The motivation and emotional state of 91 cases of attempted suicide

Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted. Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care. These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.

Seriousness of Suicide Attempt and Future Risk of Suicide: A Comment on Card's Paper

Card (1974) distinguished between the lethality of suicide methods and suicide risk. According to her interpretation of her data the two variables were clearly distinct. This report reconsiders Card's data and tests a revised hypothesis on a different set of data. The conclusion that a serious threat to life resulting from a suicide attempt indicates an increased risk of suicide in the future is consistent with previous work as well as with Card's data, provided an alternative analysis is adopted.

Predictors of suicide attempt status: acquired capability, ideation, and reasons

The present study compared Non-Attempters, Recent Attempters, and Distant Attempters on the following three constructs: Acquired capability for suicide, reasons for attempting suicide (internal perturbation based reasons vs. extrapunitive/manipulative reasons), and suicidal ideation. Participants were 40 Non-Attempters, 28 Recent Attempters, and 32 Distant Attempters at three state psychiatric hospitals. The sample consisted of 63 males and 37 females ranging in age from 18 to 63 years (M = 35.84, SD = 11.44). All patients completed the self-report measures. There were significant differences between the groups on suicidal ideation and acquired capability for suicide. The results of the present study indicate that acquired capability and reasons for attempting suicide have considerable importance for understanding suicide risk. Integration of acquired capability for suicide and reasons for attempting suicide into assessment and treatment is warranted.

["Suicidal intentions": literature review and perspectives]

INTRODUCTION

Fifteen years ago, Baechler presented his "strategic theory of suicide". Following a viewpoint initiated at the end of the 1950's by Stengel and Cook, he proposed the more accomplished theoretical development of suicidal functions. We propose a critical review of international empiric literature following this approach.

METHOD

We carried out a bibliographic research on PsychINFO(®) databank, crossing terms of suicide attempt, deliberate self-harm and parasuicide, to reasons, motivations, functions, intentions. Thirty-one articles were selected. They cover a period ranging from 1971 to 2008, and from Europe to the USA.

RESULTS

Few studies have been conducted in France, but international literature has grown since 1970, and some questionnaires have been created: e.g. the Motives for Parasuicide Questionnaire (MPQ, Kerkhof et al., 1993 [28]) and the Reasons for Attempting Suicide Questionnaire (RASQ, Holden et al., 1998 [24]). The first intentions mentioned are internal perturbations type: to get relief, to escape, cannot endure situation or thoughts any longer, loss of control. They are often blended with interpersonal intentions: to make people understand what they felt, to seek help, to make things easier for others, while more aggressive, punitive or manipulative functions are seldom reported. Women report more reasons than men, but do not differ in their pattern of intentions. Suicide attempters report varying desire to die across studies. Some inconsistent distinctions can be made from age and gender but few from subjects' suicidal history.

DISCUSSION

One can wonder if subject's answers are really honest, particularly in regards to social desirability. Links between internal perturbations and suicidal intent, hopelessness, and depression are logically found, which aims to give evidence that, at least for this dimension, subjects give true answers, but which also point out the redundant aspect of some items of the suicidant functions scales (e.g. "to die"). Today, it turns out that this kind of research should be managed in France, by creating tools and questionnaires, validating existing ones and, internationally, by taking into account gender, age, and subjects' suicidal history to obtain more clear results.

CONCLUSION

So far, to our knowledge, this kind of review has never been conducted. Suicidal functions appear to be a rich and relevant approach to better understand suicide attempts, notably in a "suicidal crisis" perspective. In the future, some links with coping strategies and cathartic effect of the attempts could be made. We also point out that it could be relevant for psychotherapeutic care.

Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: a multi-modal analysis

The primary aim of this study was to examine the prospective association of shame with self-inflicted injury (SII), including suicide attempts and nonsuicidal self-injury, among women with borderline personality disorder (BPD) who were enrolled in a clinical trial (N = 77). A multi-method approach was used to assess self-reported shame, nonverbal shame behaviors, and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII. Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII, and shorter time to SII, after controlling for past SII as well as other emotions associated with SII. Self-reported state shame and assessor ratings of shame were associated with prospective SII, but not after controlling for other emotions. These findings underscore the important role of shame in SII, particularly shame in the presence of contextual prompts for events that surround episodes of SII.

