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Relations of psychological characteristics to suicide behaviour: Results from a large sample of male prisoners
Personality and Individual Differences 47 (2009) 250–255
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Relations of psychological characteristics to suicide behaviour: Results from a large sample of male prisoners M. Sarchiapone a,*, N. Jovanovic´ b, A. Roy c, A. Podlesek d, V. Carli a, M. Amore e, M. Mancini f, A. Marušicˇ g a
Faculty of Medicine, University of Molise, Loc. Tappino, 86100 Campobasso, Italy Faculty of Medicine, University of Zagreb, Psychiatric Clinic, Kispaticeva 12, Zagreb, Croatia c Psychiatry Service, Veterans Affairs Medical Center, East Orange, NJ 07018, USA d University of Ljubljana, Faculty of Arts, Department of Psychology, Askerceva 2, SI-1000 Ljubljana, Slovenia e Department of Neuroscience, Psychiatric Section, Strada del Quartiere 2/A, 43100 Parma, Italy f MAPPsi (Medici associati per la psichiatria e la psicoterapia), Lungarno Colombo 28 A, Firenze, Italy g University of Primorska, Koper, Slovenia b
a r t i c l e
i n f o
Article history: Received 23 July 2008 Received in revised form 3 March 2009 Accepted 6 March 2009 Available online 3 April 2009 Keywords: Prisoners Suicide ideation Suicide attempt Psychological characteristics Childhood trauma Emotional lability Substance abuse Sensation seeking behaviour
a b s t r a c t Aim was to investigate psychological characteristics that may predict suicide ideation and behaviour in male prisoners. Sample consisted of 1117 prisoners detained in jails of the District of Abruzzo-Molise in Italy. All underwent psychiatric interviews and comprehensive psychometric assessments related to different psychological characteristics. Principal component analysis of psychometric variables derived four components. Multivariate logistic regression was designed to test them as predictors of suicidal ideation and attempt. Main findings: (1) approximately 40% prisoners reported lifetime suicide ideation and 13% attempted suicide; (2) different psychometric variables tend to associate in male prisoners. Three of them – childhood trauma, emotional lability and substance abuse – seem to increase the risk of suicide ideation and attempt, while sensation seeking behaviour might decrease it; (3) ideators and attempters scored higher on scales measuring aggression, hostility, childhood trauma, depression, psychoticism and neuroticism, when compared to non-ideators and non-attempters; (4) suicide ideators and attempters scored lower on extraversion and resilience scales; and (5) childhood trauma was the strongest positive predictor for suicide ideation and attempt. This is the first report on psychological characteristics in a large sample of prisoners. We believe it might add new value to evidence-based suicide prevention strategies in prisons. Ó 2009 Published by Elsevier Ltd.
1. Introduction Prisoners are at increased risk for suicide ideation and attempt (Fazel & Danesh, 2002; Jenkins et al., 2005; Preti & Cascio, 2006). Previous studies detected various risk factors such as psychiatric disorders (Marcus & Alcabes, 1993), substance misuse (Roy, 2001, 2003), previous attempt (Fruehwald & Frottier, 2005; Fruehwald, Frottier, Matschnig, & Eher, 2003) and long sentences after highly violent crimes (DuRand, Burtka, Federman, Haycox, & Smith, 1995). Moreover, it has been suggested that psychological characteristics are strongly associated with suicidal behaviour and that individual personality differences might predict suicide attempts. However, no large study examining psychological profiles of suicide attempters in prisons has ever been conducted. In 2006, Brezo and co-authors analysed 90 original studies exploring different personality traits in the context of suicide ideation, attempts and
* Corresponding author. Tel.: +39 3204795630. E-mail address: [email protected] (M. Sarchiapone). 0191-8869/$ - see front matter Ó 2009 Published by Elsevier Ltd. doi:10.1016/j.paid.2009.03.008
completions (Brezo, Paris, & Turecki, 2006). They concluded that hopelessness, neuroticism and extraversion might be of greatest help when aiming to detect those at increased risk for suicide ideation or attempt. Traits such as aggression, impulsivity and social introversion may be useful in differentiating between ideators, attempters and completers. In the present study we investigated a variety of psychological characteristics, such as depression, aggression, hostility, impulsivity, psychoticism, extraversion and neuroticism, childhood trauma, diagnosis of mental disorder and substance abuse. This is the first study of such a large sample of male prisoners in which we searched for new features of psychological proneness to suicide. 2. Methodology 2.1. Participants A total of 1177 male prisoners detained in jails of the District of Abruzzo-Molise in Italy took part in the study. We included both
M. Sarchiapone et al. / Personality and Individual Differences 47 (2009) 250–255
high and low security correctional facilities. All prisoners that were present in the jails were considered eligible for the study. The only inclusion criterion was willingness to participate with a signed informed consent. Exclusion criteria were absence of sufficient linguistic abilities in Italian, inability to read, mental retardation or severe mental disorder. We studied only male prisoners since there were less than 2% of women. Age ranged between 18 and 81 (M = 39.5; SD = 10.6), the majority were single (N = 538), with completed lower secondary school (N = 674) and employed (N = 610). At each prison a list of prisoners was obtained from the Prison Register Office and all of them were consecutively informed about the study. There were 1436 subjects who were invited to participate, but 259 refused (18%). The ethics committee of the University of Molise approved the study. 2.2. Materials A specifically trained team of psychiatrists and psychologists conducted an in-depth psychiatric interview, which included the Italian version of the structured Mini International Neuropsychiatric Interview (MINI) (Conti, 1999). Outcome variables were self-reported presence or absence of lifetime suicide ideation (SI) and history of suicide attempt (SA). The first was also assessed according to the participant’s answer to the 68th item of the Eysenck personality questionnaire: ‘‘Have you ever wished that you were dead?” (Eysenck & Eysenck, 1975). In cases where the two answers were different, subjects were called for an additional interview and the final answer was entered into the database. Suicide attempt was clearly defined as a self-destructive act with some intent to end one’s life that was not self-mutilatory in nature. A DSM-IV psychiatric diagnosis was formulated upon agreement of two experienced psychiatrists (M.S. and V.C.). After collecting demographic data on marital status, education and employment, prisoners underwent comprehensive psychometric assessments. Severity of depressive symptoms was measured with the Hamilton depression rating scale (HDRS) (Hamilton, 1960), already standardised in Italian (Conti, 1999). Early traumatic experiences were evaluated with a 34-item version of the childhood trauma questionnaire (CTQ) (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). The personality traits of psychoticism, extraversion, and neuroticism were assessed using the standardised version in Italian of the Eysenck personality questionnaire (Conti, 1999; Eysenck & Eysenck, 1975). Prisoners’ lifetime history of aggression was measured using the translated Brown–Goodwin assessment for lifetime history of aggression interview (BGLHA) (Brown, Goodwin, Ballenger, Goyer, & Major, 1979). Hostility was assessed according to the standardised Italian version of the Buss and Durkee hostility inventory (BDHI) (Buss & Durkee, 1957; Conti, 1999). In order to measure impulsive traits, we employed the Barratt impulsivity scale (BIS, 7B version) which was used to assess impulsivity as a personality trait (Barratt, 1993). The questionnaire consists of 48 statements to which subjects respond by choosing one of the following responses: rarely/never, occasionally, often, and usually. Resilience was assessed using the translated Connor–Davidson resilience scale (CDRISC) (Connor & Davidson, 2003). The MINI Interview, EPQ, HDRS and BDHI have been standardised and widely used in Italy (Castrogiovanni, 1982; Conti, 1999; Rossi et al., 2004). Other scales were adapted for the Italian population just prior to the beginning of the study. Psychometric and statistical techniques were used to establish the equivalence of the source and target language versions of the instrument. Reliability was assessed through internal consistency (Cronbach’s alphas) and the results were as follows: .76 for BDHI, .87 for BGLHA, .73 for BIS, .84 for CDRISC, .804 for HDRS, .736 for EPQ and .79 for CTQ.
