مشکلات پرخاشگری-تکانشگری، درد روانی، و ارتباطات در اقدام کنندگان به خودکشی پزشکی جدی و پزشکی غیرجدی

Background Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt. Objectives To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters. Method The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression–impulsivity, mental pain, and communication difficulties. Results The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p < .001 for all) and on anger-in, anger-out, violence, and impulsivity (p < .05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p < .05) and more schizoid tendencies (p < .001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p < .05). Analysis of aggression–impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone. Conclusions Aggression–impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.

Suicide is often the end result of a complex interaction of a very many diverse variables, including demographics, personality traits, clinical symptoms and disorders, environmental pressures, social support, and history of suicide attempt as well as biological factors such as genetics, medications, and concordant illness [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12] and [13]. Suicide may be preceded by suicidal thoughts, threats, gestures, nonsuicidal self-injuries, and suicide attempts of various degrees of lethality, all of which are generally lumped together under the rubric of “suicidality.” Recently, researchers have attempted to define these behaviors more clearly [14]. Interest has focused on individuals who make nearly lethal suicide attempts, as the study of this subgroup can best shed light on actual suicide attempters [15], [16], [17] and [18]. As such, it is important to identify risk factors that distinguish nearly lethal from less serious forms of suicide. Our earlier study showed that mental pain and depression are more associated with suicidal behavior in general whereas problems with social communication and loneliness are more associated with more lethal suicide attempts [19]. However, more research is necessary to determine the role of aggression and impulsivity in the lethality of suicide (for review, see Gvion and Apter [20]). Aggression has been linked to the act of suicide in multiple epidemiologic, clinical, retrospective, prospective, and family studies [21], Furthermore low serotonin turnover appears to be common to both aggressive and suicidal behaviors [22] and [23] suggesting a common neurobiology [24]. Regarding its effect on the lethality of suicide, one study yielded significantly higher levels of aggression in medically serious suicide attempters than in healthy controls [25], and others reported that individuals with personality disorders, particularly those related to impulsive and aggressive tendencies and a co-morbid depressive disorder were at higher risk for more frequent and more medically severe suicidal behavior than subjects with major depressive disorder or bipolar depression alone [26] and [27]. From the aspect of choice of method, one study found that violent methods of suicide may serve as a behavioral marker of a higher level of lifetime impulsive–aggressive behaviors [28]. More violent methods were used more often by males and by suicide completers with psychosis. Conner et al. [29] showed that violence during the last year of life was more frequent among suicide victims than accident victims, suggesting that aggression may be indirectly linked to high lethality attempts. By contrast, Soloff et al. [30] found no difference in level of aggression between high- and low-lethality suicide attempters. Impulsivity encompasses a broad range of behaviors that reflect impaired self-regulation, such as poor planning, responding prematurely before considering the consequences, sensation seeking, risk taking, poor inhibition of responses, and preference for immediate over delayed rewards [31] and [32]. Although many studies have identified impulsivity as a common correlate and risk factor for suicidal behavior [33] and [34], it is not known if it increases the risk of suicide independently of aggressive traits [35] or if it is related to the medical severity of suicide attempts. Some authors reported evidence of higher levels of impulsivity in individuals who died by suicide than those who did not [28] and [36] whereas others found that although people who attempt suicide tend to be more impulsive than people who do not, the actual act of completed suicide is often not made impulsively (e.g., Anestis et al. 37]). Simon et al. [38] reported that only 24% of survivors of near-lethal suicide attempts had thought about their attempt for less than 5 minutes. Those who made their attempt within 5 minutes of deciding to do so were less likely to have considered another method of suicide. They also had a greater likelihood of discovery and a lower expectation of death. Baca-Garcia et al. [39] and [40] claimed that impulsivity is a characteristic of nonlethal suicide attempts or suicide gestures whereas planned suicide involves a more subjective element drawn from the desired outcome and the perceived lethality of the act of self-harm. Other authors emphasized the mediatory role of the intent to die at the time of the suicide attempt. Hawton [41] observed that less than 50% of subjects with a history of suicide attempts really wanted to die; he defined their attempts as little-planned impulsive acts. Motives reported in impulsive suicides ranged from escaping from an intolerable situation to manipulation [42]. Some of the data collected to date on the role of aggression and impulsivity in suicide and suicide lethality need to be reconsidered in light of differences among the studies in definitions used, methods employed, and the selected population. Most did not include a nonsuicidal psychiatric group or psychiatric patients with aggressive–impulsive features [43], and even studies that investigated more specific aspects of aggression [44] and [45] failed to control for level of the medical seriousness of the attempt. Furthermore, the concept of aggression is complicated by the interchangeable use of the terms aggression, violence, irritability, and anger in the literature. Indeed, Spielberger [46] has emphasized that the expression of anger differs when it is directed toward others or self; this difference has been explored extensively in the classic psychoanalytic literature [47]. The concept of impulsivity is complicated by the confusion in the literature between the state and trait dimensions (see Gvion and Apter [20] for review); that is, between the impulsivity of the suicidal act and impulsivity as an individual personality trait [40]. Finally, both aggression and impulsivity may be related to mental pain and other risk factors of suicide. Clinical and research experience suggests that people who are in agony and depression may often be irritable and angry [48]. This, in turn, raises the likelihood of distancing and rejection from family and peers [49], augmenting loneliness and the risk of suicidal behaviors. The aim of the present study was to further evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts. Five hypotheses were tested: (1) aggression, defined by anger-in, anger-out, and violence, differentiates suicide attempters from non-attempters and medically serious suicide attempters from medically non-serious suicide attempters; (2) impulsivity differentiates suicide attempters from non-attempters and medically serious suicide attempters from medically nonsuicide attempters; (3) based on our previous study [19], mental pain, depression, and hopelessness differentiate suicide attempters from non-attempters but not medically serious from medically non-serious suicide attempters; (4) based on our previous study [19], communication problems, defined by low self-disclosure, loneliness, and schizoid features, differentiates medically serious from medically non-serious suicide attempters; and (5) aggression and impulsivity have a catalyzing effect on the lethality of suicide attempts, over and above the mental pain and communication difficulties.

