Impulsivity and clinical symptoms among adolescents with non-suicidal self-injury with or without attempted suicide
Introduction
Suicide, suicide attempts, and non-suicidal self-injurious behaviors are prevalent, costly, and preventable public health problems. Non-suicidal self-injury (NSSI) is defined as a non-fatal act that results in bodily injury without the intent to die, while suicide attempts (SA) are acts committed with the intent to cause death (O'Carroll et al., 1996). Both NSSI and suicidal behaviors are prevalent among adolescents and are often initiated during this developmental transition to adulthood. NSSI most often begins during adolescence (Pattison and Kahan, 1983), and estimates of prevalence rates range widely. Estimates of NSSI in adolescents range from 5.1% to 40% (Darche, 1990, Patton et al., 1997, Ross and Heath, 2002) and NSSI has been reported in different community cohorts (Patton et al., 1997, Ross and Heath, 2002) and in clinical samples (Hjelmeland and Grohalt, 2005). The nationwide 2005 Youth Risk Behavior Survey reported a prevalence rate of 8.4% (i.e., 1169 of 13,917 adolescents) for at least one suicide attempt within the last 12 months (Eaton et al., 2006). Community-based studies show that suicide is the 4th leading cause of death among 10–14 year olds and the third leading cause of death among 15–24 year olds (Anderson and Smith, 2003).
Although NSSI and SA are two forms of behavior that exist on a continuum of self-injury that ends with completed suicide (O'Carroll et al., 1996), a fundamental question in the field has been whether those with NSSI and/or SA represent distinct clinical populations. The expressions of these behaviors often co-occur (Muehlenkamp and Gutierrez, 2007, Nock et al., 2006); studies have shown that the majority of adults (55%–85%; Roy, 1978) and adolescents (55%–70%; Nock et al., 2006) with NSSI also have histories of attempted suicide. While these studies have documented the co-occurrence of these behaviors, the question of their differentiation remains. Two key studies have tested this question, finding that individuals with both NSSI + SA are more clinically impaired than those with either SA-Only or NSSI-Only. In one test of this question, Stanley et al. (2001) compared clinical characteristics of adult patients (primarily Borderline Personality Disorder) with attempted suicide presenting with (NSSI + SA, n = 30) or without NSSI (SA-Only, n = 23). Compared to patients with histories of SA-Only, patients with histories of NSSI + SA reported significantly higher levels of anxiety, depression, hopelessness, suicidal ideation, aggression, and impulsivity (Stanley et al., 2001). Another study (Muehlenkamp and Gutierrez, 2007) compared four groups of adolescents, those without self-harm or suicide attempts (n = 406), SA-Only (n = 10), NSSI-Only (n = 87), and NSSI + SA (n = 38) behaviors. Compared to adolescents with NSSI-Only, those with histories of NSSI + SA reported significantly higher levels of suicidal ideation, more depressive symptoms, and fewer reasons for living, although the SA-Only group did not differ significantly from either the NSSI + SA or the NSSI-Only groups, which was “likely the result of the small n-size” (Muehlenkamp and Gutierrez, 2007; p. 84). Together, these two studies suggest that individuals with both NSSI + SA report more clinical symptoms than either of those self-harm behaviors alone. Building on these findings, continued research in this area is needed to understand the clinical distinctions between individuals with NSSI and/or SA to refine treatment for these behaviors.
Theories of suicidal behavior (e.g., Mann et al., 1999) have included impulsivity as an important component that may be especially relevant to understanding both suicidal and self-injurious behaviors. Impulsivity has been defined as “a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to themselves or others” (Moeller et al., 2001; p. 1784). While this type of behavior is a common characteristic of adolescent development, impulsivity has been specifically identified as an important risk factor for suicidal behavior in both adolescent community-based and clinical samples (Gorlyn, 2005, Horesh, 2001, Sanislow et al., 2003). The propensity for Impulsive behavior has also been consistently linked to biological mechanisms implicated in suicidal behaviors (Kety, 1990, Mann et al., 2001) and has been shown to account for variance that is independent of other known suicidal risk factors (e.g., depression; Kingsbury et al., 1999).