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2.3. Statistical analysis Data analysis started with describing the sample’s general characteristics. Chi-square analysis was used to compare categorical variables. Means and SDs were calculated for all psychometric tests used in the study and their subscales. Comparisons of psychometric tests’ means between the study subgroups (presence/absence of SI and presence/absence of SA) were based on independent-samples t-test and effect size was assessed with Cohen’s d. Psychiatric diagnosis (yes/no), substance abuse (yes/no), scores on subscales in multidimensional tests and total scores in unidimensional tests (altogether 26 variables) were entered all at the same time into logistic regression models. Dependent variables were clearly dichotomous – presence or absence of SI and SA. Many correlations among exploratory variables were statistically significant (Keiser–Meier–Olkin measure was .836). In order to further analyse the correlates and to explore distinguishing features of different types of personality characteristics, we decided to reduce the large amount of data. Principal component analysis (PCA) using Varimax rotation was performed on all 26 exploratory variables. Rotation converged in six iterations. Scree plot suggested extraction of four to six components. Although the parallel analysis (for normally distributed random data generation) suggested a sixcomponent solution, we decided to extract four components because the structure was simpler and more interpretable. The four components together explained 46.8% of the variance. Four variables, which loaded more than .30 on two components or more, and one variable with loadings lower than .30, were excluded from further analysis. The PCA was rerun on the remaining variables, resulting in a clear four-component solution explaining 50.5% of the variance. Component scores were used as independent variables when creating two logistic regression models – one for the presence of SI and another for the presence of SA.
3. Results A total of 515 participants (43.8%) reported having suicide ideation, while 155 (13.2%) attempted suicide at some point in their lives. There were no age and education differences between them. Attempters differed from non-attempters in marital status, v2(3) = 10.08, p = .018; the percentage of married, divorced, single, and widowed participants was 27.5, 17.4, 51.0 and 4.0 among attempters. The two subgroups also differed in employment status, v2(2) = 23.27, p = .000; the percentage of unemployed, employed, and retired was 44.0, 40.7 and 15.3 among attempters. Similar differences were found between the subgroups according to SI. They differed in marital status, v2(3) = 27.96, p = .000 as the percentage of married, divorced, single and widowed ideators was 28.9, 14.6, 54.3 and 2.2. The difference between the two subgroups in employment status was significant, v2(2) = 42.28, p = .000. In ideators the percentage of unemployed, employed and retired was 46.5, 43.6 and 9.8. Mean values of psychometric tests used in the study are shown in Table 1. Since there are no normative values for most of these scales, we decided to show all our results. We found that participants with SA, when compared to those without a history of SA, scored significantly higher on all scales, except extraversion, resilience and interpersonal impulsive behaviour. Similar results were found regarding suicide ideators. They scored higher on all scales but extraversion and resilience. In an attempt to find variables that might predict suicide ideation, we created an ‘‘all-variables-in” logistic regression model. Results are shown in Table 2. Participants who were more likely to have SI were substance abusers (OR = 1.68) and scored higher on CTQ – emotional abuse, CTQ – emotional neglect, EPQ – neuroticism,
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Table 1 Means and standard deviations of scores on psychometric tests used in the study and the differences between the subgroups with different history of suicide attempt (SA) and suicide ideation (SI). All participants
Statistical testa
Dependent variable
Absent
Present
M
SD
M
SD
df
p
d
SI SA SI SA SI SA SI SA SI SA
6.11 6.83 6.26 7.01 7.18 7.44 20.39 21.89 11.41 12.25
2.19 3.19 2.61 3.70 2.28 2.75 8.05 8.83 3.74 4.40
8.39 8.93 8.61 9.15 8.06 8.35 25.11 26.21 14.11 14.89
4.36 4.76 5.08 5.59 3.70 4.31 10.24 11.69 5.59 6.58
10.84 5.31 9.54 4.63 4.77 2.56 8.59 4.42 9.46 4.84
713.4 175.5 723.0 174.9 807.1 173.5 955.3 181.6 853.4 175.5
.000 .000 .000 .000 .000 .011 .000 .000 .000 .000
0.65 0.60 0.58 0.53 0.29 0.30 0.50 0.46 0.56 0.55
754.4 171.4
.000 .000
0.71 0.67
M
SD
CTQ – emotional abuse
7.11
3.51
t
CTQ – physical abuse
7.29
4.06
CTQ – sexual abuse
7.56
3.02
CTQ – emotional neglect
22.46
9.37
CTQ – physical neglect
12.59
4.83
CTQ total
7.96
2.64
SI SA
7.14 7.73
1.75 2.32
9.02 9.49
3.16 3.84
12.16 5.57
EPQ – psychoticism
5.61
3.13
EPQ – extraversion
13.54
3.66
EPQ – neuroticism
12.01
4.73
SI SA SI SA SI SA
5.16 5.46 14.07 13.78 10.35 11.60
3.02 3.08 3.36 3.54 4.30 4.61
6.19 6.59 12.86 11.95 14.15 14.75
3.16 3.26 3.92 4.07 4.38 4.55
5.64 5.64 5.59 5.29 14.90 14.90
1175.0 1175.0 1011.8 191.0 1175.0 1175.0
.000 .000 .000 .000 .000 .000
0.33 0.36 0.33 0.50 0.80 0.67
BIS – impulsivity self-assessment
17.77
7.61
BIS – interpersonal behaviour
5.54
3.54
BIS – motor impulsivity
10.48
5.20
BIS – risk taking
8.85
4.19
BIS – sensory stimulation
4.79
2.66
SI SA SI SA SI SA SI SA SI SA
17.42 17.71 5.42 5.58 10.13 10.41 8.84 8.81 4.58 4.79
7.32 7.55 3.49 3.53 5.16 5.19 4.24 4.16 2.62 2.63
18.23 18.17 5.71 5.28 10.94 10.95 8.85 9.11 5.06 4.84
7.96 8.04 3.58 3.55 5.21 5.22 4.12 4.38 2.70 2.85
1.78 0.66 1.41 0.99 2.67 1.21 0.02 0.84 3.08 0.23
1056.7 197.4 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0
.076 .510 .160 .325 .008 .225 .987 .401 .002 .821
0.11 0.06 0.08 0.08 0.16 0.10 0.00 0.07 0.18 0.02
BIS total
47.44
14.80
SI SA
46.39 47.30
14.28 14.57
48.79 48.35
15.36 16.28
2.76 0.82
1175.0 1175.0
.006 .410
0.16 0.07
BGLHA
36.12
11.38
SI SA
33.11 35.27
10.00 11.02
39.99 41.71
11.86 12.12
10.56 6.69
1001.7 1175.0
.000 .000
0.60 0.57
Connor–Davidson resilience scale
64.99
14.05
SI SA
68.02 66.18
12.47 13.18
61.09 57.14
14.98 16.83
992.9 183.8
.000 .000
Hamilton depression scale
7.86
6.62
SI SA
5.57 7.02
4.83 5.98
10.81 13.40
7.40 7.87
13.95 9.68
840.2 182.0
.000 .000
0.79 0.96
BDHI – assault
5.01
2.15
BDHI – indirect
4.17
1.96
BDHI – irritability
4.54
2.22
BDHI – negativism
3.19
1.30
BDHI – resentment
3.64
1.70
BDHI – suspicion
4.86
2.43
BDHI – verbal
6.69
2.37
BDHI – guilt
4.85
2.13
SI SA SI SA SI SA SI SA SI SA SI SA SI SA SI SA
4.62 4.92 3.79 4.07 4.05 4.44 2.99 3.15 3.31 3.55 4.50 4.78 6.33 6.61 4.51 4.78
2.11 2.15 1.87 1.93 2.16 2.19 1.31 1.30 1.64 1.68 2.42 2.41 2.27 2.35 2.04 2.13
5.51 5.63 4.66 4.81 5.16 5.18 3.45 3.46 4.07 4.25 5.31 5.35 7.16 7.21 5.28 5.28
2.10 2.04 1.96 2.04 2.15 2.33 1.24 1.26 1.68 1.72 2.37 2.54 2.41 2.45 2.18 2.11
7.17 3.85 7.67 4.37 8.79 3.90 6.17 2.83 7.79 4.76 5.75 2.71 6.02 2.92 6.20 2.71
1175.0 1175.0 1078.9 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1072.4 1175.0 1175.0 1175.0
.000 .000 .000 .000 .000 .000 .000 .005 .000 .000 .000 .007 .000 .004 .000 .007
0.41 0.33 0.44 0.37 0.50 0.33 0.36 0.24 0.45 0.41 0.33 0.23 0.35 0.25 0.36 0.23
BDHI total
36.94
10.76
SI SA
34.10 36.30
10.20 10.58
40.60 41.15
10.38 11.07
10.76 5.29
1175.0 1175.0
.000 .000
0.60 0.45
8.45 6.40
0.49 0.64
Note: CTQ denotes childhood trauma questionnaire, EPQ Eysenck personality questionnaire, BIS Barrat impulsiveness scale, BGLHA Brown–Goodwin lifetime history of aggression, and BDHI Buss–Durkee hostility inventory. a Independent-samples t-test was used, comparing mean values between the subgroup with a history of suicide ideation (+SI; N = 515; 43.8%) and the subgroup without it ( SI; N = 662; 56.2%), and between the +SA subgroup (N = 155; 13.2%) and the SA subgroup (N = 1022; 86.8%). Whenever Levene’s test showed that variances of the two subgroups differ significantly, dfs were corrected. Effect size was evaluated with Cohen’s d.