Motives and suicide intent underlying hospital treated deliberate self-harm and their association with repetition

The association between motives for deliberate self-harm (DSH), level of suicide intent, and history of DSH is poorly understood. As part of the WHO/EURO Multicentre Study on Suicidal Behavior, the Suicide Intent Scale, and the Motives for Parasuicide Questionnaire were administered to 146 patients presenting with DSH in the Cork region in Ireland. DSH patients reporting high suicide intent were more motivated to escape from their problem (M = 3.15, p < .001) compared to those with low suicide intent, who were more motivated to appeal to others (M = 1.61, p < .001) and to get a temporary break from their problem (M = 2.47, p < .001). Repeaters more often reported motives aimed at escape (M = 2.98, p < .01), revenge (M = .60, p < .005), and appeal (M = 1.43, p = <.05). Selfharming patients are characterized by ambivalence and struggle with aversive thoughts and situations. Therapeutic approaches should include distress management and coping strategies.

LONELINESS, SOCIAL CONNECTEDNESS, AND FAMILY INCOME AMONG UNDERGRADUATE FEMALES AND MALES IN TAIWAN

This study investigated loneliness and its relationships with social connectedness and family income among female and male college students in Taiwan. The Revised UCLA, Loneliness Scale (R-UCLA; Russell, Peplau, & Cutrona, 1980); translated into Chinese and adapted by Wang, 1989, for measuring global, intimate, and social loneliness, and the Social Connectedness Scale (Lee, Draper, & Lee, 2001), were administered to undergraduates. Analysis of the statistical data utilized Pearson's, product-moment correlations and multiple regression techniques. The findings reveal that college males experienced more loneliness than females in global and social loneliness. Furthermore, social connectedness significantly predicted global, intimate, and social loneliness in both females and males. Family income significantly predicted global and social loneliness in college men only. Implications for future research are discussed.

The clinical significance of loneliness: a literature review

Satisfying social relationships are vital for good mental and physical health. Accordingly, we recommend that the alleviation and prevention of social relationship deficits be a key focus of clinicians. In this review, we focus on loneliness as a crucial marker of social relationship deficits and contend that loneliness should command clinicians' attention in its own right--not just as an adjunct to the treatment of other problems such as depression. With a particular focus on the adolescent developmental period, this review is organized into five sections: Drawing on developmental and evolutionary psychology theories, the nature of social relationships and the function they serve is first discussed. In the second section, loneliness is introduced as an exemplar of social relationship deficits. Here a definition of loneliness is provided, as well as an explanation of why it may pose a situation of concern. This is followed by a review of the prototypic features of loneliness through examination of its affective, cognitive, and behavioral correlates. The fourth section includes a review of theories related to the antecedent and maintenance factors involved in loneliness. Finally, methodological and theoretical considerations are addressed, and conclusions and proposals for future research directions are put forth.

Why people engage in parasuicide: a cross-cultural study of intentions

Information obtained at interview from 1,646 parasuicide patients in 14 regions in 13 European countries participating in the WHO/EURO Multicentre Study on Suicidal Behaviour was used to study self-reported intentions involved in parasuicide. Comparisons were made across cultures, genders, and age groups. Although some statistically significant differences were found, the effect sizes were very small. The main finding from this study is thus that parasuicide patients in different countries tend to indicate that similar types of intentions are involved in their acts of parasuicide, and that the intentions do not vary greatly with gender or age. The hypothesis that rates of suicide and parasuicide vary between regions with the frequency with which suicidal intention is indicated by the patients was also tested, but was supported only for women and in relation to national suicide rates. The findings from this study are likely to be generalizable to other settings and have implications for clinical practice.

Attempted suicide. Do we understand the patients' reasons?

