Association between anger expression and attempted suicide at a general emergency hospital in the south of Brazil

Abstract Introduction Suicide is one of the leading causes of death in the world. For every person who commits suicide, twenty or more have attempted to take their own lives. The emotional state of anger is often associated with suicidal behavior. However, this association needs to be further clarified. Objectives This study sought to investigate the profiles of traits and expressions of anger in inpatients admitted to a general emergency hospital after surviving a suicide attempt. Methods In this case-control study, a sample of 28 suicide survivors was matched for sex, age, and educational level with 56 controls. The State-Trait Anger Expression Inventory-2 was used to measure anger traits and expression. Results Suicide survivors scored higher for anger traits and expression and lower for anger control than the control group. They also had lower levels of state anger and willingness to express anger verbally than the control group. Conclusions Patients who attempted suicide and had high scores for anger expression (in and out) are inclined to have extreme difficulty in interpersonal relationships and rigidity towards change and are at higher risk of developing psychopathologies.


Introduction
Suicide is an important contributor to mortality worldwide. 1 Specifically, in Brazil, there is evidence 2 that the country will not have been able to reduce the suicide rate by 10%, as proposed in the World Health Organization (WHO) Action Plan for 2020. 3 This suggests that more efforts are needed to protect people from suicidal behavior, including designing prevention and intervention programs for suicide survivors. To provide a better health service to people with suicidal ideation, it is essential to identify as many psychological characteristics as possible that play a role in protection from or risk of suicidal behavior. The current study focuses on anger experiences in relation to suicide attempts.
Anger can be described according to two main components: state and trait. 4 The former is an emotional experience involving negative feelings that can vary in intensity depending on the situational event, such as an injustice. The latter is a dispositional tendency to experience angry feelings as a personality trait.
In both cases, anger is considered a transdiagnostic feature in several mental disorders, 5 including suicidal behavior, 6,7 and suicidal ideation. 8 Shri et al. 9 found a relationship between irritable mood and suicidal behavior in a thorough analysis of suicide attempts.
Those who had attempted suicide were more likely to express aggressive traits than those who had not.
In another study, Ammerman et al. 10 investigated the role of anger in the incidence of suicidal and violent behavior in 2,295 undergraduate students aged 18 to 57 years. They found that trait anger was significantly associated with suicide attempts and violent behavior.
The current study arises from the need to seek a deeper understanding of feelings of anger in state and trait forms in individuals who have attempted suicide and those who have not. We are particularly interested in understanding the role of specific facets of anger in suicidal behavior. In view of the lack of studies on this subject in the literature, we hope our findings can improve prevention and health promotion practices.
Thus, this study was designed, first, to assess whether there are differences in measures of anger expression in hospitalized patients who have attempted suicide compared to those who have not and, second, to evaluate aspects of anger as a risk factor for suicidal actions.

Sociodemographic questionnaire
A general information questionnaire was prepared to obtain participant data on gender, age, years of education, income, marital status, and occupation.

State-Trait Anger Expression Inventory-2 (STAXI-2)
This instrument consists of 57 items grouped into six scales, five subscales, and one Anger Expression Index, A p-value lower than 0.05 was considered statistically significant.

Sample description
The gender distribution in the total sample (n = 84) was recent marital separation, which had happened to 7 respondents (25%). Ten (36%) of the people who had attempted suicide reported suffering an intense loss in childhood.

Comparison of anger levels between control and case groups
To identify the profile of anger experiences of suicide survivors, a GEE model was used to compare STAXI-2 factor scores between the control and case groups. tended to experience anger states more frequently, in addition to being more prone to irritability and having more problems with expression and control of anger than the participants in the control group.
The patients' high scores on the state anger scales indicate that they were feeling angry at the time of data collection (S-Ang/F) and that they were probably willing to express their anger verbally (S-Ang/V) at that time. The design of the present study did not enable identification and characterization of the type of anger experienced by these patients during data collection.
However, according to observations, the case group tended to be momentarily angrier than the control group when the data were being collected. Regarding the ability to express anger, the results showed that the participants in the case group tended to express anger at a higher level than those in the control group, both against others and against themselves. In

fact, the estimated mean values of the AX-O and AX-I
subscale T-scores were above 75, indicating 2.5 SD above the mean. In addition to this result, the case group's ability to control anger was significantly lower than that of the control group (AC-O and AC-I; p < 0.001). Together, these results suggest that patients who attempted suicide tended to have no control over their anger, which resulted in chronic anger and increased risk of self-harm.

