important predictor of a future death from suicide (Gunnell and Lewis, 2005). Almost one quarter of suicides are preceded by non-fatal suicidal behaviors in the previous year (Owens and House, 1994) and approximately 2% of suicide attempters end their own life during the 12 months subsequent to the index event (Owens et al., 2002). In the years following an initial suicide attempt, studies indicate a suicide risk ranging from 3.2% (Suokas and Lonnqvist, 1991) to 11.6% (Nielsen et al., 1990) within 5 years, 4.8% (Beck and Steer, 1989) to 12.1% (Nielsen et al., 1995) within 10 years, 6.7% within 18 years (De Moore and Robertson, 1996), and 10–15% within lifetime (Suominen et al., 2004). As non-fatal suicide attempt is often the first step of a process that ends with suicide completion, intervention on attempted suicide could reasonably reduce mortality from suicide. Personality traits have several properties that make them attractive targets for suicidality research and intervention. (1) They affect variables that may contribute to the diathesis for suicide, namely, our perception of and adaptations to the environment and “self” (Dean et al., 1996). (2) Their maturational patterns may render them more suitable for long-term public health interventions compared with other, more changeable risk factors. More specifically, even though traits are amenable to modification only relatively early in life, any intervention that is carried out at this time would have longer-lasting effects (Roberts and DelVecchio, 2000). (3) Personality may be useful in early identification of subgroups of suicidal individuals, such as repeated attempters (Evans et al., 1996, Laget et al., 2006) and older completers (Useda et al., 2007). (4) Gender-specific personality differences may contribute to gender dissimilarities observed in suicide attempts and completions (Widiger and Anderson, 2003). (5) Personality traits, that are partly under genetic control, may be endophenotypes for the genetic component of suicidal behavior (Baud, 2005).
Clinical and community research suggest links between suicide attempts and psychological traits of aggression, anger and impulsivity. Aggressiveness has been related to suicidality in mood disorders. Straub et al. compared four groups of depressed women with suicide ideation, violent suicide attempt, non-violent suicide attempt and depression without suicidality: aggression scores, together with other psychophysiological features, were shown to differentiate between such groups (Straub et al., 1992). In their sample of psychiatric inpatients (51% with mood disorder) Mann et al. found higher rates of lifetime aggression in suicide attempters compared to non-suicidal patients (Mann et al., 1999). Oquendo et al. (2000), and, more recently, Grunebaum et al. (2006) reported that lifetime aggression traits did correlate with suicide attempts in patients with mood disorder. In a recent study, regression tree analysis applied to a large group of bipolar patients identified current depression and aggressive traits as indicators of a remote suicide attempt (Mann et al., 2008). A link between aggressiveness and suicidal behavior has also been shown in schizophrenia (Hong et al., 2004, Malone et al., 2003, Mann et al., 2008, McGirr and Turecki, 2008), borderline personality disorder (Brodsky et al., 2006, Horesh et al., 2003) and substance use disorders (Sher et al., 2005, Sher et al., 2008, Tremeau et al., 2008), and in non-clinical samples (Ille et al., 2001). In suicidal patients, aggressive traits have often been studied together with impulsivity. Aggression/impulsivity and pessimism have emerged as clinical predictors of suicidal acts after a major depressive episode in patients with mood disorder (Oquendo et al., 2004). Suicide completers with impulsive personality features exhibited higher measures of aggressive behavior (Zouk et al., 2006). Aggressive traits and impulsivity appear to be more common in suicide attempters with bipolar disorder (Zalsman et al., 2006). Anger-related personality traits have also been linked to suicidal behavior. The association between anger and suicidality has been demonstrated in depression (Painuly et al., 2007, Seidlitz et al., 2001, Velting et al., 2000), eating disorders (Nickel et al., 2006, Verkes et al., 1996, Youssef et al., 2004) and alcohol use disorders (Haw et al., 2001). In adolescent samples studies reveal a strong correlation of anger with self-harm (Hawton et al., 1999) and attempted suicide (Cautin et al., 2001, Esposito et al., 2003, Kirkcaldy et al., 2006, Stein et al., 1998). Temperament and character dimensions have been widely investigated as personality components associated with suicidal behaviors in patients with mood disorders (Engstrom et al., 2004, Rothenhausler et al., 2006, Sayin et al., 2007), eating disorders (Anderson et al., 2002, Bulik et al., 1999, Favaro et al., 2008) and substance use disorders (Evren and Evren, 2005, Evren and Evren, 2006) as well as in samples with mixed psychiatric diagnoses (Becerra et al., 2005, Guillem et al., 2002). Overall these studies report elevation in the temperament dimensions of “novelty seeking” (NS) and “harm avoidance” (HA) (Becerra et al., 2005, Calati et al., 2008, Rothenhausler et al., 2006) and decrease in the character dimensions of “self-directedness” (SD) and “cooperativeness” (CO) (Becerra et al., 2005, Evren and Evren, 2006, Favaro et al., 2008, Rothenhausler et al., 2006) in suicide attempters compared to non-suicidal controls.
