Personality Disorder, Personality Traits, Impulsive Violence, and Completed Suicide in Adolescents

Personality Disorder, Personality Traits, Impulsive Violence, and Completed Suicide in Adolescents DAVID A. BRENT, M.D., BARBARA A. JOHNSON, M.D., JOSHUA PERPER, M.D., LL.B., JOHN CONNOLLY, M.A., JEFF BRIDGE, B.A., B.S., SYLVIA BARTLE, M.S.W., AND CHRIS RATHER

ABSTRACT Objective: This study was designed to assess the association between personality disorders, personality traits, impulsive

violence, and suicide. Method: Personality disorders and traits in 43 adolescent suicide victims and 43 community controls were assessed from the parents, using semistructured interviews and self-report forms. Results: Probable or definite personality disorders were more common in suicide victims than in controls, particularly Cluster B (impulsivedramatic) and C type (avoidant-dependent) disorders. Suicide victims also showed greater scores on lifetime aggression, even after controlling for differences in psychopathology between suicides and controls. Conclusion: Personality disorders and the tendency to engage in impulsive violence are critical risk factors for completed suicide. J. Am. Acad. Child Ado/esc. Psychiatry, 1994, 33, 8: 1080-1 086. Key Words: suicide, adolescent, personality disorder, aggression.

In psychological autopsy studies of adolescent suicide, Axis I psychiatric disorders have been found to be present in at least 90% of suicide victims (Brent et al., 1988, 1993; Marttunen et al., 1991; Shaffer et al., 1988; Shafii et al., 1985, 1988). However, given that the rate of psychiatric disorder among adolescents is approximately 20% (Costello, 1989), it is clear that only a small portion of psychiatrically ill adolescents will commit suicide. Therefore, risk factors in addition to Axis I psychiatric conditions will need to be identified in order to understand the etiology of suicide and effectively prevent its occurrence. Investigations in adult populations have suggested that one additional trait may account for increased risk for attempted and completed suicide: a tendency to impulsive violence. Recent studies have found an association between a tendency to impulsive violence and attempted suicide in alcoholics, patients with major

Accepted February 24, 1994. Dr. Perper is with the Allegheny County Coroner's Office. All other authors are with the Western Psychiatric Institute and Clinic, Pittsburgh, PA. This work was supported by the National Institute ofMental Health (MH 43366, "Adolescent Family Study"}. The authors gratefUlly acknowledge the assistance of Donna Stephens in the preparation of this manuscript. Reprint requests to Dr. Brent, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213.

0890-8567/94/3308-1080$03.00/0©1994 by the American Academy of Child and Adolescent Psychiatry.

1080

J.

depression, and those with borderline personality disorder (Coccaro er al., 1989; Virkkunen et al., 1994). One adoption study of affective illness reported that completed suicide was closely associated with a tendency to unstable and labile affect, perhaps corresponding to borderline or histrionic personality disorder (Wender et al., 1986). Moreover, there is strong evidence that this personality trait is associated with changes in central serotonin metabolism (Brown et al., 1979, 1982; Coccaro et al., 1989), which in turn is related to risk for violent suicide and suicidal behavior (Asberg et al., 1976; Traskman et al., 1981). Several studies of clinically referred adolescents have found an association between attempted suicide and personality disorder, particularly borderline personality disorder (Brent et al., 1990, 1993a; Crumley, 1979; Marton et al., 1989; McManus et al., 1984; Pfeffer et al., 1988). Borderline disorder was most often associated with suicidal behavior when comorbid with affective or substance abuse disorders (Crumley, 1979; Marton et al., 1989; McManus et al., 1984). In one study, tendency to impulsive violence was not associated with suicide attempts (Brent et al., 1993a), although aggressive behavior and suicidal risk have been found to be associated in other clinical samples (Pfeffer et al., 1988). Avoidant disorders were also found to be associated with attempted suicide in one series of adolescent psychiatric inpatients (Brent et al., 1993a). Although

AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:8, OCTOBER 1994

PERSONALITY DISORDER AND SUICIDE

novelty seeking was not associated with suicidal behavior per se, it has been associated with borderline disorder, which in turn has been associated with suicidality (Brent et al., 1990). Rich et al. (1986), in a study of suicides younger than 30 years of age, reported a rate of personality disorders of 10%. In a reanalysis of these data, a much higher rate of borderline personality disorder of 41 % was reported (Rich and Runenson, 1992). Runeson (1989) and Marttunen et al. (1991) reported similar rates of personality disorders overall, although the frequencies of borderline disorder in the two studies were 31 % and 11%, respectively. Shafii et al. (1988) reported a 29% prevalence of personality disorder, versus 10% in the comparison group. However, Axis II disorders in the above-noted study included an unspecified number of developmental disorders as well. Aside from the study of Shafii et al. (1988), none of the above-noted studies were controlled, nor was there an assessment of personality dimensions that might be associated with suicide. Therefore, although the literature is strongly suggestive of an association between personality disorder and completed suicide among youth, this relationship has never been assessed in a controlled study. Moreover, there has never been a controlled study of personality traits in adolescent suicide. In light of this, we conducted a comparison of 43 adolescent suicide completers and an equal number of demographically similar community controls with respect to diagnosable personality disorder, dimensional measures of personality traits, and measures of impulsive violence. We hypothesized that suicide victims would show a greater prevalence of personality disorder, especially of the Cluster B type (e.g., borderline, narcissistic, histrionic, antisocial) and would show a greater tendency toward novelty seeking and toward impulsive violence.

METHOD Sample The suicides are consecutive samples of adolescent suicides aged 13 to 19 drawn from a 28-county region in western Pennsylvania, and they represent 77% of all available suicides during the period of recruitment, from July 1989 through July 1993. No differences were found between acceptors and refusers with respect to age, race, gender, toxicology, or method of suicide. The families of suicide victims were contacted approximately 3 months after the death and were interviewed a median of 4 to 5 months after the

J.

AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:8, OCTOBER 1994

death. A median of three informants were interviewed for each suicide, usually consisting of one or both parents, a sibling (if available), and at least one close friend. The controls were obtained by geographic cluster sampling from census tracts that were demographically similar to the suicide victims, but where no adolescent suicide had occurred for at least 2 years (Brent et al., 1993b). Seventy-three percent (73%) of all available controls participated in the interview. Both groups were older adolescents, mostly male, white, and with a median socioeconomic status of III (Table 1). A greater proportion of controls than com plerers lived with both biological parents (53.5% versus 25.6%, X2 = 7.01, P = .008). In terms of current psychiatric disorder, com plerers were more likely than controls to have had major depression (32.6% versus 0%, Fisher's Exact Test, p < .0001), substance abuse (44.2% versus 4.8%, X2 = 17.8, P < .0001), conduct disorder (35.7% versus 7.0%, X2 = 10.5, P = .001), or anxiety disorder (16.3% versus 2.4%, X2 = 4.81, P = .03), in keeping with previous reports (e.g., Brent er al., 1993c; Shaffer er al., 1988; Shafii er al., 1988).

Assessment Axis I psychiatric disorders were assessed by use of the Schedule for Affective Disorders and Schizophrenia for School-Age ChildrenPresent and Epidemiologic Versions (Chambers er al., 1985; Orvaschel er al., 1982). Axis II disorder was assessed by use of the Structured Clinical Interview for DSM-III-R (SCID-II) (Spitzer et al., 1989). These interviews were conducted by master's level clinicians with extensive clinical experience with adolescents. Interrater reliability using this instrument was quite good (K = .89, SE = .10). In this study, subjects were given a diagnosis of probable personality disorder if they were one symptom shy of diagnostic criteria, and"definite" personality disorder if full criteria were met. Symptoms were counted toward an Axis II disorder only if it was clear that these symptoms were not attributable to an Axis I disorder. Dimensional measures of personality for each disorder were extracted by summing all symptoms for a given personality disorder. The Tridimensional Personality Questionnaire was filled out by parents and is a 100-item questionnaire designed to tap three dimensions of personality hypothesized to be genetically and neurobiologically distinct: novelty seeking, harm avoidance, and reward

TABLE 1 Demographic Characteristics of Suicide Victims and Controls Suicides (n = 43) Age (yr) Mean SD Sex (% male) Race (% white) SES (%) I-II III IV-V Lives with both biological parents

17.4 2.0 86.0 97.7 34.9 23.3 41.9 25.6

Controls (n = 43) 17.5 1.8 86.0 100.0 23.2 30.2 46.5 53.5**

Note: SES = socioeconomic status. ** p < .01.

