Affect Regulation and Suicide Attempts in Adolescent Inpatients

Affect Regulation and Suicide Attempts in Adolescent Inpatients CARON ZLOTNICK, PH.D., DEIDRE DONALDSON, PH.D., ANTHONY SPIRITO, PH.D., AND TERI PEARLSTEIN, M.D.

ABSTRACT Objective: To examine the relationship between affect dysregulation and self-destructive behaviors in adolescent suicide attempters. Method: Measures of affect dysregulation, number of risk-taking behaviors in past year, presence of self-mutilative behaviors in past year, and number of different types of self-mutilative behaviors in past year were individually administered to adolescents admitted to an inpatient unit who were either suicide ideators ( n = 25) or suicide attempters ( n = 35). Results: Suicide attempters reported significantly higher levels of affect dysregulation and a greater number of different types of self-mutilative behaviors in the past year than suicide ideators. In addition, the number of different types of self-mutilative behaviors in the past year had the strongest relationshipto suicide attempts. Conclusion: Suicidal behavior among adolescent psychiatric patients is related to poor affect regulation. A risk factor for suicidal behavior in adolescents is a broad range of self-mutilative acts in the year preceding the suicide attempt. J. Am. Acad. Child Adolesc. Psychiatry, 1997, 36(6):793-798. Key Words: affect regulation, suicide attempters, adolescents.

Suicide occurs at a high rate among adolescents (National Center for Health Statistics, 1993), and suicidal behavior is the leading reason for admission to an inpatient psychiatric unit. Moreover, such behavior poses a clinical challenge, as adolescent suicide attempters are at high risk for subsequent attempts (Lewinsohn et al., 1993) and completed suicide (Shaffer et al., 1996). Suicidal behavior among adolescents has been conceptualized as a maladaptive strategy to manage intense affect (Kandel et al., 1991; Khan, 1987). Empirical support for this view is found in studies that have reported that intense affect, such as hopelessness (Levy et al., 1995), anger (Myers et al., 1991), and depression (Paluszny et al., 1991), is related to increased suicidal tendencies in adolescents. Although research has demonstrated that suicidal adolescents experience negative affect, no studies, to date, have investigated the role Accepted October 11, 1996 From Butler Hospital, Brown University Department of Psychiatry and Human Behavior, Providence, RI;and Rhode Island Hospital, Brown University Department of Psychiatry and Human Behavior. This research was supported in part by the van Ameringan Foundation. Reprint requests to Dr. Zlotnick, Butler Hospital, Brown University Department of Psychiatry and Human Behavior, Providence, RI 02906 0890-8567/97/3606-0793$03.00/00 1997 by the American Academy of Child and Adolescent Psychiatry.

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of affect dysregulation-the inability to cope with heightened levels of emotions-in adolescent suicidal behavior. Affect regulation involves an action system or behavioral scheme (e.g., self-destruction or manipulating a body part) used to change or reduce heightened arousal states (Kopp, 1989). Theoretical formulations of affect dysregulation suggest that the inability to modulate emotions may give rise to a range of self-destructive behaviors that represent attempts at affect management (van der Kolk and Fisler, 1994). Research findings that adolescent suicidal behavior often occurs within the context of a variety of impulsive behaviors (Brown et al., 1991; Kandel et al., 1991; Kosky et al., 1990) support the notion that suicidal adolescents have poor affect regulation. Research has focused on substance use and conduct problems as the most typical impulsive behaviors found in adolescent suicide attempters. Few, if any, studies have examined other forms of impulsive behavior in adolescent suicide attempters, such as selfmutilative behaviors, which are estimated to be particularly prevalent among adolescents (Favazza and Conterio, 1988). Self-cutting as a suicide attempt method is well described in adults, but not in adolescents. Self-cutting by adolescents is typically discussed as a characteristic of borderline personality disorder or

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a severe psychiatric disorder (e.g., Ghaziuddin et al., 1992) rather than as specific to suicide attempters. To determine whether affect dysregulation and destructive behaviors represent risk factors for adolescent suicide attempts, the present study compared adolescents who actually attempted suicide with those who thought about attempting suicide. It is important that clinicians identify which factors may contribute to an adolescent’s attempting suicide as opposed to thinking about suicide’ in Order to target intervention strategies to deal with this life-threatening behavior. Of the few studies that have compared adolescent suicide ideators with adolescent suicide attempters, most have been unable to differentiate the level of psychopathology in the two groups (e.g., Paluszny et al., 1991). Studies have yet to examine affect regulation in these two groups. The general aim of the present study was to examine the impact of affect dysregulation on adolescent suicidal behavior. It was hypothesized that adolescent suicide attempters would report a higher level of overall affect dysregulation and more behavioral manifestations of affect dysregulation (i.e., a greater number of types of risk-taking behavior, an increased rate of self-mutilative behavior, and a greater number of types of self-mutilative acts) than adolescent suicide ideators within a sample of psychiatric inpatients. In addition, because past suicidal behavior is a predictor of future suicidal behavior in adolescents (Diekstra, 1989), the present study explored the independence and relative association of past suicidal behavior and affect dysregulation in relation to suicide attempts.