BGLHA and HDRS. Those with higher scores on BDHI – suspicion were less likely to have a history of SI.
Table 2 also shows predictors of suicide attempt. The likelihood of SA was increased in those with substance abuse and higher
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M. Sarchiapone et al. / Personality and Individual Differences 47 (2009) 250–255 Table 2 ‘‘All-variables-in” logistic regression models for predicting suicide ideation and suicide attempt.
Suicide ideation Substance abuse CTQ – emotional abuse CTQ – emotional neglect EPQ – neuroticism BGLHA HDRS BDHI – suspicion Constant Suicide attempt Psychiatric diagnosis BIS – risk taking BIS – sensory stimulation CDRISC HDRS Constant
b
SE(b)
Wald
df
p
OR
95% CI for OR
0.52 0.07 0.02
0.26 0.03 0.01
4.12 3.83 5.49
1 1 1
.042 .050 .019
1.68 1.07 1.02
1.02–2.78 1.00–1.14 1.00–1.04
0.10 0.02 0.10 0.07 4.14
0.02 0.01 0.02 0.04 0.66
21.09 4.01 39.46 4.22 39.80
1 1 1 1 1
.000 .045 .000 .040 .000
1.10 1.02 1.10 0.93 0.02
1.06–1.15 1.00–1.03 1.07–1.13 0.87–1.00
1.18 0.09 0.08
0.32 0.03 0.04
14.00 9.23 3.90
1 1 1
.000 .002 .048
3.25 1.09 0.92
1.75–6.03 1.03–1.15 0.85–1.00
0.02 0.07 3.63
0.01 0.02 0.83
4.48 16.60 19.16
1 1 1
.034 .000 .000
0.98 1.07 0.03
0.97–1.00 1.04–1.11
second component (C2, childhood trauma) correlated with all indicators of deprived upbringing that were assessed in this study, such as childhood emotional, physical, and sexual abuse and emotional and physical neglect. The third component (C3) was named sensation seeking behaviour since it showed high loadings on impulsivity, interpersonal impulsive behaviour, risk taking, sensory stimulation and extraversion. The fourth component (C4) was named Substance abuse since it showed relation to two variables – psychiatric diagnosis and substance abuse, and the majority of our subjects were substance abusers. As shown in Table 4, all components obtained from the PCA were subsequently entered into a final multivariate logistic regression model. Out of all, early life trauma was most likely to increase the likelihood of experiencing SI (OR = 2.43). Results from a similar multivariate model for predicting suicide attempt risk showed that childhood trauma again had the strongest positive predictive value (OR = 1.63), while sensation seeking behaviour was found to decrease the likelihood of attempting suicide (OR = 0.83). 4. Discussion
Note: Only statistically significant results (p < .05) are presented. OR denotes odds ratio, CI confidence interval.
scores on BIS – risk taking and HDRS, and decreased in those with higher scores on BIS – sensory stimulation and CDRISC. Features of different types of psychological and mental health patterns were explored in a PCA. Table 3 shows the resulting components. The first component (C1) was named emotional lability since it tends to be associated with psychoticism, neuroticism and various mesurements of hostility such as assault, indirect hostility, irritability, negativism, resentment, suspicion and guilt. The
The main findings of our study are: (1) in a large sample of more than a thousand male prisoners, approximately 40% reported lifetime SI and 13% had a history of SA; (2) different psychometric variables tend to associate in male prisoners. Childhood trauma, emotional lability and substance abuse seem to increase the risk of suicide ideation and suicide attempt, while sensation seeking behaviour might decrease it; (3) ideators and attempters were significantly more often single and unemployed and scored higher on scales measuring aggression, hostility, childhood trauma, depression, psychoticism and neuroticism; (4) suicide ideators and attempters scored lower on extraversion and resilience scales;
Table 3 Rotated component matrix, displaying four components solution. Exploratory variables
All-variables-in
Clear-saturation-variables-in
C1
C2
C3
C4
C1
C2
C3
C4
Psychiatric diagnosis Substance abuse CTQ – emotional abuse CTQ – physical abuse CTQ – sexual abuse CTQ – emotional neglect CTQ – physical neglect BIS – impulsivity BIS – interpersonal behaviour BIS – risk taking BIS – sensory stimulation EPQ – extraversion EPQ – psychoticism EPQ – neuroticism BDHI – assault BDHI – indirect hostility BDHI – irritability BDHI – negativism BDHI – resentment BDHI – suspicion BDHI – guilt BDHI – verbal hostility BGLHA CDRISC HDRS BIS – motor impulsivity
.164 .124 .139 .055 .119 .024 .139 .263 .072 .041 .141 .192 .415 .648 .603 .613 .739 .519 .750 .674 .518 .538 .339 .220 .325 .185
.075 .013 .818 .772 .511 .692 .747 .023 .028 .040 .143 .182 .066 .285 .082 .059 .066 .054 .122 .125 .131 .024 .455 .303 .352 .061
.074 .054 .005 .012 .067 .085 .068 .551 .591 .663 .564 .556 .098 .098 .282 .143 .194 .266 .066 .070 .179 .327 .317 .481 .250 .261
.873 .870 .049 .060 .053 .029 .055 .141 .058 .085 .063 .129 .214 .130 .214 .179 .180 .137 .034 .038 .142 .198 .271 .337 .229 .222
.194 .163 .156 .073 .132 .042 .160 .280 .063 .028 .142 .217 .454 .657 .596 .608 .745 .511 .767 .692 .517
.069 .031 .832 .792 .495 .709 .743 .002 .023 .034 .124 .160 .042 .254 .071 .059 .055 .055 .116 .117 .135
.043 .042 .003 .003 .086 .080 .052 .575 .621 .692 .623 .549 .132 .070 .272 .159 .203 .265 .060 .069 .179
.900 .913 .078 .092 .078 .022 .043 .068 .037 .072 .073 .086 .158 .107 .183 .147 .151 .124 .027 .023 .086
Variance accounted for (%) Eigenvalue
16.37 4.26
12.32 3.20
9.94 2.58
8.17 2.12
18.10 3.80
13.31 2.79
10.37 2.18
8.71 1.83
Note: Saturations above .300 are written in bold. In the first step, all variables were entered into principal components analysis. In the second step, only variables with saturation above .300 on a single component were entered into analysis. The resulting components are: C1 – emotional lability, C2 – childhood trauma, C3 – sensation seeking behaviour, and C4 – substance abuse.