1081

BRENT ET AL.

dependence (Cloninger, 1987). Adequate test-retest reliability, internal consistency, and concurrent validity have previously been demonstrated (Cloninger, 1987). In this investigation, internal consistency was adequate for all three scales (a values from .62 to .79). Two measures of tendency to aggression were also obrained. The first, the Buss-Durkee Hosrility Inventory (Buss and Durkee, 1957), is a self-report thar was filled out by parents. Two subscales, "assault" and "irritability," were chosen, because they have been shown to correlate with measures of central serotonergic dysfunction (Coccaro et al., 1989). Internal consistency was acceptable in this study (a = .86 for both subscales). The second measure of tendency toward aggression, the BrownGoodwin Assessment for Lifetime History of Aggression, is a 12item interview, administered to the parents of both suicides and controls (Brown et al., 1979, 1982). This instrument has shown acceptable psychometric properties and correlates with both cerebrospinal and neuroendocrine measures of serotonergic function (Brown et al., 1979, 1982; Coccaro et al., 1989). In this study, the internal consistency of this instrument was high (a = .91).

Data Analyses The two groups were compared on categorical measures using Pearson's X2 and on continuous measures using either a MannWhitney U or a Student's t test. For comparisons of groups on categorical data where one or more cells was zero, Fisher's Exact Test was used. For comparisons between categorical variables, where adjustment for covariates was required, logistic regression was used, whereas if the dependent measure was continuous, analysis of covariance was used. The interrelationships between personality disorder and both Axis I disorder and personality traits were assessed using a X2 and either a t test or a Mann-Whitney U test, respectively.

Any personality disorder Cluster A Paranoid Schizoid Schizotypal Cluster B Histrionic Narcissistic Borderline Antisocial Cluster C Avoidant Passive-aggressive Dependent Compulsive

Suicides (n = 43)

Controls (n = 43)

41.9 7.0 7.0

12.2** 0.0 0.0 0.0 0.0 2.4* 0.0 0.0 0.0

2.3 0.0 20.9

2.3 4.7 7.0 11.9 26.2 14.0 11.9 7.0

2.3

2.3 9.5* 4.7

2.3 0.0 2.4

Note: Values are percentages. < .05; ** P < .01.

*p

If just the parent reports of Axis II disorder are used, then there was still an increased rate of personality disorder in suicide victims versus controls (23.3% versus 7.0%, X2 = 4.44, P = .04), with a specific elevation in the rates of Cluster B disorder (14.0% versus 0.0%, Fisher's Exact Test, p = .03). Association of Personality Disorder and Suicide, Adjusting for Differences in Current Psychopathology

RESULTS Personality Disorder

Suicide completers were much more likely to have had a probable or definite personality disorder than were controls (Table 2) (41.9% versus 12.2%, X2 = 9.29, P = .002), particularly Cluster B (20.9% versus 2.4%, X2 = 7.04, P = .008) and Cluster C (26.2% versus 9.5%, X2 = 3.98, P = .05). There were no individual personality disorder diagnoses that were increased to a statistically significant degree in the suicide completers, although there were trends for increased rates of paranoid, dependent, antisocial, avoidant, borderline, and passive-aggressive personality disorders. If analyses were restricted to only definite personality disorders, the difference for the overall category of personality disorder between suicides and controls was still significant (23.8% versus 2.5%, X2 = 8.01, P = .005), and a trend for an increased rate of Cluster B disorders in suicide victims was also noted (11.9% versus 0%, Fisher's Exact Test, p = .06).

