Temperament and character personality profile and affective temperaments in self-poisoning nonlethal suicide attempters
Introduction
Failed suicide attempts are considered to be 10–40 times higher than completed suicide attempts (Bertolote et al., 2006, National Center for Injury Prevention and Control, 2014, World Health Organization, 2014). It is estimated that between 9 and 36 million people attempt suicide every year (Bertolote et al., 2006).
Suicidal behaviour, especially the preferred method of suicide, varies considerably between different population groups (Ajdacic-Gross et al., 2008, World Health Organization, 2014). Many factors, including the social acceptability and availability of the method, contribute to the characteristics of suicidal behaviour (Ajdacic-Gross et al., 2008). Apart from societal factors, gender seems to be one of the key factors influencing the choice of suicide method. Generally, women tend to choose less violent and less lethal methods of suicide, like poisoning (Ajdacic-Gross et al., 2008, Hawton and van Heeringen, 2009). According to the United States' National Centre for Injury Prevention and Control (NCIPC), poisoning was the second most common cause of nonfatal, non-accidental injury in 2012 and the second leading method of suicide in the United States for women (National Centre for Injury Prevention and Control, 2014).
Numerous factors increase the risk of suicide and self-harm (O’Connor andand Nock, 2014). The risk of completed suicide among suicide attempters is several times higher than in the general population (Hawton and Fagg, 1988). Any attempt might lead to more serious future suicide attempts: in fact, it has been estimated that up to 15% of attempters will eventually die by suicide (Christiansen and Jensen, 2007, Suominen et al., 2004). The risk is highest during the first few years, especially in the first six months: almost 2% of individuals who attempt suicide die within one year (Hawton and Fagg, 1988, Owens et al., 2002). Although suicide attempts are considered as a psychiatric emergency, only a minority of people suffering from psychiatric disorders commit suicide (Hawton, 2014). More specific markers of suicidal behaviour therefore need to be identified (O’Connor and Nock, 2014).
Many features of suicidal behaviour seem to be consistent across different countries (O’Connor and Nock, 2014). A recent review considers personality and individual differences, along with cognitive factors, social aspects and negative life events, as key contributors to suicidal behaviour (O’Connor and Nock, 2014).
Personality, defined as “the dynamic organization within the individual of those psychophysical systems that determine his unique adjustments to his environment” (Allport, 1937), comprises both predisposing and protective factors for suicidal behaviour (Brezo et al., 2006). Personality has been described using various models in recent decades. Cloninger's model of personality, which is based on a comprehensive psychobiological theory of personality (Cloninger, 1986) consists of four temperaments – Novelty Seeking (NS), Harm Avoidance (HA), Reward Dependence (RD) and Persistence (P) – and three characters – Self-Directedness (SD), Cooperativeness (CO) and Self-Transcendence (ST) (Cloninger, 1994a). Temperaments, defined as “the automatic associative responses to emotional stimuli that determine habits and moods” (Cloninger et al., 1993), are considered to be modestly stable throughout an individual's lifespan (Cloninger, 2003). On the other hand, characters, defined as “the self-aware concepts that influence our voluntary intentions and attitudes” (Cloninger et al., 1993), tend to constantly develop as an individual’s insight matures owing to experience throughout his/her life (Cloninger, 2003).
Personality traits have been attractive targets for research in suicidality. Both HA and NS (from the temperament dimension) have been repeatedly shown to be associated with suicidal behaviour. van Heeringen et al. (2003), Becerra et al. (2005) and Grucza et al. (2005) found that individuals with suicidal behaviour had higher HA scores. On the other hand, there have been some discrepancies regarding whether NS is a protective or a predisposing factor (Brezo et al., 2006, Calati et al., 2008). Low SD and high ST (from the character dimension) have also been associated with suicidal behaviour, though less consistently (Brezo et al., 2006, Calati et al., 2008). These great research efforts notwithstanding, the relationship between personality and suicidal behaviour still remains a controversial field of study with many unresolved dilemmas (Hawton, 2014).
