State and Trait Anxiety in Adolescent Suicide Attempters

State and Trait Anxiety in Adolescent Suicide Attempters RICHARD OHRING, M.S., ALAN APTER, M.D., GIDEON RATZONI, M.D., RONIT WEIZMAN, M.D., SAM TYANO, M.D., AND ROBERT PLUTCHIK, PH.D.

ABSTRACT Objective: To examine the relationship between anxiety and suicidal behavior in adolescents. Method: Forty-six adolescents who had been hospitalized in an inpatient psychiatric unit after a suicide attempt were compared on measures of anxiety and depression with 72 adolescent psychiatric inpatients who had no history of suicide attempts. Results: The suicide attempters exhibited significantly higher levels of both state and trait anxiety. However, when controlling for depression, the attempters did not differ in their level of state anxiety from the nonattempters, but they still manifested significantly higher levels of trait anxiety than nonattempters. Conclusions: The results suggest that anxiety, both state and trait, is a risk factor for suicidal behavior in adolescents. Yet, only trait anxiety appears to be relatively independent of depression in its effect on suicidal behavior risk. These findings imply that clinicians should take into account anxiety, both state and trait, for assessment and treatment of adolescents at risk for suicidal behavior. J. Am. Acad. Child Adolesc. Psychiafry, 1996, 35(2):154-157. Key Words: suicide attempt, state anxiety, trait anxi-

ety, adolescent.

Suicidal behavior is a significant mental health problem among adolescents. A high and rising rate of adolescent suicide prevails throughout much of the industrialized world, and suicide is a leading cause of death in this otherwise healthy age group. For example, between 1980 and 1986, suicide rates among 15- to 19-yearolds increased by 20% (Meehan et al., 1991). Attempted suicide is also a serious health problem. In England, the highest rates of hospitalization because of an attempted suicide are found in women aged 15 through 19 and in men aged 20 through 34 years. Meehan et al. (1992) surveyed first-year students in an American university. Of 694 respondents, 10% reported an episode of attempted suicide, and 5% stated that they had suffered injury or illness as a result. Recently, anxiety has been identified as an important risk factor for suicidal behavior in adults. A follow-up study of patients with major affective disorder (Fawcett

Accepted April I I , 1995. From the Department of Children and Adolescents, Geha Hospital, Beilinson Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Israel. Dr. Plutchik is with the Department of Psychiaq, Albert Einstein CoLege of Medicine and Montefiore Medical Center, Bronx, NY Reprint requests to Dr. Apter, Geha Hospital, Beilinson Medical Center, P.O. Box 102, Petah Tikva, Israel 49100. 0890-8567/96/3502-0 154$03.00/00 1996 by the American Academy of Child and Adolescent Psychiatry.

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et al., 1990) found that anxiety symptoms were strongly related to completed suicide within 1 year of assessment. There have also been studies that indicate that anxiety disorders are associated with an increased risk of suicidal behavior (Allgulander and Lavori, 1991; Mannuzza et al., 1992; Massion et al., 1993; Weissman et al., 1989). Studies with adolescents have shown mixed results. Taylor and Stansfield (1984) found that suicide attempters, in comparison with psychiatric outpatients, exhibited higher levels of anxiety (38% versus 22%). Yet this difference was not significant. Another study (Kosky et al., 1986) reported that depressed suicidal ideators (of whom 39% had attempted suicide) manifested high levels of anxiety (76.4%), but these levels were not significantly different from those of depressed nonsuicidal adolescents. Bettes and Walker (1986) found in a large sample of disturbed youths (inpatients and outpatients) that male adolescents who expressed suicidal thoughts in the absence of acts were more likely to be rated as anxious than were suicide attempters. The authors interpreted this finding by suggesting that engaging in suicidal acts may serve to reduce symptoms, and this might account for the lower rate of anxiety among males who engage in such acts. Consistent with the above, Andrews and Lewinsohn (1992) found a significant association between anxiety disorders and