1082

TABLE 2 Prevalence of Probable or Definite Personality Disorder in Suicide Victims and Controls

If the comparisons of the rates of Axis II disorders are restricted to suicides and controls with a definite or probable Axis I disorder, then completers still showed elevated rates of Axis II disorder (43.6% versus 22.2%) and Cluster B disorders (20.5% versus 5.3%), although neither comparison approached statistical significance. The overall category of personality disorder (probable or definite) was associated with substance abuse (43.5% versus 18.0%, X2 = 5.77, P = .02), conduct disorder (45.5% versus 13.1%, X2 = 9.96, P = .002), and major depression (30.4% versus 11.5%, X2 = 4.32, P = .04). In a series oflog-linear analyses, the associations among personality disorders, psychiatric disorders, and suicide were examined. Consistently, there were no three-way interactions, suggesting, at least in this sample, that personality disorder and Axis I disorder contributed to risk for suicide independently of one another. Logistic regression was used to adjust for differences in rates of current Axis I psychopathology between suicides

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:8, OCTOBER 1994

PERSON ALITY DISORDER AND SUICIDE

and controls. After controlling for depression, conduct disorder, and substance abuse, personality disorder did appear to be a risk factor for completed suicide, even though the odds ratio included unity (odds ratio [OR] = 2.9, 95% confidence interval [CI] 0.7 to 11.7). None of the interaction terms (depression X personality, substance X personality, or conduct X personality, or, in a separate regression, a general term Axis I disorder X personality) entered the regression equations. Subsequent logistic regressions examined the association of Cluster B and Cluster C disorders with suicide, while controlling for Axis I psychopathology. Cluster B disorder was strongly associated with completed suicide (OR = 8.5, 95% CI = 0.8 to 91.5) , but Cluster C was not. Dimensional Measures

Dimensional analyses were also performed looking at symptom counts derived from the SCID II (Table 3). The suicide completers on average had more than seven symptoms of personality disorder versus fewer than three in controls (Mann-Whitney U [MWU] = 1,317.0, P = .0003). There were significant differences between groups in the symptoms counts for each of the three clusters (p values .04 to .006), as well as for narcissistic (MWU = 1,091.5, P = .02) and avoidant (MWU = 1,110.0 , P = .01) disorders. TABLE 3 Axis II Symptom Counts in Suicide Victims and Community Controls Completers (n = 43) Any Axis II Cluster A Paranoid Schizoid Schizotypal Cluster B Histrionic Narcissistic Borderline Antisocial Cluster C Avoidant Passive-aggressive Dependent Compulsive

7.5 (8.9) 0.4 (1.1) 0.2 (0.9) 0.1 0.1 3.6 0.2 1.1

1.3 1.0 3.2 l.l

0.6 0.8 0.7

(0.4) (0.4) (65) (0.7) (2.2) (3.2) (2.6) (5.2) (2.2) (2.1) (2.8) (1.9)

Controls (n = 43) 2.7 0.0 0.0 0.0 0.0 1.1 0.1

(6.7}*** (O.O)** (O.O)** (O.O) (O.O) (3.3)*

(0.3) 0.3 (1.2)* 0.3 (1.2) 0.4 (1.5) 1.6 (3.7)* 0.4 (1.6)** 0.7 (1.9) 0.3 (1.4) 0.3 (1.0)

Note: Values represent mean (SD). * P < .05; ** P < .01; *** P < .001.

j. AM. ACAD . CHILD AD OLE SC. PSYCHIATRY, 33:8, OCTOBER 1994

Parent questionnaires were available on a subsample of completers (n = 29) and controls (n = 39) (Table 4). According to the Tridimensional Personality Questionnaire , completers were rated as higher than controls on "harm avoidance" (MWU = 718 .0, P = .04), but no different on novelty seeking or reward dependence. Harm avoidance was correlated with anxiety and affective disorders, and after analysis of covariance for these disorders, this group difference was no longer significant. With regard to ratings of impulsive aggression, the two groups were no different on the "assault" subscale of the Buss-Durkee Hostility Inventory, but suicide victims were rated higher on "irritability" (MWU = 707.5 , P = .009). "Irritability" was correlated with substance abuse, and analysis of covariance, controlling for substance abuse, showed a trend for group differences (F [I ,61] = 3.42, P = .07). On lifetime rating of aggressive acts using the Brown-Goodwin Inventory, suicide completers scored much higher than controls (MWU = 955.5, P = .0001). If completers and controls with Axis I psychopathology were compared, the completers scored higher on the BrownGoodwin Inventory (MWU = 350.0 , P = .05). The Brown-Goodwin Inventory was correlated with affective disorder, substance abuse, and conduct disorder. Since the criteria for conduct disorder overlap so closely with the items of the Brown-Goodwin, only the former two correlates were included in an analysis of covariance, which still showed a significantly greater score on the Brown-Goodwin Inventory in suicide victims than in controls (F[I,67] = 5.21, P = .03). Concurrent Validity of Personality Disorder Diagnoses

