Annotated Abstracts of Journal Articles
2015, 2nd Quarter


Annotation by Kemuel Philbrick, MD, FAPM
June 2015


  1. Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters


PUBLICATION #1 — Suicide
Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters

Gvion Y, Horresh N, Levi-Belz Y, et al
Compr Psychiatry 2014; 55(1):40-50

ANNOTATION (Kemuel Philbrick)

The Finding: A broad range of potential risk factors has been associated with suicidality. In an effort to further refract the clarity of our assessment of those most likely to successfully end their lives, attention has turned to individuals who make nearly lethal suicide attempts, i.e., those whose attempts result in medically serious conditions.
The authors hypothesized that aggression and impulsivity might distinguish those suicide attempters who fall short of death but generate medically serious consequences. However, the results demonstrated that although aggression and impulsivity are clearly associated with increased risk for attempting suicide, only communication difficulties (as measured by three instruments: the Journard Self-Disclosure Questionnaire which reflects self-disclosure to at least one close individual; the SCID-II using only the seven-item section on schizoid personality disorder; and the UCLA Loneliness Scale that assesses loneliness in everyday life) differentiated attempts that resulted in medically serious consequences from those that precipitated medically non-serious sequelae.

Strengths and Weaknesses: Four groups (medically serious attempters, defined as those who required hospital admission > 24 hours and treatment in either a specialized medical unit or surgery under general anesthesia; medically non-serious attempters; psychiatric inpatients without a history of suicidal behavior; and healthy controls) were studied with interviews and 11 validated instruments assessing aggression, impulsivity, mental pain, and communication difficulties. The study’s limitations are that the groups were relatively small (196 total subjects, with more than 40 in each group) and the study was conducted in a retrospective fashion.

Relevance: Consultation psychiatrists are regularly asked to assess ongoing suicidal risk and recommend appropriate disposition (e.g., inpatient psychiatric care, whether voluntary or involuntary; outpatient day treatment programs; return home, with or without supervision) in patients who have made a suicide attempt. The circumstantial risk factors for each individual are unique, collateral history may be difficult to acquire or non-existent, and the stakes may be high. This study underscores the value of paying attention to an individual’s communication difficulties, as assessed by their patterns of self-disclosure (or not), schizoid style, and everyday loneliness as elements that are significantly associated with medically serious suicide attempts.


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.

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