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suicide attemms in males, but not in females, in a large community sample of adolescents. Most research on anxiety as a risk factor for suicidal behavior has focused on the measurement of state anxiety, that is, anxiety as it is assessedat a given point in time. This may not be a method if State anxiety is siEnificantly reduced after a suicide attempt. ” Ideally, risk factors used for predictive purposes should be stable (Hawton, l987). As such, research On the relationship between anxiety and suicidal behavior might benefit by focusing on the measurement of anxiety as a trait rather than as a state. In fact, recently, Apter and colleagues (1990, 1993) found that adult psychiatric inpatient suicide attempters had significantly higher levels of trait anxiety than inpatient nonattempters, whereas state anxiety did not discriminate between the two groups. Moreover, trait anxiety was highly associated with a self-report scale of suicide risk. The purpose of the present study is to extend previous research on adult inpatients to adolescent inpatients to determine whether there are age continuities in the relationship between trait anxiety and suicidal behavior across the developmental spectrum. In addition, since anxiety and depression have been shown to be closely linked in 50% to 70% of patients with major depression manifesting severe anxiety symptoms (Stein and Uhde, 1988), and since many studies have identified depression as a risk factor for suicidal behavior in adolescents (Andrews and Lewinsohn, 1992; Myers et al., 1991), the extent to which anxiety is mediated by levels of depression will also be investigated. Finally, since previous studies (Andrews and Lewinsohn, 1992; Bettes and Walker, 1986) have found anxiety to be associated with suicidal behavior only in males, gender differences will be examined.

METHOD Subjects Forty-six adolescents (32 female, 14 male) who had been hospitalized after a suicide attempt were recruited from consecutive admissions to the inpatient adolescent unit at Geha Psychiatric Hospital in Petach Tikvah, Israel, which is affiliated with Tel Aviv University. Their ages ranged from 12 to 19 years, with a mean age of 15.67 years (SD = 1.45). A DSM-iii-R diagnosis was assigned by a child psychiatrist and confirmed in a staff meeting. Diagnoses included conduct disorder (26), schizophrenia (5), affective disorder (5), eating disorder ( 8 ) ,anxiety disorder ( I ) , and Tourette’s disorder (1).

I.

The psychiatric control group of 72 adolescents (26 female, 46 male) was recruited from consecutive admissions to the same inpatient unit as were the suicide attempters. None of the patients in the control group - - were admitted after a suicide attempt, nor did any have a previous history of suicide attempts. Their ages ranged from 12 to 21 years, with a mean age of 16.26 years (SD = 2.09). Diagnoses were conduct disorder (40), schizophrenia (13), affective disorder (9), eating disorder (2), anxiety disorder (2), Tourette’s disorder (4), and -mental retardation (2). All patients were Caucasian and Jewish. Ninety percent of the patients were from a middle-class background, which represents the usual distribution for our Datient DoDulation. I

I

Measures State-Trait Anxiety Invent0y. The State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1970) has been used extensively in research with both adults and adolescents. The STAI consists of separate 20-item self-report rating scales for measuring state and trait anxiety. The State Anxiety scale requires people to describe how they feel right now, that is, at this moment. State anxiety scores increase in response to situational stress and decline under relaxed conditions. Examples of items are: “I find myself worrying about something,” and “I am calm.” The Trait Anxiety scale asks people to describe how they generally feel. Trait anxiety scores reflect relatively stable individual differences in anxiety proneness that are impervious to situational stress. Examples of items are: “I worry too much over something that really doesn’t matter,” and ‘‘I take disappointments so keenly that I can’t put them out of my mind.” The items are rated on a Likert scale of 1 to 4. The STAI has demonstrated high internal consistency and high testretest reliability (Spielberger et al., 1970). Beck Depression invenroy. The Beck Depression Inventory (BDI) (Beck et al., 1961) is a 21-item self-report instrument designed to measure the severity of depression in adults and adolescents. The frequency of depressive symptoms is rated on a 4-poinr Likert scale ranging from 0 to 3. The BDI has demonstrated high internal consistency and high test-retest reliability (Beck and Steer, 1987).

Procedure The two inventories were administered to all subjects as part of a comprehensive assessment battery, which was conducted within the first 2 weeks of their admission to the unit. The battery was administered to each subject in an individual session, with a clinician present in the room, to explain and help with any problems that might arise.

RESULTS

Analyses were conducted in order to evaluate differences between the suicide attempters and nonattempters on age and gender. There was no significant age difference between the groups. However, suicide attempters were more likely to be female than were nonattempters (69.6% versus 36.1%), ~ ’ ( 1 )= 12.57, p < .0005. The group means on the STAI and BDI can be found in Table 1. A two-way analysis of variance (ANOVA) was conducted to examine group and gender

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O H R I N G ET A L .

TABLE 1

TABLE 2

Means and Standard Deviations of Self-Report Measures across Groups

Correlations among Dependent Measures

Attempters ( n = 46) Measure STAI-State Mean SD STAI-Trait Mean SD BDI Mean SD

Measure

Nonattempters ( n = 72) Male Female ( n = 46) ( n = 26)

Male ( n = 14)

Female ( n = 32)

55.07 13.01

56.63 16.80

42.85 17.60

53.96 16.39

53.50 14.41

53.97 16.45

40.65 14.42

47.92 13.08

44.0 13.43

47.94 17.01

34.22 12.53

40.24 15.83

Note: STAI = State-Trait Anxiety Inventory; BDI sion Inventory.