The effect of mood disorders on suicidal behaviours is widely discussed in the literature. More than two-thirds of suicide attempters are suffering from (mostly untreated) major depressive episodes at the time of their suicidal behaviour (Gonda et al., 2007) and lifetime risk of suicide in people suffering from mood disorders is fifteen times higher than in the general population (Harris and Barraclough, 1997).
In an Italian–German collaboration, Calati et al. (2008) compared the temperament and character profiles of 190 suicide attempters with 1148 healthy individuals and found that the suicide attempters scored higher in HA and lower in SD and CO. Interestingly, they failed to show any significant difference in personality traits between the suicide attempters and a group of 223 patients suffering from mood disorders without any history of suicidal behaviour. They concluded that the differences found in the temperament and character of suicide attempters might be due to the effect of mood disorders on the personality profile. Furthermore, Pawlak et al. (2013) compared 198 bipolar suicide attempters with 297 bipolar patients without any history of suicidal behaviour and, consistent with the findings of Calati et al. (2008), found no association between temperament and character profiles and suicidal behaviour. Although personality traits, particularly NS/impulsivity, seem to be correlated with the transition to the act of suicide, previous studies have failed to discriminate these personality traits between patients with or without history of a mood disorder.
The recently re-emerged spectrum concept of bipolarity, which is based on the theories of Kraepelin and Kretschmer (Cassano et al., 2004), suggests that trait-related affective temperament types, Depressive (D), Cyclothymic (C), Hyperthymic (H), Irritable (I) and Anxious (A), are subclinical manifestations and frequently the antecedents of the major mood disorders (Akiskal and Akiskal, 2005, Cassano et al., 2004). Hyperthymic temperament is proposed as a protective factor against suicidal behaviour, and other affective temperaments are found to be predisposing factors for suicidal behaviour (Pompili et al., 2008, Rihmer et al., 2009). Affective temperaments have proven to be effective in predicting symptom formation and suicidal behaviours in acute mood episodes in the long run (Akiskal et al., 2005).
Regarding the findings of Calati et al. (2008) and Pawlak et al. (2013), which suggested a confounding role for mood disorders in the personality profile of suicide attempters, we set out to investigate the longer term risk factors of suicidal behaviours by studying affective temperaments in addition to temperament and character personality profiles in a sample of Iranian self-poisoning nonlethal suicide attempters and compared them with healthy individuals. Our main aim was to recognize whether there is an association between personality profile and nonviolent suicide attempts independent of affective temperaments or, contrarily, whether the association should always be acknowledged in the context of the effect of emotionality on the attempters’ behaviours.
Section snippets
Methods and materials
This was a cross-sectional case-control study conducted in the Emam Reza Medical Centre in Mashhad, the second largest city in Iran. The Emergency Toxicology Clinic of the Emam Reza Medical Centre is one of only three specialised toxicology treatment centres in Iran and the main referral centre for toxicology emergencies for Northeast Iran, with more than 10,000 referrals each year (Afshari et al., 2004).
Socio-demographic characteristics
Of 140 self-poisoning nonlethal suicide attempters, 114 (81.4%) were female and 26 (18.5%) were male (F/M Ratio: 4.38). Their mean age was 20.65±4.36 years, ranging from 14 to 35 years. The majority of cases were single (60.7%), whereas 35.7% were married and 3.6% divorced. Most of our cases (48.6%) held a high school diploma, followed by 28.3% who held a Bachelor’s or equivalent degree, and 13.8% who were high school students. The results obtained in patients were compared with the control
Discussion
Suicide is preventable, and suicide prevention merits high priority in public health (World Health Organization, 2014). Although a great body of research exists on the neurobiology of suicide (van Heeringen and Mann, 2014), more lethal forms have always attracted the most attention (Hawton, 2014). Abnormalities in the serotonin system have been emphasized in the more lethal forms of suicidal behaviours (van Heeringen and Mann, 2014). On the other hand, based on a large study of suicidal
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Preparation of this manuscript was supported by Grant 89985 from PBSRC, MUMS.
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