Those subjects in the study who had personality disorder were compared to those who did not on questionnaire and interview data. Those with any personality disorder (probable or definite) scored higher on novelty seeking (22.6 [6.7] versus 18.6 [7.0], t = 2.15, df = 64, P = .04) and on lifetime aggression (14.7 [l0.3] versus 7.4 [9.0], MWU = 274.0, P = .003). Those with avoidant disorder scored higher on harm avoidance (20.9 [6.0] versus 12.7 [7.2], t = 2.90, df = 65, P = .005) and irritability (19.2 [2.8] versus 15.4 [3.4], t = 2.64 , df = 63, P = .01), whereas those with borderline disorders tended to score higher on assaultiveness as rated by the Buss-Durkee Hostility Inventory (19.5 [0.7] versus 15.3 [3.1], MWU = 11.5, P = .05) and the Brown-Goodwin Inventory (16.4

1083

BRENT ET AL.

TABLE 4 Dimensional Measures of Personality Based on Parent Report Cornpleters (n = 29) Tridimensional Personality Questionnaire 21.7 Novelty seeking Harm avoidance 15.6 Reward dependence 16.5 Buss-Durkee Hostility Inventory 16.2 Assault 17.0 Irritability 14.3 Brown-Goodwin Inventory

Controls (n = 39)

(6.8) 18.8 (7.1) (7.9) 11.9 (6.7)* (5.1) 16.7 (4.9) (3.2) 15.1 (3.0) (3.2) 14.8 (3.4)** (9.3) 6.3 (8.8H

Note: Values represent mean (SD). * P < .05; **P < .01; t p < .0001.

[0.8] versus 9.2 [10.0], MWU = 42.0, P = .08). However, within the suicide completer group, there were no significant correlations between the overall category of personality disorder, or specific personality Clusters A, B, or C, and the characteristics of suicidal behavior, suicidal intent, or method of suicide. DISCUSSION

In this study, several of our hypotheses were confirmed. Personality disorders, particularly Cluster B type disorders, were more common in suicide victims than in controls, even after controlling for differences in Axis I psychopathology. Dimensional measures of personality showed higher degrees of lifetime history of aggression and of an increased tendency to impulsive violence, and of "harm avoidance." However, the dimension of novelty seeking was not found to be increased in suicide victims, as originally hypothesized. This study is subject to several limitations, which should be discussed in order to place these findings in context. First, assessment of personality disorder and traits was largelydependent on parent report. While there is some evidence supporting the importance of an informant in the assessment of personality disorders (Zimmerman et al., 1986), the lack of self-report may have resulted in underreporting of certain personality traits or disorders, particularly those that are more internal and not as prominently displayed in social settings. However, a comparison of reports by parents of completers to reports by parents of controls still resulted in significant differences between groups in the prevalence of probable and definite personality disorder and for certain personality traits. Therefore,

1084

J.

