Misclassification of Self-Directed Violence.

Background: Classification of acts of self-directed violence has been shown to be inadequate in past research. Furthermore, level of expertise have been shown to be unrelated to classification correctness. Aim: The aim of the present study was to investigate whether participants provided with a definition are more reliable in their judgment than participants without a definition. Method: Two hundred sixty-one participants (psychology students, psychotherapists-in-training) were presented with case vignettes describing different acts of self-directed violence and were asked to make a classification. On the basis of randomized allocation, half of the participants received a definition of the different acts of self-directed violence, whereas the others did not. Results: Overall, 24.9% of the cases were misclassified. The presentation of a definition was not accompanied by a higher classification accuracy. Limitations: There may be issues about the validity of the case vignettes. Conclusions: The results highlight the importance of more methodological training of psychologists regarding suicidal issues.

Psychotherapists' Knowledge of Guideline Recommendations for the Treatment of Depressed Suicidal Patients.

Objective: Clinical practice guidelines present expert consensus on the treatment of mental disorders. Yet, studies have shown that knowledge of and adherence to recommendations are moderate. The aim of the present study was to investigate, whether and to what extent psychotherapists are aware of and follow the German guideline recommendations for the treatment of suicidal depressed patients. Methods: 174 participants (licensed psychotherapists, psychotherapists-in-training) were presented with five groups of guideline recommendations (referring to inpatient admission, psychotherapy, acute pharmacotherapy, pharmacologic relapse prevention, follow-up appointments) and were asked to identify the guideline recommendation and indicate whether they provided treatment according to the guideline. Results: Knowledge and adherence to the guidelines recommendations on psychotherapy and inpatient admission were well present. However, knowledge about pharmacological treatment recommendations was low; same as the knowledge on the necessity of immediate follow-up appointments after discharge of patients hospitalized due to suicidality. Discussion: The results highlight the importance of greater dissemination of various facts about the management of suicidal patients.

The Effects of Modifying Dysfunctional Appraisals in Posttraumatic Stress Disorder Using a Form of Cognitive Bias Modification: Results of a Randomized Controlled Trial in an Inpatient Setting.

INTRODUCTION: Dysfunctional appraisals about traumatic events and their sequelae are a key mechanism in posttraumatic stress disorder (PTSD). Experimental studies have shown that a computerized cognitive training, cognitive bias modification for appraisals (CBM-APP), can modify dysfunctional appraisals and reduce analogue trauma symptoms amongst healthy and subclinical volunteers. OBJECTIVE: We aimed to test whether CBM-APP could reduce dysfunctional appraisals related to trauma reactions in PTSD patients, and whether this would lead to improvements in PTSD symptoms. METHODS: We compared CBM-APP to sham training in a parallel-arm proof-of-principle double-blind randomized controlled trial amongst 80 PTSD patients admitted to an inpatient clinic. Both arms comprised a training schedule of 8 sessions over a 2-week period and were completed as an adjunct to the standard treatment programme. RESULTS: In intention-to-treat analyses, participants receiving CBM-APP showed a greater reduction in dysfunctional appraisals on a scenario task from pre- to posttraining (primary outcome) assessments, compared to those receiving sham training (d = 1.30, 95% CI 0.82-1.80), with between-group differences also found on the Posttraumatic Cognitions Inventory (PTCI; d = 0.85, 95% CI 0.39-1.32) and the PTSD Checklist for DSM-5 (PCL-5; d = 0.68, 95% CI 0.23-1.14), but not for long-term cortisol concentrations (d = 0.25, 95% CI -0.28 to 0.78). Reductions in dysfunctional appraisals assessed via the scenario task correlated with reductions on the PTCI, PCL-5, and hair cortisol concentrations from pre- to posttraining time points. CONCLUSIONS: Results support dysfunctional appraisals as a modifiable cognitive mechanism, and that their proximal modification transfers to downstream PTSD symptoms. These findings could open new avenues for improving present therapeutic approaches.

Associations Between Difficulties in Emotion Regulation and Post-Traumatic Stress Disorder in Deployed Service Members of the German Armed Forces.