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Table 4 Final multivariate logistic regression models for predicting suicide ideation and suicide attempt with four components.
Suicide ideation Emotional lability Childhood trauma Sensation seeking behaviour Substance abuse Constant Suicide attempt Emotional lability Childhood trauma Sensation seeking behaviour Substance abuse Constant
b
SE(b)
Wald
df
p
OR
95% CI for OR
0.71 0.89 0.08
0.07 0.08 0.07
94.77 110.68 1.29
1 1 1
.000 .000 .255
2.04 2.43 0.93
1.77–2.36 2.06–2.86 0.81–1.06
0.51 0.26
0.07 0.07
58.65 14.36
1 1
.000 .000
1.66 0.77
1.46–1.90
0.48 0.49 0.19
0.10 0.08 0.09
25.91 42.83 4.48
1 1 1
.000 .000 .034
1.62 1.63 0.83
1.35–1.95 1.41–1.88 0.69–0.99
0.47 2.14
0.09 0.11
25.56 419.18
1 1
.000 .000
1.60 0.12
1.34–1.93
Note: OR denotes odds ratio, CI confidence interval.
this component might be considered as ‘‘dependency”. The relationship between dependency and suicide is complex, and possibly mediated via impulsiveness and aggression. In the present study, this component almost equally predicted both SI and SA. Trémeau and colleagues studied 160 opioid-dependent subjects and found that 48% had a history of SA. They were more aggressive, impulsive and with early onset of heroin use (Trémeau et al., 2008). Previously, we reported that prisoners with substance abuse constitute a subgroup characterized by high impulsivity and aggressiveness, poor resilience and higher suicidal risk (Cuomo, Sarchiapone, Giannantonio, Mancini, & Roy, 2008). Study limitations include retrospective design and self-reported information about suicide ideation and attempts. Another limitation is that only male subjects participated in the study; thus our results may not be generalized to women. Strengths are large sample size and inclusion of many relevant personality and other psychometric tests which allowed us to comprehensively study this highly vulnerable group. 5. Conclusion
and (5) childhood trauma as a group of variables was the strongest positive predictor for SI and SA. The novelty this study brings into the field is detection of specific psychological characteristics of male prisoners and description of principles in which they tend to be associated in suicide ideators and attempters. There were four components that we managed to describe. ‘‘Emotional lability” was associated with risk factors such as neuroticism, hostility, and psychoticism. All these traits have been previously described as suicide risk factors. For example, longitudinal investigations have demonstrated associations of self-reported aggression (Angst & Clayton, 1986) and hostility (Romanov et al., 1994) with completed suicide. Christensen and Kessing (2006) support the hypothesis that neuroticism is a premorbid risk factor for developing depression, the psychiatric disorder most commonly associated with suicide (Malone, Haas, Sweeney, & Mann, 1995). In our study we managed to quantify that this component doubled the risk for SI among prisoners. The second extracted component was associated with all types of childhood trauma assessed in this study. It was shown to be the strongest predictor for SI and almost equally strong as all others when predicting SA. A link between aggressive tendencies and childhood trauma has been already established. In previous studies we reported correlations between CTQ scores, aggression and hostility in different samples of psychiatric patients (Roy, 2001, 2003, 2005; Sarchiapone, Carli, Cuomo, & Roy, 2007). Brodsky and collaborators reported that childhood abuse, impulsivity and aggression scores were associated with suicide attempts in psychiatric patients and concluded that childhood abuse may be an environmental risk factor for development of impulsivity and aggression as well as suicide attempts (Brodsky et al., 2001). The third component (sensation seeking behaviour) comprised extraversion and some patterns of impulsivity (risk taking behaviour, interpersonal impulsivity and sensory stimulation). In our study it decreased the risk for SI and SA. Extraversion and novelty seeking behaviour reflect individuals’ tendencies to take risks and alter their views. These subjects, easily found in the prison settings, poorly tolerate a monotonous mode of life, enjoy dangerous sports and show high levels of antisocial behaviour. However, these traits may protect against the development of conscious suicidal tendencies. For example, extraversion has already been described as a protective factor towards suicide (Allen et al., 2005). Finally, it could be suggested that personalities of prisoners can be adaptive and findings regarding this component might prove this. The fourth component was related to substance abuse. Putting this finding into perspective of different personality characteristics,
We succeeded in reducing a large set of psychological variables to four components of psychological proneness to suicide: emotional lability, childhood trauma, sensation seeking behaviour and substance abuse. Prisoners who are more likely to have SI are characterized by experience of childhood trauma, emotional lability and substance abuse. All these components might be present among attempters, with childhood trauma being the strongest predictor. Sensation seeking behaviour might decrease the likelihood of both ideation and attempt. Our results support previous findings that marriage and employment might protect against suicide ideation and behaviour. We believe they might add new value to evidence-based suicide prevention strategies in prisons. Acknowledgements The paper is dedicated to the memory of Andrej Marušicˇ, a leading Slovenian psychiatrist and psychologist and a visionary suicidologist who passed away on June 1, 2008. References Allen, M. H., Chessick, C. A., Miklowitz, D. J., Goldberg, J. F., Wisniewski, S. R., Miyahara, S., et al. (2005). Contributors to suicidal ideation among bipolar patients with and without a history of suicide attempts. Suicide and Life Threatening Behaviour, 35, 671–680. Angst, J., & Clayton, P. (1986). Premorbid personality of depressive, bipolar, and schizophrenic patients with special reference to suicidal issues. Comprehensive Psychiatry, 27, 511–531. Barratt, E. (1993). Impulsivity: Integrating cognitive, behavioural, biological and environmental data. In W. McCowan & M. Shure (Eds.), The impulsive client: Theory, research and treatment (pp. 39–119). Washington, DC: APA. Bernstein, D. P., Ahluvalia, T., Pogge, D., & Handelsman, L. (1997). Validity of the childhood trauma questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 340–348. Brezo, J., Paris, J., & Turecki, G. (2006). Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: A systematic review. Acta Psychiatrica Scandinavica, 113, 180–206. Brodsky, B. S., Oquendo, M., Ellis, S. P., Haas, G. L., Malone, K. M., & Mann, J. J. (2001). The relationship of childhood abuse to impulsivity and suicidal behaviour in adults with major depression. American Journal of Psychiatry, 158, 1871–1877. Brown, G. L., Goodwin, F. K., Ballenger, J. C., Goyer, P. F., & Major, L. F. (1979). Aggression in humans correlates with cerebrospinal fluid amine metabolites. Psychiatry Research, 1, 131–139. Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of hostility. Journal of Consultation Psychology, 21, 343–349. Castrogiovanni, P. (1982). Per una valutazione dell’aggressività nell’uomo: Contributo alla validazione di un questionario per la tipizzazione del comportamento aggressivo’ [Evaluation of human aggression: Contribution to the evaluation with a questionnaire which assesses aggressive behaviour]. Rivista di Psichiatria, 17, 276. Christensen, M. V., & Kessing, L. V. (2006). Do personality traits predict first onset in depressive and bipolar disorder? Nordic Journal of Psychiatry, 60, 79–88.