these significant differences between the two groups are not likely to be artifacts of the absence of selfreport on the part of the suicide victims. Second is the related concern about the reliability and validity of diagnoses obtained through the psychological autopsy procedure. We have previously shown that report by parents on a wide range of psychiatric symptoms is unaffected ' by the degree of parental distress (Brent et al., 1988). More recently, we have shown that the diagnoses of suicide victims obtained through psychological autopsy correspond to those in first-degree relatives obtained blind to diagnosis of the suicide victim (Brent et al., 1993d). This supports the validity of psychiatric diagnosis obtained through the psychological autopsy procedure. While no data exist on the validity of personality diagnoses per se made through a psychological autopsy procedure, the above-noted evidence supports the validity of psychiatric assessment in general using this procedure. Third, while there is accumulated evidence of the reliability of personality disorder assessment in adolescents, there is much less written about the validity of these diagnoses in this age group (Brent et al., 1990; Marton et al., 1989; McManus et al., 1984). Longitudinal studies of adolescent personality disorders, family studies, and biological investigations of personality disorders are strategies that will be most likely to advance claims of the validity of adolescent personality disorders as a diagnostic category. Fourth, given the sample size and low prevalence of both Axis I and personality disorder in the control group, it was not possible to estimate the risk for suicide associated with both Axis I and personality disorder. That is, while we found evidence that both Axis I and II disorders contributed independently to risk for suicide, our failure to find an interactive effect between Axis I and II disorders, as predicted by Blumenthal and Kupfer (1986), may be due to abovenoted statistical considerations. Finally, there are both advantages and disadvantages to using a community control group. As an advantage, the control group is nonreferred, as is the group of suicide victims. Moreover, there is so little known about the prevalence of personality disorders in the general population that a community sample seemed to be a useful reference point. However, the use of a community control group contributed to the above-noted concerns about power, making it difficult to assess the interaction of Axis I and II disorders.

AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 33:8, OCTOBER 1994

PERSONALITY DISORDER AND SUICIDE

Personality disorder was more prevalent among suicide victims than among controls, and in particular, Cluster B disorders were more common in completers than in controls. Despite these findings, we did not find the high rates of borderline disorder reported in two large series of young adult suicide victims (Rich and Runeson, 1992; Runeson, 1989; Runeson and Beskow, 1991). Paris et al. (1989) reported that borderline disorder typically results in suicide relatively early in its course, but the median age of death in this series was 32 years. It is possible that borderline personality disorder is not a risk factor for completed suicide until young adulthood (compared to adolescence), after years of interpersonal rejection, disappointment, and turmoil. In our sample, contrary to our original hypotheses, suicide was also associated with Cluster C disorders, most prominently avoidant disorder. This is consistent with our previous findings of a relationship between both avoidant and dependent traits and attempted suicide in clinically referred samples (Brent et al., 1993a). These results are consistent with prior reports of anxious, rigid, inhibited, perfectionistic adolescents ·who commit suicide (Shaffer, 1974; Shafii et al., 1985), possibly conforming to one or more of these types of Cluster C disorders. An anxious, inhibited temperament may predispose to suicidal behavior. Longitudinal studies of behaviorally inhibited children may clarify this relationship further (Biederman et al., 1993). The dimensional measures of personality traits were not particularly revealing. We hypothesized that completers would score higher on novelty seeking, but this assumption was not borne out by our findings. It may seem counterintuitive that completers scored higher on "harm avoidance" than controls. This subscale seems to tap a dimension of an inhibited and fearful temperament that correlates with both affective and anxiety disorders on Axis 1. Once these diagnostic variables were controlled for, the difference in harm avoidance between the groups disappeared. We have previously found an association between this dimension and suicide attempts in a mostly female, affectively ill, clinically referred sample (Brent et al., 1993a). These findings underscore the importance of exploring further the relationship between an "anxious" temperament and tendency to engage in suicidal behavior. As hypothesized, completers showed a greater tendency to engage in assaultive behavior. Indeed, suicide victims had higher lifetime histories of aggression, even

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:8, OCTOBER 1994

after we controlled for differences in Axis I diagnoses. This finding is consistent with reports that link both tendency to impulsive violence and suicidal behavior with the same types of central serotonegic deficits (Brown et al., 1979, 1982; Coccaro et al., 1989; Linnoila et al., 1983; Virkkunen et al., 1987), as well as with our previous observation that homicidal ideation is quite prominent the week before completed suicide in adolescents (Brent et al., 1993c). There are significant clinical implications to these findings. The assessment of personality disorders and traits should be part of the clinical assessment of every patient judged to be at suicidal risk. Conversely, if a patient is identified as having a personality disorder, assessment and monitoring of suicidal risk is a critical aspect of proper patient care. Treatments that target aspects of personality dysfunction, such as dialecticbehavioral therapy for parasuicidal borderline patients, have been shown to be effectivein reducing the number and severity of parasuicidal episodes (Linehan et al., 1991, 1993). The use of neuroleptics has been proposed to treat recurrently suicidal, personality-disordered patients (Montgomery and Montgomery, 1982), although the long-term side effects of neuroleptics remain a real concern. It is important to note that failure to address clinical issues relative to personality disorder may leave a patient at continued high suicidal risk, even if the Axis I disorder is being treated. Further research in the interrelationship of personality traits and suicidal risk is indicated. Careful psychobiological investigation into correlates of Axis I and personality traits, and their interrelationship with risk for suicide, are also likely to shed light on the etiology of suicidal behavior and treatment of patients at risk for suicide (Coccaro et al., 1989). Psychosocial and pharmacological interventions that target dysfunctional personality traits may reduce subsequent risk for suicide. Such interventions should be subjected to rigorous clinical trials in order to assess and, ultimately, improve our ability to treat personality-disordered patients at high risk for suicide.