BACKGROUND: Experiencing a traumatic event can lead to post-traumatic stress disorder (PTSD), but not every traumatized person develops PTSD. Several protective and risk factors have been identified in civilians and veterans to explain why some individuals develop PTSD and others do not. However, no research has confirmed the relationship between emotion regulation and PTSD in deployed German Armed Forces service members after a foreign assignment. Previous studies have identified some protective factors, such as social support, social acknowledgment, specific personal values, and posttraumatic growth, as well as risk factors, like moral injury and emotion regulation. Thus, the aim of the present study is to confirm the relationship between emotion regulation and PTSD and to test for factors that are associated with higher severity of PTSD symptoms in such a sample. METHODS: A post-hoc secondary analysis was conducted on data collected in a randomized controlled trial. Participants (N = 72) were male active and former military service members that have returned from deployment and were recruited from the German Armed Forces. These participants were separated into two groups according to PTSD diagnosis based on the results of a structured diagnostic interview. Data from evaluation questionnaires administered upon entry into the study were subjected to a cross-sectional analysis. The measures included the severity of PTSD symptoms, clusters of PTSD symptoms, clinical measures, and several measures assessing PTSD-related constructs. Analyses included the Spearman rank correlation coefficient, X2 tests for nominal data, Mann-Whitney U-tests for non-parametric data, and a mediation analysis. RESULTS: The results of the mediation analysis revealed that difficulties in emotion regulation were significantly associated with the severity of PTSD symptoms, which was mediated by social acknowledgment and experimental avoidance but not by moral injury. The analyses showed that the severity of PTSD symptoms and all clusters of PTSD symptoms were significantly associated with most of the measured constructs in expectable directions. Participants in the PTSD group showed significantly higher mean scores on questionnaires measuring constructs that have been associated with PTSD, like emotion regulation and moral injury. They also showed lower mean scores in questionnaires for social support and social acknowledgment as a victim or survivor than participants in the non-PTSD group. CONCLUSION: The present results show that difficulties in emotion regulation are directly associated with the severity of PTSD symptoms in service members of the German Armed Forces. This association is mediated by social acknowledgment and experimental avoidance, but not by moral injury. Thus, future studies should investigate these potentially crucial factors for better understanding of the development and maintenance of PTSD in service members of the German Armed Forces after deployment to create possible treatment adaptions. CLINICAL TRIAL REGISTRATION: Australian Clinical Trials Registry, identifier ACTRN 12616000956404 http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370924.

Psychometric properties of the German version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in clinical routine settings: study design and protocol of a multitrait-multimethod study.

INTRODUCTION: The aim of this study is to investigate the diagnostic accuracy, psychometric properties and clinical utility of the German version of the Clinician-Administered Post-Traumatic Stress Disorder (PTSD) Scale for Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) (CAPS-5) in routine clinical settings. METHODS AND ANALYSIS: This study is a non-interventional, multitrait-multimethod design, multicentre study that will be carried out at German civil and military inpatient and outpatient clinics. A total sample size of n=219 participants who have experienced at least one traumatic event according to criteria as defined in the DSM-5 will be recruited. For the investigation of the diagnostic accuracy and clinical utility of the CAPS-5, participants will be categorised into one of three groups, depending on their traumatic experiences and post-traumatic symptomatology: (1) monotraumatisation with PTSD; (2) multiple traumatisation with PTSD and (3) traumatisation without PTSD. Interviews will be conducted face to face by interviewers in routine clinical settings. All participants will also be asked to complete a comprehensive set of questionnaires in order to investigate different facets of construct validity and clinical utility. First, differences between all three groups in CAPS-5 sum and subscale scores will be investigated. Test-retest reliability and inter-rater reliability will be determined. Internal consistency will be calculated using structural equation modeling (SEM) based internal consistency coefficients. Construct validity will be measured with Spearman's rank correlation analyses and multivariate analyses of variance with Holm-Bonferroni corrected post hoc analysis of variances. In order to test diagnostic accuracy, receiver operating characteristics and sensitivity and specificity analyses will be conducted. The model structure of the German CAPS-5 will be analysed using confirmatory factor analyses. ETHICS AND DISSEMINATION: The study received ethical approval by the Ethics Committees of the Faculty of Psychology at the Ruhr-Universität Bochum (reference numbers: 331 and 358). The results of the study will be presented nationally and internationally at scientific conferences and will be published in scientific journals. TRIAL REGISTRATION NUMBER: DRKS00015325.