METHOD Subjects The sample consisted of 62 adolescents who were consecutively admitted to an inpatient treatment unit for acute care of adolescents with psychiatric problems. The unit is part of a psychiatric hospital that is situated in an urban area in the Northeast. As part of the admission interview, a physician classified each patient as either a suicide attempter or suicide ideator and provided descriptions of the suicide attempt or suicidal ideation. A suicide attempt was defined as an instance of deliberate self-harm behavior in which there was a conscious or clearly apparent wish to die. This study excluded instances of behaviors that involved self-harm in which the conscious intent to die was absent, such as alcohol or drug use, disordered eating behavior, or self-mutilative acts. Suicidal ideation was defined as suicidal thoughts reported at the time of examination or verbalization of suicide intention.

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The study identified 37 (60%) adolescents as suicide attempters and 25 (40%) as suicide ideators. Of the subjects, 40 (65%) were female and 22 (35%) were male. The average age was 14.9 years (SD = 1.2). The primary Axis I discharge diagnoses obtained from chart reviews were as follows: 32 (51.2%), mood disorder; 9 (14.5%), disruptive behavior disorder; 6 (9.7%), adjustment disorder; the remaining diagnoses included posttraumatic stress disorder, psychotic disorder, and drug abuse.

procedure Within 48 hours of admission, all subjects completed a standard batten, of measures that assessed mood state (anger and demession) as well as a number of other psychological cvharacteris6cs. The interviews were conducted by trained research assistants. Only the results of the affect regulation and self-injury measures are reported here. This procedure was approved by the institutional review board of the hospital.

Measures To assess affect regulation, the Regulation of Affect and Impulses subscale of the Structured Interview for Measurement of Complex PTSD (SICP) (Pelcovitz et al., 1997) was administered. The Regulation of Affect and Impulses subscale consists of several dimensions that tap affect regulation, modulation of anger, selfdestructive behavior, suicidal preoccupation, and excessive risktaking behavior. The Regulation of Affect and Impulses subscale includes items such as “Do you have trouble letting go of things that upset you?” “Do you have trouble controlling your anger?” “When you feel upset, do you have trouble finding ways of calming yourself down?” and “Do you find yourself careless about making sure that you are safe?” In the present study, the SICP ratings of current functioning were used. The current rating consists of a 4-point severity rating of the past month for each item (“none or no problem with symptom” to “extremely problematic”). These ratings were then summed across all items that comprised the Regulation of Affect and Impulses subscale as a measure of the degree of general affect regulation. A validation study on the SICP, using a sample of adolescents and adults, found that the internal consistency for the Regulation of Affect and Impulses subscale was .90, and the interrater reliability K values for the overall ratings of the SICP ranged from .88 to 1.00 (Pelcovitz et al., 1997). The Self-Injury Inventory (SII) (Zlotnick et al., 1996) was used to assess two aspects of self-regulation, self-injurious behaviors and self-mutilative behaviors, within the year preceding hospitalization. The self-injurious behaviors that are listed in the SII include impulsive behaviors, such as binge eating, driving recklessly, having unprotected sex, shoplifting, and consuming large amounts of drugs or alcohol. The types of self-injurious behaviors in the questionnaire were based on common self-injurious acts reported in the literature. In this study, the Cronbach coefficient C( for the self-injury subscale of the SII was .68. For the self-mutilation subscale of the SII, adolescents were instructed to report on only those behaviors that were deliberate, direct acts of self-harm to their bodies that were not motivated by a desire to die within the year preceding hospitalization. The types of self-mutilative behaviors included cutting oneself with a sharp object, burning oneself, carving words on skin, and banging one’s body to the point of bruising. In this study, the Cronbach coefficient CL for the self-mutilation subscale of the SII was .76.