REFERENCES Asberg M, Traskman L, Thoren P (1976), 5-HIAA in the cerebrospinal fluid: a biochemical suicide predictor? ArchGenPsychiatry 33: I 193-1 197 Biederman ], Rosenbaum ]F, Bolduc-Murphy EA et al. (1993), A threeyear follow-up of children with and without behavioral inhibition. ]

Am Acad Child Ado/esc Psychiatry 32:814-821

1085

BRENT ET AL. Blumenthal SJ, Kupfer DJ (1986), Generalizable treatment strategies for suicidal behavior, In: Psychobiology ofSuicida/Behavior, Mann JJ, Stanley M, eds. New York: New York Academy of Sciences, 487:327-340 Brent DA, Johnson B, Bartle S et al. (1993a), Personality disorder, tendency to impulsive violence, and suicidal behavior in adolescents. JAm Acad

Child Ado/esc Psychiatry 32:69-75 Brent DA, Perper J, Kolko DJ, Zelenak JP (1988), The psychological autopsy: methodologic considerations for the study of adolescentsuicide.

JAm Acad Child Adolesc Psychiatry 27:362-366 Brent DA, Perper JA, Moritz G et al. (1993b), Psychiatric sequelae to the loss of an adolescent peer to suicide. J Am Acad Child Ado/esc

Psychiatry 32:509-517 Brent DA, Perper JA, Moritz G er al. (1993c), Psychiatric risk factors for adolescent suicide: a case-control study. J Am Acad Child Ado/esc

Psychiatry 32:521-529 Brent DA, Perper JA, Moritz G er al. (1993d), The validity of diagnoses obtained through the psychological autopsy procedure: use of family history. Acta Psychiatr Scand 87:118-122 Brent DA, Zelenak JP, Buksrein 0, Brown RV (1990), Reliability and validity of the strucrured interview for personality disorders in adolescents. JAm Acad Child Ado/esc Psychiatry 29:349-354 Brown GL, Goodwin FK, Ballenger JC, Goyer PF, Major LF (1979), Aggressionin humans correlateswith cerebrospinal fluid amine metabolites. Psychiatry Res 1:131-139 Brown GL, Ebert MH, Goyer PF et al. (1982), Aggression, suicide, and serotonin: relationships to CSF amine metabolites. Am J Psychiatry 139:741-746 Buss A, Durkee A (1957), An inventory for assessing different kinds of hostility. J Consult Psycho/21:343-349 Chambers W], Puig-Anrich J, Hirsch M et al. (1985), The assessment of affective disorders in children and adolescents by semi-structured interview: test-retest reliability of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present Episode version.

Arch Gen Psychiatry 42:696-702 Cloninger C (1987), A systematic method for clinical description and classification of personality variants: a proposal. Arch Gen Psychiatry 44:573-588 Coccaro E, Siever L, KIar HM et al. (1989), Serotonergic studies in patients with affectiveand personality disorders. ArchGenPsychiatry 46:587-599 Costello EJ (1989), Developments in child psychiatric epidemiology. JAm Acad Child Adolesc Psychiatry 28:836-841 Crumley FE (1979), Adolescent suicide attempts. JAMA 241:2404-2407 Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL (199I), Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48:1060-1064 Linehan MM, Heard HL, Armstrong HE (1993), Naturalistic follow-up of a behavioral treatment for chronicallyparasuicidalborderline patients. Arch Gen Psychiatry 50:971-974 Linnoila M, Virkkunen M, Scheinin M, Nuutila A, Rimon R, Goodwin FK (1983), Low cerebrospinal fluid 5-hydroxyindoleaceticacid concentration differentiates impulsive from nonimpulsive violent behavior. Life Sci 33:2609-2614 Marton P, Korenblum M, Kutcher S, Stein B, Kennedy B, PakesJ (1989), Personality dysfunction in depressed adolescents. Can J Psychiatry 34:810-813