This explorative study compared the patients', doctors', and nurses' views regarding their attribution of reasons for attempting suicide and the patients' emotional state immediately preceding their suicide attempts. A sample of 30 out of 94 consecutive patients seen in the emergency room of University Hospital were examined shortly after they had attempted suicide. Immediately after the routine clinical interview, conducted by a psychiatric resident and a nurse, patients filled in a questionnaire giving 14 possible reasons for attempting suicide as well as 8 feelings characterizing the emotional state preceding the suicide attempt. In the meantime, and without prior discussion of the case, the resident and the nurse independently completed the same questionnaire. In addition, sociodemographic and clinical data were obtained. Intrapersonal reasons such as to get relief from a terrible state of mind or from an unbearable situation were most frequently chosen by patients, nurses, and doctors alike. The most striking difference was found for "loss of control": this item was chosen significantly more often by patients than by nurses and doctors. Accordingly, patients reported significantly more often feelings of anxiety/panic and emptiness (mental vacuum), whereas feelings of despair and powerlessness/hopelessness were mentioned most frequently by nurses and doctors. Mental health professionals should bear in mind that many suicide attempters experience feelings of anxiety/panic prior to their suicidal act, and that a majority report having lost control over themselves, thus indicating a state of emotional crisis.

Verbally expressed intentions of parasuicide: I. characteristics of patients with various intentions

Comparisons of 584 parasuicides with a verbalized intention to die and 341 parasuicides with other intentions were made on a number of sociodemographic and clinical/psychological variables. The results revealed that patients with a verbalized intention to die had different life-problems than those with other intentions. More specifically, after sex and age had been controlled for, patients with an intention to die were more often economically inactive and were more likely to report psychiatric problems as their main concern, while those with other intentions more often abused alcohol and were more likely to report family or economical problems. The identification of discriminating risk factors is important in light of the fact that those with an intention to die made more life-threatening attempts, as reflected by the choice of method and the medical judgment of the attempt's seriousness.

Risk versus motivation: the emergency room treatment of attempted suicide

This paper deals with patients who attempt suicide, focusing on their evaluation in the emergency room. It is suggested that as the actual risk of completed suicide in suicide attempters is low, the evaluating psychiatrist might preferentially focus on assessing the patient's motivation for self-destructive behaviour. Recent studies are reviewed which demonstrate a linkage between self-destructive acts and the status of relationships with significant others. An illustrative case history is presented.

Contact of parasuicide patients with the accident and emergency department

In a group of 82 consecutive parasuicide patients attending the St George's Hospital Accident and Emergency Department, London, England, 15 had attended the same department within the preceding 6 months. Thirteen of these 15 had also consulted their general practitioner during this time, as had a further 51 parasuicide patients. Only two out of the 82 patients, therefore, had had sole medical contact with the Accident and Emergency Department in the 6 months prior to their suicide attempt. This is the first such report from an accident and emergency department. It demonstrates that very few patients seek help from, or visit in isolation, this facility prior to a parasuicide episode as opposed to visiting their general practitioner whose importance is reaffirmed. The problems of identifying 'somatising' patients in an accident and emergency department are discussed.

Attitudes of health care professionals towards patients who take overdoses

The attitudes of health care professionals in Malta towards patients who take drug overdoses were studied. It was found that the intention of the overdose had a marked effect on the attitude of the health care professional towards the patients. Differences between different professionals were noted and the Maltese results were compared with those of a similar study in London.

Overdoses: explanations and attitudes in self-poisoners and significant others

Marked differences were found between the reasons chosen to explain overdoses by the closest relatives or friends (the 'significant others') of 34 self-poisoners and those reasons chosen by the self-poisoners themselves. Whilst 41% of the latter claimed suicidal intent, in only one case was the significant other in agreement. The significant others were more likely to attribute manipulative reasons, commonly viewing the overdoses as directed at themselves, but the two groups agreed that the overdoses were often a means of alleviating distress. As well as evoking sympathy, the overdoses often caused the significant others to feel considerable guilt and anger. Discrepancies in the way self-poisoners and significant others interpret overdoses, and the strong feelings that overdoses evoke in the latter, should be considered during assessment and treatment of overdose patients.

