Affective temperaments, as measured by TEMPS-A, among self-poisoning nonlethal suicide attempters
Introduction
The global rate of suicide, according to World Health Organization (WHO) statistics, is 11.4 per 100 000 population, whereas for Iran is 5.3 (World Health Organization, 2014). Making a suicide attempt, which is defined as a non-fatal deliberate (potentially) injurious behavior toward oneself with the intent to die, is the most significant risk factor for a later completed suicide and occurs 10–40 times more than completed suicide (Bertolote et al., 2006; Crosby et al., 2011). In addition to the fact that almost 3% of people make a suicide attempt in their life, the high estimated prevalence of serious suicidal ideations which is around 9% of the population, calls for worldwide attention to this issue (Nock et al., 2008). WHO established the goal of a 10% reduction in the rate of suicide by 2020 (World Health Organization, 2014).
Identification of suicide risk factors is a key part in suicide prevention measures because it helps to recognize underpinning mechanisms of suicide and at-risk individuals (Bentley et al., 2016). Several aetiologies and risk factors at different structural levels of a society are proposed for suicidal behaviors, from inefficiency of health systems, to inappropriate media reporting, to lack of social support or financial loss, to mental disorders, the latter of which were extensively explored to identify their contribution to suicidal behaviors (World Health Organization, 2014). It was estimated that 15–19% of severe patients with major depression would die by suicide (Guze and Robins, 1970). In a meta-analysis on suicide and mental disorders, Harris and Barraclough reported that the risk of suicide was 20 times higher in patients with index diagnosis of unipolar major depression. They found that this risk was 15 fold for bipolar disorder (Harris and Barraclough, 1997). In addition to psychiatric disorders, other psychological features such as personality profiles and “neurotic” or “anxiety” traits were investigated to address the complex causal interactions of suicidal risk factors (Ardani et al., 2015, Calati et al., 2008, Conrad et al., 2009). Recently, affective temperaments have been investigated as a potential predictor for suicidal behaviors (Karam et al., 2015).
According to Akiskals’ modern spectrum concept of affective disorders, affective disturbances exist in a continuum, from healthy emotional reactivity types with adaptive advantages to the individual (or his/her kin), to debilitating major affective illnesses (Akiskal et al., 2005, Akiskal and Akiskal, 2005). This model suggests five affective temperaments (“the temporally stable biological core of personality”) as subclinical affective characteristics and precursors of minor and major mood disorders (Gonda and Vázquez, 2014, Rihmer et al., 2010). These five affective temperaments are: hyperthymic (having over-energetic and over-confident traits), anxious (having exaggerated tendency to be worry), depressive (having a sensitivity to suffering), cyclothymic (bearing rapid shifts in mood and energy) and irritable (being moody, choleric, and impulsive) (Akiskal and Akiskal, 2005, Guerreiro et al., 2013). Temperament Evaluation of the Memphis, Pisa, Paris and SanDiego Auto questionnaire (TEMPS-A) has been widely used to measure these temperament dimensions (Rihmer et al., 2013).
Prior studies have investigated the association of suicidal behaviors/ideation and affective temperaments. In a study on psychiatric inpatients, Pompili et al. found that suicidal group scored significantly higher in depressive, cyclothymic, irritable, and anxious temperaments, and significantly lower in hyperthymic temperament than non-suicidal patients (Pompili et al., 2008). A sample of 263 hospitalized psychiatric patients (93 with unipolar disorders and 153 with bipolar disorders) were assessed by TEMPS-A in Turkey (Eksioglu et al., 2015). The cyclothymic temperament was a predictor for suicidal attempts in both groups, whereas the anxious subscale was found to predict suicide attempts only in unipolar patients (Eksioglu et al., 2015). In a national study in Lebanese population, TEMPS-A was administered to 1320 individuals to investigate the relationship between its scores, suicide attempts, and bearing a mental disorder (Karam et al., 2015). Anxious temperament score was a strong predictor in subjects with and without mental disorder for suicide attempts (odds ratio: 10.1 and 9.0, respectively). Depressive (odds ratio: 4.3) and irritable (odds ratio: 5.1) temperaments were associated to suicide attempts only in participants with mental disorders. In females with mental disorders, only the hyperthymic trait “having self-confidence” was protective against suicide attempts (Karam et al., 2015).
In Hungary, Rihmer et al. used TEMPS-A to assess affective temperament profiles of nonviolent suicide attempters (106 females and 44 males) and healthy controls (216 females and 86 males) (Rihmer et al., 2009). The suicide attempters’ scores of depressive, cyclothymic, irritable and anxious temperaments were significantly higher than controls (Rihmer et al., 2009). Recently, affective temperaments were studied with regard to different variables (sex, having documented history of depressive and anxiety disorders, having history of prior suicide attempts, and having positive family history of suicide) in 509 chronically ill patients (Rihmer et al., 2013). Scores of depressive and cyclothymic dimensions were significantly higher in patients with prior suicide attempts and participants who had reported the family history of suicide scored significantly higher on cyclothymic and anxious dimensions (Rihmer et al., 2013). This general pattern has also been found concerning suicide ideation in Austrian college students (n=1381) who were assessed by a short version of TEMPS-A (TEMPS-M) (Skala et al., 2012). Compared with students who recalled suicidal ideation in their life time, individuals without this history scored significantly higher in hyperthymic subscale, and significantly lower in other four subscales (Skala et al., 2012).
The scarcity of data on the relationship of affective temperaments and suicidal behaviors in Iran convinced us to conduct the first (to the best of our knowledge) study of Iranian suicide attempters as measured by TEMPS-A. Here we present the assessment of affective temperaments in self-poisoning non-lethal suicide attempters and healthy individuals.
Section snippets
Methods and materials
This study was carried out with a cross-sectional design in the Medical Toxicology Center of Imam-Reza Hospital of Mashhad, affiliated with Mashhad University of Medical Sciences, which is the main referral Poisoning Treatment Center in Northeast Iran, covering more than 6 million population (Mousavi et al., 2015).
Results
The questionnaire was administered to 141(19% male and 80% female) self-poisoning nonlethal suicide attempters and 140 control participants with the mean age of 20.7 years (SD=4.4) and 21.5 years (SD=5.6), respectively. The marital status of the patients was: 62.7% single, 34.7% married, and 3.5% divorced. The majority of cases (63.1%) had 9–12 years of education, whereas 19.1% reported at least 13 years and 17.7% had less than 9 years of education.
Except for the hyperthymic temperament, female
Discussion
On average, every 40 s a person dies due to suicide which, consequently, implies many more suicidal attempts in this range of time (World Health Organization., 2014). Different causes as social, cultural, and psychological factors contribute to make suicidal behaviors as a major health problem (World Health Organization., 2014). It has been suggested that some types of affective temperaments can be associated with higher rates of suicidal behaviors (Karam et al., 2015). In this study we assessed
Limitations
As we discussed above, the suicide attempters in the present study had been at most 12 h in the emergency room and hence we could not gather information on Axis I and II disorders. This is the most prominent limitation of the study since in a similar study, more than 90% of the nonviolent suicide attempters showed at least one current Axis I mental disorder (18). A general limitation was using an auto questionnaire which can diminish objectivity and increase misreporting. Also, the small sample
Conflict of interest
We declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
Preparation of this manuscript was supported by Grant from PBSRC, MUMS.
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