Evaluation of a complex integrated, cross-sectoral psycho-oncological care program (isPO): a mixed-methods study protocol.

INTRODUCTION: International standards of care require the complete integration of psycho-oncological care into biomedical cancer treatment. The structured integrated, cross-sectoral psycho-oncological programme 'isPO' is aiming to ensure a provision of care in inpatient and outpatient settings according to a stepped-care approach. Up to now, psycho-oncological care is missing regulated and standardised processes to demonstrate the effectiveness. This study protocol describes the process and outcome evaluation that is conducted, along with the isPO study. The programme evaluation is aiming to proof effectiveness, explain potential discrepancies between expected and observed outcomes. Additionally, provide insight into the implementation process, as well as contextual factors that might promote or inhibit the dissemination and implementation of the stepped care programme will be gained. In addition to these measures, a cost-consequence analysis will provide further evidence aimed at integrating psycho-oncological care into primary healthcare. METHODS AND ANALYSIS: The evaluation concept is based on a tripartite strategy consisting of a prospective, formative and summative evaluation. To capture all determinants, a concurrent mixed-method design is applied comprising qualitative (interviews and focus groups) and quantitative (standardised questionnaires) surveys of patients and healthcare providers. In addition, analysis of the psycho-oncological care data (isPO care data) and statutory health insurance claims data will be conducted. Primary and secondary data will complement one another (data linkage) to obtain a more comprehensive picture of the effectiveness and implementation of the complex intervention within the isPO study. ETHICS AND DISSEMINATION: The study has been approved by the ethics committee of the Medical Faculty of the University of Cologne. For all collected data, the relevant national and European data protection regulations will be considered. All personal identifiers (eg, name, date of birth) will be pseudonymised. Dissemination strategies include annual reports as well as quality workshops for the organisations, the presentation of results in publications and on conferences, and public relations. TRIAL REGISTRATION NUMBER: DRKS00015326; Pre-results.

Short defeat and entrapment scale: A psychometric investigation in three German samples.

BACKGROUND: The present study aimed to validate the German version of the Short Defeat and Entrapment Scale (SDES). METHODS: Validity and reliability were established in an online (N = 480), an outpatient (N = 277) and an inpatient sample (N = 296). Statistical analyses included confirmatory factor analyses (CFA) and group differences in defeat and entrapment. RESULTS: For the online and the inpatient sample, the CFA indicated a two-factor solution, whereas for the outpatient sample both one- and two-factor solutions fitted the data equally well. Scale properties for the two-factor solution (defeat and entrapment subscale) were excellent. Thus, further analyses were based on this solution. For the online and the outpatient sample, suicidal ideators and suicide attempters scored significantly higher in defeat and entrapment than non-ideators and non-attempters. LIMITATIONS: Limiting factors of the study were the different measures across the samples and the cross-sectional design of the study. CONCLUSION: Though results were partly mixed, we found support for a two-factor solution of the instrument showing excellent psychometric properties in all three samples. The two-factor solution is further expected to have higher clinical utility than a one-factor solution. Suicidal ideators and suicide attempters in the online and outpatient sample showed higher scores in defeat and entrapment than non-ideators and non-attempters, emphasizing these two concepts as predictors for suicidal ideation. All in all, the present study supports the general validity and reliability of the SDES. However, future investigations based on prospective data are warranted.

Reduced gray matter volume in the left prefrontal, occipital, and temporal regions as predictors for posttraumatic stress disorder: a voxel-based morphometric study.

The concept of acute stress disorder (ASD) was introduced as a diagnostic entity to improve the identification of traumatized people who are likely to develop posttraumatic stress disorder (PTSD). Neuroanatomical models suggest that changes in the prefrontal cortex, amygdala, and hippocampus play a role in the development of PTSD. Using voxel-based morphometry, this study aimed to investigate the predictive power of gray matter volume (GMV) alterations for developing PTSD. The GMVs of ASD patients (n = 21) were compared to those of PTSD patients (n = 17) and healthy controls (n = 18) in whole-brain and region-of-interest analyses. The GMV alterations seen in ASD patients shortly after the traumatic event (T1) were also correlated with PTSD symptom severity and symptom clusters 4 weeks later (T2). Compared with healthy controls, the ASD patients had significantly reduced GMV in the left visual cortex shortly after the traumatic event (T1) and in the left occipital and prefrontal regions 4 weeks later (T2); no significant differences in GMV were seen between the ASD and PTSD patients. Furthermore, a significant negative association was found between the GMV reduction in the left lateral temporal regions seen after the traumatic event (T1) and PTSD hyperarousal symptoms 4 weeks later (T2). Neither amygdala nor hippocampus alterations were predictive for the development of PTSD. These data suggest that gray matter deficiencies in the left hemispheric occipital and temporal regions in ASD patients may predict a liability for developing PTSD.