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Malone, K. M., Haas, G. L., Sweeney, J. A., & Mann, J. J. (1995). Major depression and the risk of attempted suicide. Journal of Affective Disorders, 34, 173–185. Marcus, P., & Alcabes, P. (1993). Characteristics of suicides by inmates in an urban jail. Hospital and Community Psychiatry, 44, 256–261. Preti, A., & Cascio, M. T. (2006). Prison suicides and self-harming behaviours in Italy, 1990–2002. Medicine, Science and the Law, 46, 127–134. Romanov, K., Hatakka, M., Keskinen, E., Laaksonen, H., Kaprio, J., Rose, R. J., et al. (1994). Self-reported hostility and suicidal acts, accidents, and accidental deaths: A prospective study of 21, 443 adults aged 25–59. Psychosomatic Medicine, 56, 328–336. Rossi, A., Alberio, R., Porta, A., Sandri, M., Tansella, M., & Amaddeo, F. (2004). The reliability of the mini-international neuropsychiatric interview – Italian version. Journal of Clinical Psychopharmacology, 24, 561–563. Roy, A. (2001). Childhood trauma and attempted suicide in alcoholics. Journal of Nervous and Mental Disorders, 189, 120–121. Roy, A. (2003). Characteristics of drug addicts who attempt suicide. Psychiatry Research, 121, 99–103. Roy, A. (2005). Reported childhood trauma and suicide attempts in schizophrenic patients. Suicide and Life Threatening Behaviour, 35, 690–693. Sarchiapone, M., Carli, V., Cuomo, C., & Roy, A. (2007). Childhood trauma and suicide attempts in patients with unipolar depression. Depression and Anxiety, 24, 268–272. Trémeau, F., Darreye, A., Staner, L., Corrêa, H., Weibel, H., Khidichian, F., et al. (2008). Suicidality in opioid-dependent subjects. American Journal of Addictions, 17, 187–194.
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Personality and Individual Differences journal homepage: www.elsevier.com/locate/paid
Relations of psychological characteristics to suicide behaviour: Results from a large sample of male prisoners M. Sarchiapone a,*, N. Jovanovic´ b, A. Roy c, A. Podlesek d, V. Carli a, M. Amore e, M. Mancini f, A. Marušicˇ g a
Faculty of Medicine, University of Molise, Loc. Tappino, 86100 Campobasso, Italy Faculty of Medicine, University of Zagreb, Psychiatric Clinic, Kispaticeva 12, Zagreb, Croatia c Psychiatry Service, Veterans Affairs Medical Center, East Orange, NJ 07018, USA d University of Ljubljana, Faculty of Arts, Department of Psychology, Askerceva 2, SI-1000 Ljubljana, Slovenia e Department of Neuroscience, Psychiatric Section, Strada del Quartiere 2/A, 43100 Parma, Italy f MAPPsi (Medici associati per la psichiatria e la psicoterapia), Lungarno Colombo 28 A, Firenze, Italy g University of Primorska, Koper, Slovenia b
a r t i c l e
i n f o
Article history: Received 23 July 2008 Received in revised form 3 March 2009 Accepted 6 March 2009 Available online 3 April 2009 Keywords: Prisoners Suicide ideation Suicide attempt Psychological characteristics Childhood trauma Emotional lability Substance abuse Sensation seeking behaviour
a b s t r a c t Aim was to investigate psychological characteristics that may predict suicide ideation and behaviour in male prisoners. Sample consisted of 1117 prisoners detained in jails of the District of Abruzzo-Molise in Italy. All underwent psychiatric interviews and comprehensive psychometric assessments related to different psychological characteristics. Principal component analysis of psychometric variables derived four components. Multivariate logistic regression was designed to test them as predictors of suicidal ideation and attempt. Main findings: (1) approximately 40% prisoners reported lifetime suicide ideation and 13% attempted suicide; (2) different psychometric variables tend to associate in male prisoners. Three of them – childhood trauma, emotional lability and substance abuse – seem to increase the risk of suicide ideation and attempt, while sensation seeking behaviour might decrease it; (3) ideators and attempters scored higher on scales measuring aggression, hostility, childhood trauma, depression, psychoticism and neuroticism, when compared to non-ideators and non-attempters; (4) suicide ideators and attempters scored lower on extraversion and resilience scales; and (5) childhood trauma was the strongest positive predictor for suicide ideation and attempt. This is the first report on psychological characteristics in a large sample of prisoners. We believe it might add new value to evidence-based suicide prevention strategies in prisons. Ó 2009 Published by Elsevier Ltd.
1. Introduction Prisoners are at increased risk for suicide ideation and attempt (Fazel & Danesh, 2002; Jenkins et al., 2005; Preti & Cascio, 2006). Previous studies detected various risk factors such as psychiatric disorders (Marcus & Alcabes, 1993), substance misuse (Roy, 2001, 2003), previous attempt (Fruehwald & Frottier, 2005; Fruehwald, Frottier, Matschnig, & Eher, 2003) and long sentences after highly violent crimes (DuRand, Burtka, Federman, Haycox, & Smith, 1995). Moreover, it has been suggested that psychological characteristics are strongly associated with suicidal behaviour and that individual personality differences might predict suicide attempts. However, no large study examining psychological profiles of suicide attempters in prisons has ever been conducted. In 2006, Brezo and co-authors analysed 90 original studies exploring different personality traits in the context of suicide ideation, attempts and
* Corresponding author. Tel.: +39 3204795630. E-mail address: [email protected] (M. Sarchiapone). 0191-8869/$ - see front matter Ó 2009 Published by Elsevier Ltd. doi:10.1016/j.paid.2009.03.008
completions (Brezo, Paris, & Turecki, 2006). They concluded that hopelessness, neuroticism and extraversion might be of greatest help when aiming to detect those at increased risk for suicide ideation or attempt. Traits such as aggression, impulsivity and social introversion may be useful in differentiating between ideators, attempters and completers. In the present study we investigated a variety of psychological characteristics, such as depression, aggression, hostility, impulsivity, psychoticism, extraversion and neuroticism, childhood trauma, diagnosis of mental disorder and substance abuse. This is the first study of such a large sample of male prisoners in which we searched for new features of psychological proneness to suicide. 2. Methodology 2.1. Participants A total of 1177 male prisoners detained in jails of the District of Abruzzo-Molise in Italy took part in the study. We included both
M. Sarchiapone et al. / Personality and Individual Differences 47 (2009) 250–255
