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 A number of recent studies have looked at impulsive behavior and/or substance abuse with suicidal behavior. An Australian study describes that attempted suicide is often a snap decision fuelled by drugs and alcohol. Ninety people between the ages of 17 to 65 years, who attempted suicide and had been seen in a hospital emergency department were interviewed as soon as possible after the event. It was found that over half of the study participants - 51 per cent - tried to make a suicide attempt after thinking about it for 10 minutes or less, with an additional 16 per cent contemplating it for less than half an hour. Of the 29 per cent of participants who harmed themselves while affected by alcohol, the overwhelming majority - 93 per cent - said they considered their actions for less than 10 minutes. Interestingly enough, the study found that only one fifth - 21 per cent - reported still feeling suicidal 12 hours after their attempt.
According to the author, Marianne Wyder from UWS Social Justice Social Change Research Centre, Australia "the majority of the suicide attempters in this study described impaired thinking, and were driven by anger, loss, hurt, depression, anxiety and stress, which at times, was greatly exacerbated by drugs and alcohol use." She pointed out that for many of the subjects interviewed, the suicidal behaviour was not a longing for death, but a desire to be free from the mental anguish, to have a time out, or to show others their hurt. "79 per cent reported their suicidal feelings had dissipated at the time of the interview. Nearly half of this group reported a positive shift in their mental state, which meant experiencing feelings of calm about the traumatic issues that had triggered their suicide attempt."
The study described different suicidal triggers and divided participants into two groupings - 'acute' and 'chronic' - depending on the life experiences that had brought them to the point of suicide. The acute group (37%) were described as "doing well in their lives before one or more life events, such as a depressive or schizophrenic illness, social stressors, or a loss of a relationship or employment, meant they could no longer cope."
The chronic participants (63 %) described their problems as longstanding and were more likely to have a personality disorder, chaotic home life, difficulties with anger, drug and alcohol use, and a history of abuse in their childhoods. The attempt to self harm was borne out of depressed feelings brought on by drug and alcohol abuse, "feelings of rejection, self-hatred and disconnectedness." A psychiatric disorder was equally present in both groups. (85%)
Trying to predict
Examining laboratory measured impulsivity (using the Immediate and Delayed Memory Tasks) and its relationship to suicide attempt histories revealed that behavioral measures of impulsivity can be used to discriminate among groups (not suicidal, 1 suicide attempt, or multiple suicide attempts) based on suicidal histories among samples not currently exhibiting significant suicidal behaviors.
Suicide Life Threat Behav. 2004 Winter;34(4):374-85
Various studies also looked at bipolar disorder and impulsivity as a contributor to suicidal behavior.
Alan Swann and colleagues in last month's American Journal of Psychiatry, looked at the relationship between impulsivity and severity of past suicidal behavior, which is a potential predictor of eventual suicide. In bipolar disorder subjects with either a definite history of attempted suicide or no such history, impulsivity was assessed with both a questionnaire (Barratt Impulsiveness Scale) and behavioral laboratory performance measures (immediate memory/delayed memory tasks). Diagnosis was determined with the Structured Clinical Interview for DSM-IV. Interviews of patients and review of records were used to determine the number of past suicide attempts and the medical severity of the most severe attempt. Results of this study showed that subjects with a history of suicide attempts had more impulsive errors on the immediate memory task and had shorter response latencies, especially for impulsive responses. Impulsivity was highest in subjects with the most medically severe suicide attempts. Interestingly enough, these effects were not accounted for by presence of depression or mania at the time of testing. Barratt Impulsiveness Scale scores were numerically, but not significantly, higher in subjects with suicide attempts. A history of alcohol abuse was associated with greater probability of a suicide attempt. These results suggest that a history of severe suicidal behavior in patients with bipolar disorder is associated with impulsivity, manifested as a tendency toward rapid, unplanned responses.
Am J Psychiatry. 2005 Sep;162(9):1680-7.
MacKinnon and colleagues from Johns Hopkins University School of Medicine studied rapid mood switching and suicidality in familial bipolar disorder. They found that familial suicidal behavior, as well as drug abuse, increased the likelihood of suicidal action among suicidal individuals, but did not increase the likelihood of becoming suicidal. Factors associated with high acuity of distress, such as panic attacks and unstable moods, appear to enhance the risk of suicidality in general. Factors that affected the threshold for action without increasing suicidality overall can also be seen as markers of impulsive decision-making. Of the two distinct kinds of suicidal risk, the latter - the likelihood of action given intent - appears to be the more familial.
Bipolar Disord. 2005 Oct;7(5):441-8.
Issues of impulse and lethality
In a study by Baca-Garcia and colleagues in Spain, 278 suicide attempts were studied over one year. Researchers evaluated the continuous versus dichotomous relationship between attempter impulsivity (Barratt Impulsiveness Scale) and attempt impulsivity (low scores in the planning subscale of Beck's Suicidal Intent Scale) According to the authors, impulsivity in suicidal behavior can describe the attempt (state) or the attempter (trait). There are no studies simultaneously measuring attempt impulsivity and attempter impulsivity in representative samples of suicide attempts.
They found that attempter impulsivity was not a good predictor of attempt impulsivity independently of how both dimensions were measured (continuous or dichotomous ways). Impulsive attempts were associated with low lethality and lack of depression while suicide attempts in major depression require attentive monitoring of suicidal ideation and intent.
Eur Arch Psychiatry Clin Neurosci. 2005 Apr;255(2):152-6.
John Mann and colleagues from the New York State Psychiatric Institute studied suicide attempts in families. They found that first-degree relatives of persons with mood disorder who attempt suicide are at greater risk for mood disorders and attempted or completed suicide. Their research showed that risk for suicidal behavior in families with mood disorders appears related to early onset of mood disorders, aggressive/impulsive traits, and reported childhood abuse. Genetic studies are in progress.
Am J Psychiatry. 2005 Sep;162(9):1672-9.
Borderline Personality
No discussion of suicide and impulsivity would be complete without looking at the relationship between suicidality and impulsivity in individuals with borderline personality disorder. A number of studies have found a that higher level of impulsive aggression or hopelessness or a diagnosis of borderline personality disorder predicted a greater number of suicide attempts. (Soloff et al 2000) and that borderline personality disorder patients with a history of suicide attempts had more impulsive actions, antisocial personality disorder comorbidity, and depression than those without a history of suicide attempts. (Soloff et al 1994)
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