Long-Term Effectiveness of Cognitive Behavioral Therapy in Routine Outpatient Care: A 5- to 20-Year Follow-Up Study.

OBJECTIVE: Long-term follow-ups several years after receiving cognitive behavioral therapy (CBT) are scarce and most of the existing literature describes follow-up data of randomized-controlled trials. Thus, very little is known about the long-term effects of CBT in routine care. METHODS: We investigated psychological functioning in a sample of 263 former outpatients who had received CBT for a variety of mental disorders such as depression, anxiety-, eating- or somatoform disorders 8.06 (SD 5.08) years after treatment termination. All participants completed a diagnostic interview as well as the Brief-Symptom Inventory (BSI) and the Beck Depression Inventory (BDI). Effect sizes and response rates according to Jacobson and Truax [J Consult Clin Psychol 1991;59:12-9] were calculated from pre- to posttreatment and from pretreatment to follow-up assessment. RESULTS: Pre- to posttreatment effect sizes ranged between 0.75 (BDI) and 0.63 (BSI) and pretreatment to follow-up effect sizes were 0.92 (BDI) and 0.75 (BSI). Of all patients, 29% (BDI) and 17% (BSI) experienced clinically significant change at posttreatment and 42% (BDI) and 24% (BSI) at follow-up. CONCLUSION: The results point to the long-term effectiveness of CBT under routine conditions for a wide array of problems, especially when compared to the long-term effects of medical treatment. It is noteworthy that the results at follow-up were even better than at posttreatment, indicating further improvement. However, about a quarter of the patients did not respond sufficiently to therapy, neither concerning short-term nor long-term effects.

HPA axis regulation in posttraumatic stress disorder: A meta-analysis focusing on potential moderators.

Posttraumatic stress disorder (PTSD) is often associated with alterations in the hypothalamic-pituitary-adrenal (HPA) axis. Previous findings are inconsistent, possibly due to trauma exposure of controls or different hormone measurement methods. We investigated cortisol, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S) in adults with clinical PTSD under basal or challenged conditions (Prospero registration no. CRD42016041690). A search of PubMed, Scopus, Medline, PsycINFO, Pilots/ProQuest, and Web of Science resulted in 108 included studies (N = 6484). Morning and 24 h cortisol were significantly lower in PTSD than in controls (g = -0.21; 95% CI: -0.42-(-0.01); g = -0.31; CI: -0.60-(-0.03)). Significant cortisol increases occurred after awakening in PTSD (g = 0.40; CI: 0.13-0.67) and in non-exposed controls (g = 0.96; CI: 0.59-1.33). Evening DHEA was significantly higher in PTSD than in non-exposed controls (g = 0.58; CI: 0.17-0.99). All groups showed large cortisol suppression effects after dexamethasone administration. Overall, the potential moderators investigated did not reveal a consistent pattern of HPA alterations.

Psychotherapeutic treatment and HPA axis regulation in posttraumatic stress disorder: A systematic review and meta-analysis.

Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamic-pituitary- adrenal (HPA) axis. Research over the past years has investigated potential changes of these alterations in the context of psychotherapy. Yet, no systematic review has been conducted. To summarize the current state of research on psychotherapy and HPA hormones, namely cortisol, dehydroepiandrosterone and its sulfate form (DHEA(S)), we searched for studies investigating predictions or changes in hormones over treatment course within the databases PubMed, Scopus, Medline, PsychINFO, Pilots/ProQuest, and Web of Science, and in the grey literature up to May 2018. Controlled and uncontrolled trials investigating adult samples with a clinical status of PTSD were eligible for inclusion. Twelve studies (428 participants) were included. Study quality was overall sufficient. Hormone assessment designs differed considerably. Treatment efficacy on PTSD symptom reduction was mostly high, but predictions of pre-treatment hormone concentrations on treatment efficacy were largely non-significant. Changes from pre- to post-test in basal cortisol (g = -0.07, 95% CI = -0.36; 0.21) and in the cortisol awakening response (g = -0.07, 95% CI = -0.48; 0.35) were also non-significant. Future studies require comparable designs and need to be sufficiently powered to be able to detect potential associations with HPA regulation.