1086

J. AM.

Marttunen MJ, Aro HM, Henriksson MM, Lonnquist JK (199I), Mental disorders in adolescent suicide: DSM-III-R Axes I and II diagnoses in suicides among 13 to 19-year-olds in Finland. Arch Gen Psychiatry 48:834-839 . McManus M, Lerner H, Robbins D, Barbour C (1984), Assessment of borderline symptomatology in hospitalized adolescents.JAm Acad Child

Psychiatry 23:685-694 Montgomery SA, Montgomery D (1982), Pharmacological prevention of suicidal behavior. J Affict Disord4:291-298 Orvaschel H, Puig-Anrich J, Chambers W, Tabrizi MA, Johnson R (1982), Retrospective assessment of prepubertal major depression with the Kiddie-SADS-E. JAm Acad Child Psychiatry 21:392-397 Paris J, Nowlis D, Brown R (1989), Predictors of suicide in borderline personality disorder. CanJ Psychiatry 34:8-9 Pfeffer CR, Newcom J, Kaplan G, Mizruchi MS, Plutchik R (1988), Suicidal behavior in adolescent psychiatric inpatients. JAm Acad Child

Ado/esc Psychiatry 27:357-361 Rich CL, RunesonBS (1992), Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States.

Acta Psychiatr Scand86:335-339 Rich CL, Young D, Fowler RC (1986), San Diego suicide study. I. Young vs. old subjects. Arch Gen Psychiatry 43:577-582 Runeson B (1989), Mental disorder in youth suicide: DSM-III-R Axes I and II. Acta Psychiatr Scand79:490--497 Runeson B, Beskow J (199I), Borderline personality disorder in young Swedish suicides. J Nerv Ment Dis 179:153-156 Shaffer D (1974), Suicide in childhood and early adolescence. J Child

Psychol Psychiatry 15:275-291 Shaffer D, Garland A, Gould M, Fisher P, Trautman P (1988), Preventing teenage suicide: a critical review. JAm Acad Child Ado/esc Psychiatry 27:675-687 Shafii M, Carrigon S, Whittinghaill JR, Derrick AM (1985), Psychological autopsy of completed suicide in children and adolescents. Am J Psychia-

try 142:1061-1064 Shafii M, Stelrz-Lenarsky J, Derrick AM, Beckner C, Whittinghill JR (1988), Comorbidity of mental disorders in the post-mortem diagnosis of completed suicide in children and adolescents. J Affict Disord 15:227-233 Spitzer RL, Williams JBW, Gibbon M, First MB (1989), The Structured Clinical Interview fOr DSM-III-R. New York: Biometrics Research Department, New York State Psychiatric Institute Traskman L, Asberg M, Berrilsson L, Sjostrand L (1981), Monoamine metabolites in CSF and suicidal behavior. Arch Gen Psychiatry 38:631-636 Virkkunen M, Kallio E, Rawlings Ret al. (1994), Personality profiles and state aggressiveness in Finnish alcoholic, violent offenders, fire setters, and healthy volunteers. Arch Gen Psychiatry 51:28-33 Virkkunen M, Nuutila A, Goodwin FK, Linnoila M (1987), Cerebrospinal fluid monoamine metabolite levelsin male arsonists. Arch Gen Psychia-

try 44:241-247 Wender PM, Kety SS, Rosenthal D, Schulsinger F, Ortmann J, Lunde I (1986), Psychiatric disorders in the biological and adoptive families of adopted individuals with affective disorders. Arch Gen Psychiatry 43:923-929 Zimmerman M, Pfohl B, Stangl D, Corenthal C (1986), Assessment of DSM-III personality disorders: the importance of interviewing an informant. J C/in Psychiatry 47:261-263

ACAD. CHILD ADOLESC. PSYCHIATRY, 33:8, OCTOBER 1994