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RESULTS

Preliminary analyses revealed no differences between suicide attempters and ideators on age (4601 = 0.73, not significant INS]), gender ( ~ ’ [ l=] 0.22, NS), or discharge diagnoses (x2[5]= 7.29, NS). In examining differences between suicide attempters and suicide ideators on the dependent variables, suicide attempters reported significantly higher scores on the Regulation of Affect and Impulses subscale of the SICP (t[6O]= 2.32, p < .05) and reported a greater number of types of self-mutilative acts in the past year than suicide ideators (t[6O]= 2 . 7 1 , ~ < .05). No differences between groups were obtained for the number of risktaking behaviors over the past year (4601 = 1.95, NS), the frequency of self-mutilative behaviors in the past year ( ~ ’ [ l ]= 0.46, NS), or a history of prior suicide attempts ( ~ ’ [ [ l ] = 2.13, NS). Table 1 shows the means and frequencies for each group on these variables. All correlations among those variables that were used in the logistic regression for the overall sample (i.e., past suicide attempts, number of self-mutilative acts, regulation of affect and impulses) were statistically significant. Regulation of affect and impulses was most highly correlated with the number of types of selfmutilative behaviors in the past year ( r = .58). Also, a history of past attempts was related to both the Regulation of Affect and Impulses subscale of the SICP

( r = 3 3 ) and the number of types of self-mutilative acts ( r = 37). In addition, the Regulation of Affect and Impulses subscale of the SICP was highly correlated with the number of types of self-injurious behaviors in the past year ( r = .55). Correlations were computed separately for each group (ideators and attempters) (Table 2). Fisher’s r to z transformations were conducted to examine significant differences in the correlations between these two groups. As shown, the correlation obtained between regulation of affect and impulses and number of types of self-mutilative acts for suicide attempters was significantly different from that obtained for the suicide ideators (Fisher’s z = - 2 . 7 4 3 , ~< .01). The association between history of past attempts and regulation of affect and impulses was similar across groups (Fisher’s z = 0.25, NS). The relation between history of past attempts and the number of types of self-mutilative acts was not statistically different across groups Fisher’s z

=

-1.37, NS).

Logistic regression analyses examined which factor (i.e., past suicide attempts, number of self-mutilative acts, regulation of affect and impulses) contributed most to group membership, i.e., suicide ideators versus suicide attempters. Forward stepwise selection identified the number of types of self-mutilative acts in the past year as the only significant predictor of suicide

TABLE 1 Comparisons Berween Suicide Ideators and Attempters on Regulation of Affect, Self-Mutilation Acts, and Prior Suicide Attempts Variable Regulation of Affect and Impulses Score Mean

SD No. of types of risk-taking behaviors Mean

SD No. of types of self-mutilative acts Mean

SD Rate of self-mutilation Frequency YO Past suicide attempt Frequency YO

Ideators ( n = 25)

Attempters ( n = 37)

14.26 6.78

19.71 9.02

2.32*

.68

4.04 2.05

5.32 2.83

1.95

.52

2.44 2.40

4.19 2.56

2.71’

.71

t

xz

ES

20 80

32 87

0.46

.16

12 41

24 59

2.13

.34

Note: ES = effect size. * p < .05.

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TABLE 2 Correlations Among Affect Dysregulation, Types of SelfMutilarive Acts, and Past Suicide Attempts by Suicide Ideators ( n = 25) and Suicide Attempters ( n = 37) Affect Dysregulation ~~

Types of SelfMutilative Past Suicide Acts Attempts

~~

Affect dysregulation Types of self-mutilative acts Past suicide attempts

-

.12

.37

.72' .3 1

-

.04

.39

-

Note: Correlations above the diagonal in boldface type are for suicide ideators; below the diagonal, for suicide attempters * p < .01.

status. The model was significant (x' = 5.96, p < .05) and correctly classified 67% of the cases. The unique contribution of number of types of self-mutilative acts (p = .26, p < .05) resulted in an overall R2 value of .20. DISCUSSION

The present study found that among adolescent inpatients, those who had attempted suicide before hospitalization reported higher levels of affect dysregulation than did suicide ideators. In addition, the study found that a history of past suicide attempts was positively related to a greater degree of affect dysregulation. These findings confirm clinical impressions that adolescent suicide attempters have a reduced capacity to manage their internal states and suggest that suicide attempts may represent a mechanism to reduce intolerable emotional states. Another finding of the present study was that adolescent suicide attempters reported a greater number of types of self-mutilative acts in the past year than adolescent suicide ideators. This study also found that among the variables of past suicidal behavior, affect dysregulation and number of different self-mutilative behaviors, number of different types of self-mutilative behaviors was the only significant variable to differentiate adolescent suicide attempters from ideators. These data support the contention that suicidal behavior may not be a phenomenon distinct from self-mutilative behavior and that there is a continuum of self-inflicted acts of bodily harm of increasing severity and lethality. Contrary to expectations, we found that behaviors that have been theoretically associated with affect dysregulation (i.e., the presence of self-mutilation and