Odds ratio of anger experiences as predictors of membership of the suicide survivors group
Conditional logistic regression models were used to identify the specific contribution of anger variables to prediction of people having suicidal behavior.   Table 2, the anger facet that statistically contributed to identifying people who had survived suicide was feeling

Discussion
Our study aimed to understand the role of specific in this study as a tendency to experience anger quickly and with little provocation, 4 has proved to be a crucial risk factor for suicide attempts. In fact, a high level of angry temperament has also been shown to be a predictor of aggressive behavior in a sample of patients who attempted suicide. 23 The same authors also observed that angry temperament was a predictor of violent suicide attempts. It is known that, in general, patients hospitalized for attempted suicide tend to present high levels of aggressive profiles, 24 with some differences by gender. 7 This leads us to think that people with angry temperaments are at high risk for suicidal behavior because their anger effects are easily elicited.
The other anger facet that contributed to predicting patients who have attempted suicide was anger expressed against oneself. We highlight the potentially harmful combination of these two facets (angry temperament and anger expressed against oneself) with regards to suicidal behavior. Together, these facets lead us to infer that people who have angry temperament, who tend to be constantly irritated, and who express this anger against themselves may find suicide to be a (poorly adaptive) resource for handling the negative affects inherent to this psychological functioning profile.
In fact, high levels of expression of anger against oneself proved to be a predictive factor of impulsive suicide attempts. 23 Anger can facilitate suicidal behavior through an individual's reduced ability to control or deal with the negative effects of anger. 10 Individuals with a history of suicide attempts tend to have limited perceptions of emotions, 25 which may partly explain suicidal behavior as an alternative for dealing with increased feelings of anger and as a potential mechanism for reducing the perceived negative effect. 10 Self-directed anger tends to weaken emotional self-regulation skills and make it difficult for a person to calm down autonomously, and this can limit the individual's ability to properly handle acute tendencies towards death. 7 People with anger profiles may have difficulty dealing with acute urges to die by suicide when they arise. 7 Emotional fragility makes people vulnerable to actively thinking about suicide or actually engaging in suicidal behavior. 26 The psychological dynamics of people with angry temperaments, especially cases that express selfdirected anger, seem to have some effect on suicide attempts. 23 The act of trying to end life can be considered a nonverbal expression of anger due to a failure of intrapsychic communication. 15 That is, selfdirected anger in greater intensity, typical of unstable temperament, increases the chance of tension discharge in one's body, which increases the risk of suicide.
Psychological mediations are necessary so that anger is not discharged into the body as self-destructiveness.
Through psychotherapeutic treatment, the patient can learn to regulate anger and understand emotions, which helps to prevent suicidal behavior. Functional anger management can act as a protective factor in life. Some reasons that prevent people from committing suicide are related to not wanting to harm their children or cause suffering to their families. 27 It is essential to understand the role of protective factors for suicidal behavior to be able to increase reasons for living in people at risk of suicide. 28 Some limitations should be considered in the present study. First, although a sample calculation was performed, the results of this cross-sectional study only allow reliable interpretations for the population in question. Also, the participants were hospitalized and the hospital is an environment to which they are not accustomed and this triggers negative feelings for many people, which may somehow have affected the results. Another limitation is related to the menstrual period, which is a factor that could influence women's responses because of its effects on their emotional state. This was not controlled for in data collection.
Taking these limitations into account, our findings may suggest that people who experience intense rage and have dysfunctional control of anger impulses are psychologically vulnerable to suicidal behavior.

Conclusion
After surveying the literature, we conclude that the STAXI-2 instrument is still little used in research and clinical assessments. Given that anger influences the biological, psychological, and social aspects of a person's life, anger measurement should be further explored. More direct studies on the development of rage in the family environment (bonding and parental conduct) are suggested. We suspect that better data on this topic could be of great importance for development of intervention and suicide prevention programs.