high and low security correctional facilities. All prisoners that were present in the jails were considered eligible for the study. The only inclusion criterion was willingness to participate with a signed informed consent. Exclusion criteria were absence of sufficient linguistic abilities in Italian, inability to read, mental retardation or severe mental disorder. We studied only male prisoners since there were less than 2% of women. Age ranged between 18 and 81 (M = 39.5; SD = 10.6), the majority were single (N = 538), with completed lower secondary school (N = 674) and employed (N = 610). At each prison a list of prisoners was obtained from the Prison Register Office and all of them were consecutively informed about the study. There were 1436 subjects who were invited to participate, but 259 refused (18%). The ethics committee of the University of Molise approved the study. 2.2. Materials A specifically trained team of psychiatrists and psychologists conducted an in-depth psychiatric interview, which included the Italian version of the structured Mini International Neuropsychiatric Interview (MINI) (Conti, 1999). Outcome variables were self-reported presence or absence of lifetime suicide ideation (SI) and history of suicide attempt (SA). The first was also assessed according to the participant’s answer to the 68th item of the Eysenck personality questionnaire: ‘‘Have you ever wished that you were dead?” (Eysenck & Eysenck, 1975). In cases where the two answers were different, subjects were called for an additional interview and the final answer was entered into the database. Suicide attempt was clearly defined as a self-destructive act with some intent to end one’s life that was not self-mutilatory in nature. A DSM-IV psychiatric diagnosis was formulated upon agreement of two experienced psychiatrists (M.S. and V.C.). After collecting demographic data on marital status, education and employment, prisoners underwent comprehensive psychometric assessments. Severity of depressive symptoms was measured with the Hamilton depression rating scale (HDRS) (Hamilton, 1960), already standardised in Italian (Conti, 1999). Early traumatic experiences were evaluated with a 34-item version of the childhood trauma questionnaire (CTQ) (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997). The personality traits of psychoticism, extraversion, and neuroticism were assessed using the standardised version in Italian of the Eysenck personality questionnaire (Conti, 1999; Eysenck & Eysenck, 1975). Prisoners’ lifetime history of aggression was measured using the translated Brown–Goodwin assessment for lifetime history of aggression interview (BGLHA) (Brown, Goodwin, Ballenger, Goyer, & Major, 1979). Hostility was assessed according to the standardised Italian version of the Buss and Durkee hostility inventory (BDHI) (Buss & Durkee, 1957; Conti, 1999). In order to measure impulsive traits, we employed the Barratt impulsivity scale (BIS, 7B version) which was used to assess impulsivity as a personality trait (Barratt, 1993). The questionnaire consists of 48 statements to which subjects respond by choosing one of the following responses: rarely/never, occasionally, often, and usually. Resilience was assessed using the translated Connor–Davidson resilience scale (CDRISC) (Connor & Davidson, 2003). The MINI Interview, EPQ, HDRS and BDHI have been standardised and widely used in Italy (Castrogiovanni, 1982; Conti, 1999; Rossi et al., 2004). Other scales were adapted for the Italian population just prior to the beginning of the study. Psychometric and statistical techniques were used to establish the equivalence of the source and target language versions of the instrument. Reliability was assessed through internal consistency (Cronbach’s alphas) and the results were as follows: .76 for BDHI, .87 for BGLHA, .73 for BIS, .84 for CDRISC, .804 for HDRS, .736 for EPQ and .79 for CTQ.
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2.3. Statistical analysis Data analysis started with describing the sample’s general characteristics. Chi-square analysis was used to compare categorical variables. Means and SDs were calculated for all psychometric tests used in the study and their subscales. Comparisons of psychometric tests’ means between the study subgroups (presence/absence of SI and presence/absence of SA) were based on independent-samples t-test and effect size was assessed with Cohen’s d. Psychiatric diagnosis (yes/no), substance abuse (yes/no), scores on subscales in multidimensional tests and total scores in unidimensional tests (altogether 26 variables) were entered all at the same time into logistic regression models. Dependent variables were clearly dichotomous – presence or absence of SI and SA. Many correlations among exploratory variables were statistically significant (Keiser–Meier–Olkin measure was .836). In order to further analyse the correlates and to explore distinguishing features of different types of personality characteristics, we decided to reduce the large amount of data. Principal component analysis (PCA) using Varimax rotation was performed on all 26 exploratory variables. Rotation converged in six iterations. Scree plot suggested extraction of four to six components. Although the parallel analysis (for normally distributed random data generation) suggested a sixcomponent solution, we decided to extract four components because the structure was simpler and more interpretable. The four components together explained 46.8% of the variance. Four variables, which loaded more than .30 on two components or more, and one variable with loadings lower than .30, were excluded from further analysis. The PCA was rerun on the remaining variables, resulting in a clear four-component solution explaining 50.5% of the variance. Component scores were used as independent variables when creating two logistic regression models – one for the presence of SI and another for the presence of SA.
3. Results A total of 515 participants (43.8%) reported having suicide ideation, while 155 (13.2%) attempted suicide at some point in their lives. There were no age and education differences between them. Attempters differed from non-attempters in marital status, v2(3) = 10.08, p = .018; the percentage of married, divorced, single, and widowed participants was 27.5, 17.4, 51.0 and 4.0 among attempters. The two subgroups also differed in employment status, v2(2) = 23.27, p = .000; the percentage of unemployed, employed, and retired was 44.0, 40.7 and 15.3 among attempters. Similar differences were found between the subgroups according to SI. They differed in marital status, v2(3) = 27.96, p = .000 as the percentage of married, divorced, single and widowed ideators was 28.9, 14.6, 54.3 and 2.2. The difference between the two subgroups in employment status was significant, v2(2) = 42.28, p = .000. In ideators the percentage of unemployed, employed and retired was 46.5, 43.6 and 9.8. Mean values of psychometric tests used in the study are shown in Table 1. Since there are no normative values for most of these scales, we decided to show all our results. We found that participants with SA, when compared to those without a history of SA, scored significantly higher on all scales, except extraversion, resilience and interpersonal impulsive behaviour. Similar results were found regarding suicide ideators. They scored higher on all scales but extraversion and resilience. In an attempt to find variables that might predict suicide ideation, we created an ‘‘all-variables-in” logistic regression model. Results are shown in Table 2. Participants who were more likely to have SI were substance abusers (OR = 1.68) and scored higher on CTQ – emotional abuse, CTQ – emotional neglect, EPQ – neuroticism,