=

2

3

1. STAI-State

2. STAI-Trait 3. BDI Note: STAI = State-Trait Anxiety Inventory; BDI sion Inventory.

=

Beck Depres-

* p < ,001.

DISCUSSION

Beck Depres-

differences on the State Anxiety scale of the STAI. Suicide attempters had significantly higher state anxiety scores than nonattempters, F(1,114) = 4.85, p < .04. There was no main effect of gender on state anxiety, and the interaction between group and gender on state anxiety scores was not significant. T o examine group and gender differences on the Trait Anxiety scale of the STAI, another two-way ANOVA was conducted. Suicide attempters had significantly higher trait anxiety scores than nonattempters, F(1,114) = 8.92, p < .004. There was no main effect of gender on trait anxiety, and the interaction between group and gender on trait anxiety scores was not significant. A third two-way ANOVA was conducted to examine group and gender differences on the BDI. Suicide attempters had higher BDI scores than nonattempters, F(1,113) = 8.61, p < .005. There was no main effect of gender on depression, and the interaction between group and gender on depression scores was not significant. Since state and trait anxiety were highly correlated with depression (Table 2), the above findings of group differences in state and trait anxiety could possibly be explained by the severity of depressive symptoms. T o control for this possibility, an analysis of covariance was conducted. When controlling for depression, attempters did not differ from nonattempters on their state anxiety scores, whereas attempters still had significantly higher trait anxiety scores than nonattempters, F(1,112) = 4.05, p < .05.

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1

The results of this study provide further support for the relationship between anxiety and suicidal behavior. Adolescent suicide attempters reported significantly higher levels of trait anxiety than did nonattempters in an inpatient sample. These findings are consistent with a study that investigated adult inpatients (Apter et al., 1990, 1993), suggesting that there are age continuities in the relationship between anxiety and suicidal behavior across the developmental spectrum. These results are also consistent with a recent study (De Wilde et al., 1993), which found that adolescent suicide attempters exhibited significantly higher levels of trait anxiety than did nondepressed nonattempters. In the present study trait anxiety was still associated with suicidal behavior when controlling for depression (whereas state anxiety was not). This suggests that trait anxiety is relatively independent of depression in its effect on suicidal behavior. It is interesting that in De Wilde and coworkers' (1993) study attempters did not differ from depressed nonattempters on levels of trait anxiety and depression. However, all eight adolescents (three depressed nonattempters and five attempters) who made a suicide attempt during a 1-year followup had exhibited higher than normal levels of trait anxiety at the initial assessment. It appears that the comorbidity of anxiety and depression has a cumulative effect on suicide risk. With regard to gender, there were no significant differences. Male and female adolescent suicide attempters exhibited an elevated level of state and trait anxiety. This finding does not support the notion advanced by Bettes and Walker (1986) that anxiety is associated with suicidal behavior only in male adolescents. These inconsistent findings may be due to sampling differences (Bettes and Walker used both inpatients and outpatients), measurement differences

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(Bettes and Walker used a nonstandardized measure to assess anxiety), or cultural differences (Americans versus Israelis). The significant relationship found between trait anxiety and suicidal behavior can be examined within the framework of a two-stage model of suicidal and violent behavior (Plutchik et al., 1989). Within this model, Apter et al. (1993) proposed that trait anxiety acts in stage two of the model as an amplifier of inwardly directed aggression. Our results are consistent with this notion in that trait anxiety appears to be an amplifier of suicide risk. This model is helpful because it provides a context for the integration of relevant variables from a number of different viewpoints. A note on the limitations of our study: It is not clear how generalizable the results are to other cultures and to noninpatient populations. Cross-cultural studies, as well as investigations with outpatient and community samples, are needed. Also, our sample of male attempters was small. Further research with larger samples is warranted. Furthermore, this was a retrospective study. Prospective studies are needed to validate the findings. Finally, we would like to mention a number of clinical applications of our findings for diagnosis and treatment. With regard to assessment of suicide risk in adolescents, it is important to consider the level of anxiety, both state and trait, as one possible risk factor of suicidal behavior. Clinicians should be aware that even if a patient is not exhibiting a high level of state anxiety, his or her level of trait anxiety may still be high. This underscores the importance of assessing trait anxiety when evaluating suicide risk. Concerning treatment, our results imply that any effort made to reduce anxiety should have a beneficial effect on reducing suicidal behavior in adolescents. This is relevant for the treatment of patients through psychopharmacological as well as psychotherapeutic interventions.

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