Table 1 presents the demographic characteristics of the study participants. There were no differences in age, sex, or marital status among the four study groups or the three suicide/psychiatric groups. Compared to the other groups, the healthy control subjects had a significantly higher income (p < .001) and more years of education (p < .001), and most of them (89.5%) lived with families or partners. Table 1. Demographic characteristics of the study groups (n = 196). Characteristic MSSA (n = 43) MNSSA (n = 49) Psychiatric controls (n = 47) Healthy controls (n = 57) Analysis Sex, n (%) χ2 = 3.07 Male 26 (60.5) 34 (69.4) 33 (70.2) 31 (54.4) Female 17 (39.5) 15 (30.6) 14 (29.8) 26 (45.6) Age (yr) M = 37.37 M = 40.31 M = 40.96 M = 37.28 F = .98 SD = 13.31 SD = 13.76 SD = 14.07 SD = 12.34 Marital status, n (%) Single 27 (62.8) 21 (42.9) 21 (44.7) 30 (52.6) χ2 = 5.33 Married 9 (20.9) 17 (34.7) 12 (25.5) 20 (35.1) Div/Wid/Sep 7 (16.3) 11 (22.4) 14 (29.8) 7 (12.3) Living status, n (%) χ2 = 15.62 a Alone 10 (23.3) 7 (14.3) 14 (29.8) 6 (10.5) Not alone 26 (60.5) 37 (75.5) 29 (61.7) 51 (89.5) Hostel/street 7 (16.3) 5 (10.2) 4 (8.5) 0 (0.0) Income (1–5 scale) M = 2.5 M = 2.43 M = 2.26 M = 3.39 F = 22.6 b SD = 1.0 SD = 1.1 SD = 0.9 SD = 0.92 Education (yr) M = 12.9 M = 12.0 M = 12.4 M = 14.9 F = 26.1 b SD = 2.9 SD = 2.8 SD = 2.1 SD = 1.9 MSSA = medically serious suicide attempters; MNSSA = medically non-serious suicide attempters; Div/Wid/Sep = Divorced/Widowed/Separated. a p < .05. b p < .001.