[Concordance of DSM-5®-Diagnoses Based on Diagnostic Interviews with People with Mental Disorders and Relatives or Friends: Implications for Psychological Autopsy Studies]. / Konkordanz von DSM-5®-Diagnosen basierend auf diagnostischen Interviews mit Personen mit psychischen Störungen und ihren Angehörigen: Implikationen für die Methode der psychologischen Autopsie.

BACKGROUND: The evaluation whether a person who died by suicide suffered from a psychiatric disorder poses a diagnostic problem on psychological autopsy studies and is debated controversially. OBJECTIVE: Do patients and relatives or friends agree on DSM-5®-diagnoses? METHODS: A sample of N=20 inpatients and their relatives or friends were interviewed using a structured-clinical interview. In total agreement on 78 patient-based and 72 relatives- or friends-based diagnoses could be assessed. RESULTS: Agreement of patients' and relatives' or friend's diagnoses was low. Moderate concordance was found for the following diagnoses: Posttraumatic Stress Disorder, Somatic Symptom Disorder, Borderline Personality Disorder, and Binge-Eating Disorder. Only for the Persistent Depressive Disorder, the Binge-Eating Disorder, and the Borderline Personality Disorder good positive predictive values (0.75-0.80) were observed. CONCLUSION: On the basis of interviews with relatives or friends, no reliable diagnostic decisions can be made.

Brief reasons for living inventory: a psychometric investigation.

BACKGROUND: The present study aimed at validating the German version of the Brief Reasons for Living inventory (BRFL). METHODS: Validity and reliability were established in a community (n = 339) and a clinical sample (n = 272). Convergent and discriminant validity were investigated, and confirmatory factor analyses were conducted for the complete BRFL as well as for a 10-item version excluding conditional items on child-related concerns. Furthermore, it was assessed how BRFL scores moderate the association between depression and suicide ideation. RESULTS: Results indicated an adequate fit of the data to the original factor structure. The total scale and the subscales of the German version of the BRFL had sufficient internal consistency, as well as good convergent and divergent validity. The BRFL demonstrated clinical utility by differentiating between participants with vs. without suicide ideation. Reasons for living proved to moderate the association between depression and suicide ideation. CONCLUSIONS: Results provide preliminary evidence that the BRFL may be a reliable and valid measure of adaptive reasons for living that can be used in clinic and research settings.

Information order effects in clinical psychological diagnoses.

Despite the wide application and long history of diagnostic systems, several sources of diagnostic errors remain in the criterion-based diagnosing of mental disorders. The aim of this study was to investigate whether the presentational order of diagnosis-relevant information and pretreatment reports predict diagnostic errors. One hundred twenty psychotherapists participated in the present online study. The study employed a 2 (symptom presentation: core symptoms at vignette's beginning vs. core symptoms at the end of the case vignette) × 2 (pretreatment report: receiving a pretreatment report with an incongruent diagnosis to the case vignette vs. receiving no pretreatment report) between-subjects experimental design, with random assignment. Participants were asked to make diagnoses after reading three case vignettes describing patients with different disorder constellations. Additionally, participants rated their confidence in the diagnoses and their estimation of the severity of each diagnosed condition. Results indicated that order of symptom descriptions predicted the correctness of diagnostic decisions, with a recency effect causing more fully correct diagnostic decisions in cases where diagnostic information was presented last. Receiving incongruent pretreatment reports was predictive for diagnostic errors. In conclusion, the results of this study indicate that diagnoses of mental disorders can depend on the way symptoms are presented or reported. KEY PRACTITIONER MESSAGE: Therapists' diagnostic decisions are not influenced by pretreatment reports. Diagnostic decisions are affected by information order effects. Diagnostic accuracy of psychotherapists is debatable. High rate of misdiagnoses in case vignette with comorbid disorders.