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greater degree of risk-taking behaviors) were unrelated to suicide attempts in an inpatient sample of adolescents. Given that this study found that a greater degree of risk-taking behaviors was related to an elevated level of affect dysregulation, it is possible that both suicide attempters and suicide ideators engage in these behaviors to modulate their affect, but the arousal level of suicide attempters is not dampened by these behaviors. Furthermore, our finding that a greater range of selfmutilative activities and a higher level of affect dysregulation were correlated in adolescent attempters suggests that adolescent suicide attempters may engage in a variety of self-inflicted assaults on their bodies in search of an effective method to modulate their affect. Perhaps a suicide attempt is a final attempt to adapt to intense negative emotions. An interesting finding of the current study was that the majority of our sample of adolescent inpatients had engaged in self-mutilative behavior during the year before hospitalization. Although the rate of selfmutilation in adolescent inpatients was not a focus of our study, these findings are noteworthy as there is little available data on the self-mutilative activities of adolescents. T o date, research has demonstrated that self-mutilation can be contagious in disturbed adolescents (Walsh and Rosen, 1988) and that self-mutilative behavior, a chronic condition, typically begins in the adolescent years (Favazza and Conterio, 1988). The finding that adolescent inpatients with a range of mental disorders frequently engage in self-mutilative behaviors suggests that clinicians treating adolescent inpatients should routinely inquire about self-mutilative behavior. Moreover, since self-mutilation can result in great personal and relational morbidity, further research is needed to understand and treat this serious problem in adolescents. There are several limitations to our study. First, the psychometric properties of the measures assessing affect dysregulation and self-destructive behaviors in adolescent inpatients are unknown. Establishment of the reliability and validity of instruments that assess affect dysregulation and self-destructive behaviors is an important area for future research. Second, the relationships among affect dysregulation, types of selfmutilative behaviors, and suicidal behavior were only correlational, which restricts any conclusions about causality. Because of the cross-sectional design of our study, it is unclear whether an association between

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affect dysregulation and suicide attempts indicates that affect dysregulation precedes and/or is a consequence of the suicidal act. Other more distal factors, such as childhood abuse, may precede both processes. Third, the current study did not use any standardized diagnostic interviews to determine the diagnostic composition of our sample. Thus, it was not possible to determine whether suicidal behavior cuts across diverse diagnostic groups or is a feature of specific mental disorders, such as depression or borderline personality. Given that emotional dysregulation and suicide attempts are key features of borderline personality disorders, it is possible that the relationship between suicide attempts and emotional dysregulation in adolescent suicide attempters reflects an underlying borderline personality disorder. Research with adolescent psychiatric inpatients has found that borderline personality disorder is related to suicidal behavior (Pfeffer et al., 1988) and that suicide attempters are more likely to have higher rates of borderline personality disorder than a nonsuicidal control group (Orvaschel et al., 1982). Another limitation of the present study was the generalizability of our findings to samples of adolescent outpatients or adolescents in the general population as the present study used a select sample of psychiatric inpatients. Moreover, the sample of suicide ideators in the present study included a number of adolescents (48% of the ideators) with past histories of attempted suicide. This may further compromise the generalizability of results pertaining to suicide ideators. In addition, the grouping of adolescents with histories of past suicide attempts with current suicide ideators may have accounted for our negative results concerning a lack of a relationship between suicide attempters and number of risk-taking behaviors, as differences between the two groups may have been obscured. Finally, the high correlation we found between the number of types of self-mutilation and affect dysregulation in suicide attempters probably explains cur finding that the number of types of selfmutilation was the only significant variable in the regression analysis to be associated with suicide attempters. Despite difficulties in understanding the dynamics of suicide attempts, increased knowledge of the correlates of adolescent suicidal behavior can provide clinicians with a far more comprehensive picture of adolescent suicide attempters who seek treatment. One

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implication of our findings for clinicians is that adolescents in treatment should be screened for multiple selfmutilative behaviors, as this behavior may be a risk factor for suicidal behavior. Furthermore, the clinician should determine the ability of adolescent suicide attempters to modulate their emotions in an adaptive manner, especially in distressing situations. The presence of poor affect regulation in adolescent suicide attempters may have important treatment implications. For example, adolescent suicide attempters may benefit from strategies and interventions that focus on the acquisition of emotional regulation skills, such as dialectical behavior therapy (Linehan, 1993), which has been effective in reducing suicidal and self-mutilative behaviors in adults with borderline personality disorder (Linehan et al., 1991). Empirical data will be needed to test the effectiveness of such a treatment in adolescent suicide attempters.

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