Despite this great research effort, the relationship between personality and suicidality is still a controversial area of study with unresolved definitional, conceptual and research quandaries. One such quandary is the link between impulsivity and aggressiveness. A variety of studies, in particular conducted by the McGill Group for Suicide Studies (Canada), demonstrated an association between impulsive personality traits and lifetime aggression in suicidal subjects (McGirr et al., 2008, McGirr and Turecki, 2007, Turecki, 2005, Zouk et al., 2006). Such findings have led researchers to speculate on a common impulsive–aggressive dimension that may predispose to suicidality (McGirr and Turecki, 2007, Turecki, 2005). Conversely others reported a weak correlation between measures of aggression and impulsivity (Critchfield et al., 2004). Such inconsistent findings may be due to different operationalizing criteria and instruments used to assess aggression and impulsivity in suicide research. Aggressiveness has been measured by self-report questionnaires on aggressive tendencies (Doihara et al., 2008, Giegling et al., 2006, Giegling et al., 2007, Pompili et al., 2008) or operationalized as a lifetime history of aggressive behaviors (McGirr et al., 2008, Oquendo et al., 2007, Oquendo et al., 2004, Renaud et al., 2008, Zouk et al., 2006). Impulsivity may be conceptualized as the inability to resist impulses, which, from the strict phenomenological point of view, refers to explosive and instantaneous, automatic or semi-automatic psychomotor actions that are characterized by their sudden and incoercible nature (Kempf, 1976). A more behavioral definition considers impulsivity as a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual (Moeller et al., 2001). The lack of consensus about a definition of impulsivity leads to difficulties in its measurement. Impulsivity self-report scales exhibit low intercorrelations, are subject to response bias, and incorporate multiple sub-factors (Gorlyn, 2005). An alternative approach is to define impulsivity from the point of view of temperament by considering NS dimension according to Cloninger’s model (Cloninger et al., 1993). High NS was found to be an important predictor of risk of a future suicide attempt in cohort studies (Fergusson et al., 2003, Fergusson et al., 2000).
In clinical evaluation of suicide attempt premeditation is a critical factor. Indeed different interventions may be necessary for a subject who has carefully planned his attempt for a long period or is liable to act out suddenly in response to circumstances. A considerable proportion of attempts are made without premeditation. Although such impulsive suicide attempts are often pointed to being different from planned attempts, few studies have compared the two forms yielding inconsistent results (Brown et al., 1991, Mitrev, 1996, Polewka et al., 2005, Simon et al., 2001, Witte et al., 2008, Wyder and De Leo, 2007). Methods chosen for suicide attempt should be carefully considered in prevention tasks as they vary considerably in terms of violence and lethality. Research suggests that personality traits of anger, aggression and impulsivity may influence the choice of suicide methods, although there are no consistent results from available studies (Dumais et al., 2005b, Held et al., 1998, Seidlitz et al., 2001, Straub et al., 1992).
Our research group used two independent samples previously collected for genetic association studies in order to ascertain temperament and character correlates of suicidal behavior (Calati et al., 2008). One group, recruited in our research centre in Munich (Germany), included 144 mental disorder patients with history of suicide attempt, 76 mood disorder patients without suicide attempt and 1148 non-psychiatric controls who completed the Temperament and Character Inventory (TCI) (Cloninger et al., 1994). A second sample, enrolled in our mood disorder centre in Milan (Italy), consisted of 46 suicide attempters and 147 mood disorder patients without history of suicide attempt who were also evaluated with the TCI. The study could differentiate patients from healthy controls by their temperament and character features; however there were similar TCI profiles in suicide attempters and non-suicidal mood disorder subjects. Moreover TCI profiles did not statistically differ between impulsive and planned suicide attempts as well as between violent and non-violent suicide methods. These findings did not allow to infer an association between attempted suicide and attempter’s temperament and character features.
This study analysed a part of the same sample with a different research focus, no longer history of suicide attempt but personality predisposition to self-aggressive behaviors regardless of their severity (self-aggression). In brief, the objective of the study was to explore the correlation of aggression and self-aggression with anger, impulsivity (defined by the temperament dimension of NS) and the other temperament and character dimensions of personality in suicide attempters. In addition the study compared anger- and aggression-related traits between impulsive and premeditated suicide attempts as well as between violent and non-violent suicide methods.
Section snippets
Sample
Suicide attempters were inpatients consecutively admitted to the general psychiatric ward of the Department of Psychiatry, Ludwig-Maximilians-University, Munich (Germany).
Inclusion criteria were: (1) age > 18 years; (2) a lifetime history of at least one clear-cut suicidal behavior, according to the definition of suicide and suicide attempt proposed by De Leo et al. (2004); (3) presence of an Axis I disorder and no additional Axis I disorder; (4) presence of an Axis II disorder, no additional
Characteristics of the sample
The sample’s characteristics are reported in Table 1.
Predictors of aggression and self-aggression
Multiple regression analysis was performed to identify personality trait predictors of aggression and self-aggression component. Tested models are reported above (see statistical analysis).
Discussion
This study used a part of a previously reported sample (Calati et al., 2008) in order to investigate personality correlates of aggression and self-aggression in suicide attempters. Unlike previous study, the current one was concerned with a different measure of self-harm. Research focus was on anger and impulsivity. Temperament and character dimensions were controlled for as covariates. The study also investigated how personality traits could impact on clinically meaningful characteristics of
Conclusions
Our results emphasize the independent contribution of temperament traits impulsivity and HA to self-aggression, which appears to be a distinct component of aggression construct. These findings could explain the connection between temperament dimensions and suicidality but further research is needed. Some limitations of this study should be acknowledged. The sample was recruited in a specialized research centre. These patients might suffer from more severe mental disorders than those attending
Contributors
None declared.
Role of funding source
None declared.
Conflict of interest
None declared.
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2021, Journal of Psychiatric ResearchCitation Excerpt :Avoidant attitude is a temperamental coping style characterized by a greater likelihood of giving in to avoid difficult situations, and a tendency to resign oneself to the situation (McAuliffe et al., 2006). Avoidant attitude is related to an increased risk of self-aggression, and suicide (Giegling et al., 2009; McAuliffe et al., 2006; McGirr et al., 2008; Perroud et al., 2013; Seguin et al., 2017; Su et al., 2018). Dispositional avoidance may also result in the tendency to inhibit anger expression in order to avoid negative reactions from others.