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M. Sarchiapone et al. / Personality and Individual Differences 47 (2009) 250–255
Table 1 Means and standard deviations of scores on psychometric tests used in the study and the differences between the subgroups with different history of suicide attempt (SA) and suicide ideation (SI). All participants
Statistical testa
Dependent variable
Absent
Present
M
SD
M
SD
df
p
d
SI SA SI SA SI SA SI SA SI SA
6.11 6.83 6.26 7.01 7.18 7.44 20.39 21.89 11.41 12.25
2.19 3.19 2.61 3.70 2.28 2.75 8.05 8.83 3.74 4.40
8.39 8.93 8.61 9.15 8.06 8.35 25.11 26.21 14.11 14.89
4.36 4.76 5.08 5.59 3.70 4.31 10.24 11.69 5.59 6.58
10.84 5.31 9.54 4.63 4.77 2.56 8.59 4.42 9.46 4.84
713.4 175.5 723.0 174.9 807.1 173.5 955.3 181.6 853.4 175.5
.000 .000 .000 .000 .000 .011 .000 .000 .000 .000
0.65 0.60 0.58 0.53 0.29 0.30 0.50 0.46 0.56 0.55
754.4 171.4
.000 .000
0.71 0.67
M
SD
CTQ – emotional abuse
7.11
3.51
t
CTQ – physical abuse
7.29
4.06
CTQ – sexual abuse
7.56
3.02
CTQ – emotional neglect
22.46
9.37
CTQ – physical neglect
12.59
4.83
CTQ total
7.96
2.64
SI SA
7.14 7.73
1.75 2.32
9.02 9.49
3.16 3.84
12.16 5.57
EPQ – psychoticism
5.61
3.13
EPQ – extraversion
13.54
3.66
EPQ – neuroticism
12.01
4.73
SI SA SI SA SI SA
5.16 5.46 14.07 13.78 10.35 11.60
3.02 3.08 3.36 3.54 4.30 4.61
6.19 6.59 12.86 11.95 14.15 14.75
3.16 3.26 3.92 4.07 4.38 4.55
5.64 5.64 5.59 5.29 14.90 14.90
1175.0 1175.0 1011.8 191.0 1175.0 1175.0
.000 .000 .000 .000 .000 .000
0.33 0.36 0.33 0.50 0.80 0.67
BIS – impulsivity self-assessment
17.77
7.61
BIS – interpersonal behaviour
5.54
3.54
BIS – motor impulsivity
10.48
5.20
BIS – risk taking
8.85
4.19
BIS – sensory stimulation
4.79
2.66
SI SA SI SA SI SA SI SA SI SA
17.42 17.71 5.42 5.58 10.13 10.41 8.84 8.81 4.58 4.79
7.32 7.55 3.49 3.53 5.16 5.19 4.24 4.16 2.62 2.63
18.23 18.17 5.71 5.28 10.94 10.95 8.85 9.11 5.06 4.84
7.96 8.04 3.58 3.55 5.21 5.22 4.12 4.38 2.70 2.85
1.78 0.66 1.41 0.99 2.67 1.21 0.02 0.84 3.08 0.23
1056.7 197.4 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0
.076 .510 .160 .325 .008 .225 .987 .401 .002 .821
0.11 0.06 0.08 0.08 0.16 0.10 0.00 0.07 0.18 0.02
BIS total
47.44
14.80
SI SA
46.39 47.30
14.28 14.57
48.79 48.35
15.36 16.28
2.76 0.82
1175.0 1175.0
.006 .410
0.16 0.07
BGLHA
36.12
11.38
SI SA
33.11 35.27
10.00 11.02
39.99 41.71
11.86 12.12
10.56 6.69
1001.7 1175.0
.000 .000
0.60 0.57
Connor–Davidson resilience scale
64.99
14.05
SI SA
68.02 66.18
12.47 13.18
61.09 57.14
14.98 16.83
992.9 183.8
.000 .000
Hamilton depression scale
7.86
6.62
SI SA
5.57 7.02
4.83 5.98
10.81 13.40
7.40 7.87
13.95 9.68
840.2 182.0
.000 .000
0.79 0.96
BDHI – assault
5.01
2.15
BDHI – indirect
4.17
1.96
BDHI – irritability
4.54
2.22
BDHI – negativism
3.19
1.30
BDHI – resentment
3.64
1.70
BDHI – suspicion
4.86
2.43
BDHI – verbal
6.69
2.37
BDHI – guilt
4.85
2.13
SI SA SI SA SI SA SI SA SI SA SI SA SI SA SI SA
4.62 4.92 3.79 4.07 4.05 4.44 2.99 3.15 3.31 3.55 4.50 4.78 6.33 6.61 4.51 4.78
2.11 2.15 1.87 1.93 2.16 2.19 1.31 1.30 1.64 1.68 2.42 2.41 2.27 2.35 2.04 2.13
5.51 5.63 4.66 4.81 5.16 5.18 3.45 3.46 4.07 4.25 5.31 5.35 7.16 7.21 5.28 5.28
2.10 2.04 1.96 2.04 2.15 2.33 1.24 1.26 1.68 1.72 2.37 2.54 2.41 2.45 2.18 2.11
7.17 3.85 7.67 4.37 8.79 3.90 6.17 2.83 7.79 4.76 5.75 2.71 6.02 2.92 6.20 2.71
1175.0 1175.0 1078.9 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1175.0 1072.4 1175.0 1175.0 1175.0
.000 .000 .000 .000 .000 .000 .000 .005 .000 .000 .000 .007 .000 .004 .000 .007
0.41 0.33 0.44 0.37 0.50 0.33 0.36 0.24 0.45 0.41 0.33 0.23 0.35 0.25 0.36 0.23
BDHI total
36.94
10.76
SI SA
34.10 36.30
10.20 10.58
40.60 41.15
10.38 11.07
10.76 5.29
1175.0 1175.0
.000 .000
0.60 0.45
8.45 6.40
0.49 0.64
Note: CTQ denotes childhood trauma questionnaire, EPQ Eysenck personality questionnaire, BIS Barrat impulsiveness scale, BGLHA Brown–Goodwin lifetime history of aggression, and BDHI Buss–Durkee hostility inventory. a Independent-samples t-test was used, comparing mean values between the subgroup with a history of suicide ideation (+SI; N = 515; 43.8%) and the subgroup without it ( SI; N = 662; 56.2%), and between the +SA subgroup (N = 155; 13.2%) and the SA subgroup (N = 1022; 86.8%). Whenever Levene’s test showed that variances of the two subgroups differ significantly, dfs were corrected. Effect size was evaluated with Cohen’s d.
BGLHA and HDRS. Those with higher scores on BDHI – suspicion were less likely to have a history of SI.
Table 2 also shows predictors of suicide attempt. The likelihood of SA was increased in those with substance abuse and higher
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M. Sarchiapone et al. / Personality and Individual Differences 47 (2009) 250–255 Table 2 ‘‘All-variables-in” logistic regression models for predicting suicide ideation and suicide attempt.
Suicide ideation Substance abuse CTQ – emotional abuse CTQ – emotional neglect EPQ – neuroticism BGLHA HDRS BDHI – suspicion Constant Suicide attempt Psychiatric diagnosis BIS – risk taking BIS – sensory stimulation CDRISC HDRS Constant
b
SE(b)
Wald
df
p
OR
95% CI for OR
0.52 0.07 0.02
0.26 0.03 0.01
4.12 3.83 5.49
1 1 1
.042 .050 .019
1.68 1.07 1.02
1.02–2.78 1.00–1.14 1.00–1.04
0.10 0.02 0.10 0.07 4.14
0.02 0.01 0.02 0.04 0.66
21.09 4.01 39.46 4.22 39.80
1 1 1 1 1
.000 .045 .000 .040 .000
1.10 1.02 1.10 0.93 0.02
1.06–1.15 1.00–1.03 1.07–1.13 0.87–1.00
1.18 0.09 0.08
0.32 0.03 0.04
14.00 9.23 3.90
1 1 1
.000 .002 .048
3.25 1.09 0.92
1.75–6.03 1.03–1.15 0.85–1.00
0.02 0.07 3.63
0.01 0.02 0.83
4.48 16.60 19.16
1 1 1
.034 .000 .000
0.98 1.07 0.03
0.97–1.00 1.04–1.11
second component (C2, childhood trauma) correlated with all indicators of deprived upbringing that were assessed in this study, such as childhood emotional, physical, and sexual abuse and emotional and physical neglect. The third component (C3) was named sensation seeking behaviour since it showed high loadings on impulsivity, interpersonal impulsive behaviour, risk taking, sensory stimulation and extraversion. The fourth component (C4) was named Substance abuse since it showed relation to two variables – psychiatric diagnosis and substance abuse, and the majority of our subjects were substance abusers. As shown in Table 4, all components obtained from the PCA were subsequently entered into a final multivariate logistic regression model. Out of all, early life trauma was most likely to increase the likelihood of experiencing SI (OR = 2.43). Results from a similar multivariate model for predicting suicide attempt risk showed that childhood trauma again had the strongest positive predictive value (OR = 1.63), while sensation seeking behaviour was found to decrease the likelihood of attempting suicide (OR = 0.83). 4. Discussion
Note: Only statistically significant results (p < .05) are presented. OR denotes odds ratio, CI confidence interval.