Unemployment and suicidal behaviour: a review of the literature

In order to provide a framework for reviewing the voluminous literature on unemployment and suicidal behaviour, the author distinguishes between two categories of deliberately self-harmful act: those with fatal outcome (suicide) and those with non-fatal outcome (parasuicide); and differentiates four major types of quantitative research report: individual--cross-sectional; aggregate--cross-sectional; individual--longitudinal; and aggregate--longitudinal. Methodological issues and empirical research findings are discussed separately for each type of study and each category of deliberate self-harm. Cross-sectional individual studies reveal that significantly more parasuicides and suicides are unemployed than would be expected among general population samples. Likewise, parasuicide and suicide rates among the unemployed are always considerably higher than among the employed. Aggregate--cross-sectional studies provide no evidence of a consistent relationship between unemployment and completed suicide, but a significant geographical association between unemployment and parasuicide was found. Results from all but one of the individual longitudinal studies point to significantly more unemployment, job instability and occupational problems among suicides compared to non-suicides. The aggregate longitudinal analyses reveal a significant positive association between unemployment and suicide in the United States of America and some European countries. The negative relationship in Great Britain during the 1960s and early 1970s has been shown to result from a unique decline in suicide rates due to the unavailability of the most common method of suicide. However, despite the firm evidence of an association between unemployment and suicidal behaviour, the nature of this association remains highly problematic. On the basis of the available date, the author suggests that macro-economic conditions, although not directly influencing the suicide rate, may nevertheless constitute an important antecedent variable in the causal chain leading to self-harmful behaviour. Further empirical research based on a longitudinal design is recommended as a matter of urgency so that a more definitive assessment of the aetiological significance of unemployment in parasuicide may be made.

Motivational aspects of deliberate self-poisoning in adolescents

A systematic study of 50 adolescent self-poisoners aged from 13 to 18 demonstrated considerable discrepancies between the reasons chosen by the subjects to explain the overdoses and those chosen by clinical assessors. Most adolescents indicated that they had been feeling lonely or unwanted, or angry with someone, and had taken the overdose to alleviate or demonstrate this distress. A third said they had wanted to die. In contrast, clinical assessors tended to attribute the overdose to punitive or manipulative reasons and suggested that only seven out of the 50 had wished to die. The adolescents rarely indicated that they had taken the overdose to get help; this may explain the resistance that may be shown to psychiatric intervention, that casts doubt on the possible effectiveness of preventive agencies. Modification of attitudes to both self-poisoning and early help-seeking may be a more effective means of prevention.

Impulsive suicidal behavior

Previous studies have noted that a considerable proportion of suicidal behavior is impulsive. The present study aimed to ascertain the degree to which this was so and to consider whether impulsive attempters differed from non-impulsive attempters on variables such as demographic and motivational factors and circumstances that surrounded the occurrence of the act. Based on a criterion of less than 5 minutes' premeditation, 40% of two large, consecutive series were judged to have acted impulsively. While few variables differentiated between the two groups, impulsive attempters were less depressed, motivated by the desire to reduce tension, more likely to consider that they would survive, and to report that someone saw them perform the act.

The reasons people give for taking overdoses

This study investigates the reasons people give for taking overdoses of drugs. A representative sample of 128 subjects were interviewed immediately after their recovery from an overdose. During the interview they were given alternative reasons for taking overdoses and asked to choose any that applied to them. Spontaneous comments about suicidal intent were also recorded. Of the subjects, 44% indicated that they had wanted to die. On the basis of their choices 33% were 'seeking help', 42% 'escaping from the situation', 52% 'obtaining relief from a terrible state of mind' and 19% 'trying to influence someone'. The association between these various reasons and other expected effects or feelings associated with the act were examined by means of multidimensional scaling analysis. In addition, the characteristics of those expressing suicidal intent and other reasons were studied, together with such consequences as toxic effects and psychiatric after-care. The possibility is discussed that a large proportion of those indicating suicidal intent do so either to gain social acceptability for their act or to influence helping agencies.

Attitudes towards self-poisoning

Self-poisoning now constitutes one of the prime emergencies in hospital medical practice. This paper describes the results of the study of the attitudes of physicians and senior nurses towards several common illnesses in the medical wards. The junior doctors and the nurses who frequently have primary responsibility for the care of the self-poisoners tend to show unfavourable attitudes towards these patients.