Despite growing appreciation of impulsivity as a risk factor for suicidal behaviors, research is limited by the nearly exclusive use of self-report measures that rely on accurate personal insight and recollection regarding complex behavior patterns (Horesh, 2001). As an alternative, objective performance-based laboratory methodologies have proven useful for studying clinically relevant processes (Dougherty et al., 2003, Dougherty et al., 2004a, Swann et al., 2003, Swann et al., 2005), which is especially important since laboratory measures have the “potential for bridging some important gaps between research on causal processes and interventions” (Frick & Loney, 2000, p. 553). Using laboratory performance-based methodologies, two studies have reported increased impulsivity among suicide attempters as compared to those without attempts (Dougherty et al., 2004b, Horesh, 2001). However, there is no research using these laboratory methodologies to test distinctions between NSSI with or without suicide attempts.
Previous research has identified an overlap between NSSI and SA (Muehlenkamp and Gutierrez, 2007, Nock et al., 2006), and some studies have found that self-report measures can be used to distinguish between individuals with NSSI who do or do not go on to attempt suicide (Muehlenkamp and Gutierrez, 2007, Stanley et al., 2001). However, none has used objective behavioral methods to test for these differences. The aim of the current study was to determine whether laboratory behavioral impulsivity measures would be useful for distinguishing which individuals engaged in NSSI are at greater risk for attempting suicide. To accomplish this, we recruited adolescents with histories of NSSI from a psychiatric inpatient unit and assigned them to groups depending on the presence (NSSI + SA) or absence (NSSI-Only) of a history of attempted suicide. The two groups were compared using a battery of clinical interviews, self-reported ratings of mood and behavior, and laboratory behavioral measures of impulsivity. We hypothesized that adolescents with histories of both NSSI and SA would have significantly higher levels of depressive symptoms and greater behavioral impulsivity compared to adolescents with NSSI alone.
Section snippets
Subjects
Boys and girls (ages 13–17 years) who had a history of non-suicidal self-injury (NSSI) with and without suicide attempt(s) were recruited from the Child and Adolescent Inpatient Psychiatry Service at Wake Forest University Baptist Medical Center (WFUBMC), Winston-Salem, NC. This study was reviewed and approved by the WFUBMC Institutional Review Board. After a complete description of the study to the participants and their guardians, written informed assent was obtained from the adolescent and
Demographic comparisons
Fifty-six adolescents were enrolled and completed the study. Adolescents in the non-suicidal self-injury group (NSSI-Only, n = 31) had committed at least one self-harm act without the intent to cause death. Adolescents in the combined NSSI and SA group (NSSI + SA, n = 25) had committed at least one NSSI act (without intent to cause death) and at least one suicide attempt (with intent to cause death). There were no significant differences between groups in age, education, socioeconomic status, general
Discussion
This study examined the clinical features of adolescent psychiatric inpatients with histories of non-suicidal self-injury only (NSSI-Only) compared to adolescents with histories of both non-suicidal self-injury and at least one suicide attempt (NSSI + SA). Most of the adolescents in both groups were experiencing their first psychiatric hospitalization, and had a primary diagnosis of either a mood or disruptive behavior disorder. While the two groups were similar in their demographic
Acknowledgements
This project was funded by grants from the National Institute of Mental Health (R01-MH065566 and R01-MH077684). Dr. Dougherty gratefully acknowledges support from the William & Marguerite Wurzbach Distinguished Professorship.
During the course of data collection and initial manuscript preparation, all authors were affiliated with Wake Forest University Health Sciences. During revision of the manuscript, the authors Drs. Dougherty, Mathias, Marsh-Richard, Dawes, and Nouvion relocated to The
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