scores on BIS – risk taking and HDRS, and decreased in those with higher scores on BIS – sensory stimulation and CDRISC. Features of different types of psychological and mental health patterns were explored in a PCA. Table 3 shows the resulting components. The first component (C1) was named emotional lability since it tends to be associated with psychoticism, neuroticism and various mesurements of hostility such as assault, indirect hostility, irritability, negativism, resentment, suspicion and guilt. The
The main findings of our study are: (1) in a large sample of more than a thousand male prisoners, approximately 40% reported lifetime SI and 13% had a history of SA; (2) different psychometric variables tend to associate in male prisoners. Childhood trauma, emotional lability and substance abuse seem to increase the risk of suicide ideation and suicide attempt, while sensation seeking behaviour might decrease it; (3) ideators and attempters were significantly more often single and unemployed and scored higher on scales measuring aggression, hostility, childhood trauma, depression, psychoticism and neuroticism; (4) suicide ideators and attempters scored lower on extraversion and resilience scales;
Table 3 Rotated component matrix, displaying four components solution. Exploratory variables
All-variables-in
Clear-saturation-variables-in
C1
C2
C3
C4
C1
C2
C3
C4
Psychiatric diagnosis Substance abuse CTQ – emotional abuse CTQ – physical abuse CTQ – sexual abuse CTQ – emotional neglect CTQ – physical neglect BIS – impulsivity BIS – interpersonal behaviour BIS – risk taking BIS – sensory stimulation EPQ – extraversion EPQ – psychoticism EPQ – neuroticism BDHI – assault BDHI – indirect hostility BDHI – irritability BDHI – negativism BDHI – resentment BDHI – suspicion BDHI – guilt BDHI – verbal hostility BGLHA CDRISC HDRS BIS – motor impulsivity
.164 .124 .139 .055 .119 .024 .139 .263 .072 .041 .141 .192 .415 .648 .603 .613 .739 .519 .750 .674 .518 .538 .339 .220 .325 .185
.075 .013 .818 .772 .511 .692 .747 .023 .028 .040 .143 .182 .066 .285 .082 .059 .066 .054 .122 .125 .131 .024 .455 .303 .352 .061
.074 .054 .005 .012 .067 .085 .068 .551 .591 .663 .564 .556 .098 .098 .282 .143 .194 .266 .066 .070 .179 .327 .317 .481 .250 .261
.873 .870 .049 .060 .053 .029 .055 .141 .058 .085 .063 .129 .214 .130 .214 .179 .180 .137 .034 .038 .142 .198 .271 .337 .229 .222
.194 .163 .156 .073 .132 .042 .160 .280 .063 .028 .142 .217 .454 .657 .596 .608 .745 .511 .767 .692 .517
.069 .031 .832 .792 .495 .709 .743 .002 .023 .034 .124 .160 .042 .254 .071 .059 .055 .055 .116 .117 .135
.043 .042 .003 .003 .086 .080 .052 .575 .621 .692 .623 .549 .132 .070 .272 .159 .203 .265 .060 .069 .179
.900 .913 .078 .092 .078 .022 .043 .068 .037 .072 .073 .086 .158 .107 .183 .147 .151 .124 .027 .023 .086
Variance accounted for (%) Eigenvalue
16.37 4.26
12.32 3.20
9.94 2.58
8.17 2.12
18.10 3.80
13.31 2.79
10.37 2.18
8.71 1.83
Note: Saturations above .300 are written in bold. In the first step, all variables were entered into principal components analysis. In the second step, only variables with saturation above .300 on a single component were entered into analysis. The resulting components are: C1 – emotional lability, C2 – childhood trauma, C3 – sensation seeking behaviour, and C4 – substance abuse.
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Table 4 Final multivariate logistic regression models for predicting suicide ideation and suicide attempt with four components.
Suicide ideation Emotional lability Childhood trauma Sensation seeking behaviour Substance abuse Constant Suicide attempt Emotional lability Childhood trauma Sensation seeking behaviour Substance abuse Constant
b
SE(b)
Wald
df
p
OR
95% CI for OR
0.71 0.89 0.08
0.07 0.08 0.07
94.77 110.68 1.29
1 1 1
.000 .000 .255
2.04 2.43 0.93
1.77–2.36 2.06–2.86 0.81–1.06
0.51 0.26
0.07 0.07
58.65 14.36
1 1
.000 .000
1.66 0.77
1.46–1.90
0.48 0.49 0.19
0.10 0.08 0.09
25.91 42.83 4.48
1 1 1
.000 .000 .034
1.62 1.63 0.83
1.35–1.95 1.41–1.88 0.69–0.99
0.47 2.14
0.09 0.11
25.56 419.18
1 1
.000 .000
1.60 0.12
1.34–1.93
Note: OR denotes odds ratio, CI confidence interval.
this component might be considered as ‘‘dependency”. The relationship between dependency and suicide is complex, and possibly mediated via impulsiveness and aggression. In the present study, this component almost equally predicted both SI and SA. Trémeau and colleagues studied 160 opioid-dependent subjects and found that 48% had a history of SA. They were more aggressive, impulsive and with early onset of heroin use (Trémeau et al., 2008). Previously, we reported that prisoners with substance abuse constitute a subgroup characterized by high impulsivity and aggressiveness, poor resilience and higher suicidal risk (Cuomo, Sarchiapone, Giannantonio, Mancini, & Roy, 2008). Study limitations include retrospective design and self-reported information about suicide ideation and attempts. Another limitation is that only male subjects participated in the study; thus our results may not be generalized to women. Strengths are large sample size and inclusion of many relevant personality and other psychometric tests which allowed us to comprehensively study this highly vulnerable group. 5. Conclusion
and (5) childhood trauma as a group of variables was the strongest positive predictor for SI and SA. The novelty this study brings into the field is detection of specific psychological characteristics of male prisoners and description of principles in which they tend to be associated in suicide ideators and attempters. There were four components that we managed to describe. ‘‘Emotional lability” was associated with risk factors such as neuroticism, hostility, and psychoticism. All these traits have been previously described as suicide risk factors. For example, longitudinal investigations have demonstrated associations of self-reported aggression (Angst & Clayton, 1986) and hostility (Romanov et al., 1994) with completed suicide. Christensen and Kessing (2006) support the hypothesis that neuroticism is a premorbid risk factor for developing depression, the psychiatric disorder most commonly associated with suicide (Malone, Haas, Sweeney, & Mann, 1995). In our study we managed to quantify that this component doubled the risk for SI among prisoners. The second extracted component was associated with all types of childhood trauma assessed in this study. It was shown to be the strongest predictor for SI and almost equally strong as all others when predicting SA. A link between aggressive tendencies and childhood trauma has been already established. In previous studies we reported correlations between CTQ scores, aggression and hostility in different samples of psychiatric patients (Roy, 2001, 2003, 2005; Sarchiapone, Carli, Cuomo, & Roy, 2007). Brodsky and collaborators reported that childhood abuse, impulsivity and aggression scores were associated with suicide attempts in psychiatric patients and concluded that childhood abuse may be an environmental risk factor for development of impulsivity and aggression as well as suicide attempts (Brodsky et al., 2001). The third component (sensation seeking behaviour) comprised extraversion and some patterns of impulsivity (risk taking behaviour, interpersonal impulsivity and sensory stimulation). In our study it decreased the risk for SI and SA. Extraversion and novelty seeking behaviour reflect individuals’ tendencies to take risks and alter their views. These subjects, easily found in the prison settings, poorly tolerate a monotonous mode of life, enjoy dangerous sports and show high levels of antisocial behaviour. However, these traits may protect against the development of conscious suicidal tendencies. For example, extraversion has already been described as a protective factor towards suicide (Allen et al., 2005). Finally, it could be suggested that personalities of prisoners can be adaptive and findings regarding this component might prove this. The fourth component was related to substance abuse. Putting this finding into perspective of different personality characteristics,
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