Overdiagnosis of mental disorders in children and adolescents (in developed countries).

During the past 50 years, health insurance providers and national registers of mental health regularly report significant increases in the number of mental disorder diagnoses in children and adolescents. However, epidemiological studies show mixed effects of time trends of prevalence of mental disorders. Overdiagnosis in clinical practice rather than an actual increase is assumed to be the cause for this situation. We conducted a systematic literature search on the topic of overdiagnosis of mental disorders in children and adolescents. Most reviewed studies suggest that misdiagnosis does occur; however, only one study was able to examine overdiagnosis in child and adolescent mental disorders from a methodological point-of-view. This study found significant evidence of overdiagnosis of attention-deficit/hyperactivity disorder. In the second part of this paper, we summarize findings concerning diagnostician, informant and child/adolescent characteristics, as well as factors concerning diagnostic criteria and the health care system that can lead to mistakes in the routine diagnostic process resulting in misdiagnoses. These include the use of heuristics instead of data-based decisions by diagnosticians, misleading information by caregivers, ambiguity in symptom description relating to classification systems, as well as constraints in most health systems to assign a diagnosis in order to approve and reimburse treatment. To avoid misdiagnosis, standardized procedures as well as continued education of diagnosticians working with children and adolescents suffering from a mental disorder are needed.

Measuring attitudes towards suicide: Preliminary evaluation of an attitude towards suicide scale.

OBJECTIVES: Our study aimed to validate a previously published scale assessing attitudes towards suicide. Factor structure, convergent and discriminant validity, and predictive validity were investigated. METHOD: Adult German participants (N=503; mean age=24.74years; age range=18-67years) anonymously completed a set of questionnaires. An exploratory factor analysis was conducted, and incongruous items were deleted. Subsequently, scale properties of the reduced scale and its construct validity were analyzed. A confirmatory factor analysis was then conducted in an independent sample (N=266; mean age=28.77years; age range=18-88years) to further confirm the factor structure of the questionnaire. RESULTS: Parallel analysis indicated a three-factor solution, which was also supported by confirmatory factor analysis: right to commit suicide, interpersonal gesture and resilience. The subscales demonstrated acceptable construct and discriminant validity. Cronbach's α for the subscales ranged from 0.67 to 0.83, explaining 49.70% of the total variance. CONCLUSIONS: Positive attitudes towards suicide proved to be predictive of suicide risk status, providing preliminary evidence for the utility of the scale. Future studies aiming to reproduce the factor structure in a more heterogeneous sample are warranted.

Misclassification of Self-Directed Violence.

BACKGROUND: Inconsistent nomenclature and classification of suicidal behaviour have plagued the field of suicidology for a long time. Recently, the United States Centers for Disease Control (CDC) advocated for the usage of a specific classification system. Aim of the current study was to determine the extent of misdiagnosed acts of self-directed violence-controlling for the level of expertise in psychology/psychotherapy. Additionally, the effect of gender and diagnosis on misclassifications was assessed. METHOD: A total of 426 participants (laypersons, psychology students, psychotherapists-in-training, licensed psychotherapists) were presented with an array of case vignettes describing different acts of self-directed violence (e.g., non-suicidal self-directed violence, suicide attempt, suicide ideation) and were asked to make a classification. Gender and given diagnosis were varied systematically in two vignettes. RESULTS: Overall 51.6% of the cases were misclassified (according to the Self-Directed Violence Classification System). The level of expertise was almost unrelated to classification correctness. Yet, psychotherapists were more confident about their judgments. Female gender of the character described in the vignette and an ascribed diagnosis of Borderline Personality Disorder were associated with higher misclassification rates. LIMITATIONS: The validity of case vignettes is discussible. CONCLUSIONS: The results highlight the importance of more methodological and diagnostic training of psychologists regarding suicidal issues. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Misclassification of non-suicidal and suicidal events is common. Expertise is only weakly associated with classification correctness. Misclassification of suicide attempts occurs more often in women. Misclassification of suicide attempts occurs more often in Borderline Personality Disorder. The use of standardized diagnostic tools in relation to self-directed violence is highly recommended.