Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk.

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

Suicide Crisis Syndrome Mediates the Relationship Between Long-term Risk Factors and Lifetime Suicidal Phenomena.

In recent years, there has been growing attention to the distinction between acute and long-term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS), as a marker of near-term suicidal risk. Here, we test whether documented long-term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS. A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS-3) as a measure of the SCS. While both STS-3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS-3 was related to pre-admission suicide attempts. The STS-3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long-term risk factors increase suicidal risk.

Attachment anxiety and avoidance as mediators of the association between childhood maltreatment and adult personality dysfunction.

This paper tests the hypothesis that the association between childhood maltreatment and adult personality dysfunction is at least partially attributable to insecure attachment, that is that attachment style mediates the relationship between childhood maltreatment and adult personality dysfunction. Associations between childhood trauma, as measured by the Childhood Trauma Questionnaire (CTQ), anxious and avoidant attachment in romantic relationships, as measured by the Experiences in Close Relationships-Revised (ECR-R), and five personality domains, as measured by the Severity Indices of Personality Problems (SIPP-118), were examined in a sample of 72 psychiatric inpatients. The SIPP-118 domains included relational capacities, identity integration, self-control, responsibility, and social concordance. The direct effect of childhood trauma on all SIPP-118 domains was not significant after controlling for the indirect effect of attachment. In regression modeling, a significant indirect effect of childhood trauma via adult attachment style was found for SIPP-118 relational capacities, identity integration, self-control, and social concordance. Specifically, anxious attachment was a significant mediator of the effect of childhood trauma on self-control, identity integration, and relational domains. These results suggest that childhood trauma impacts a broad range of personality domains and does so in large part through the pathway of anxious romantic attachment style.

Maladaptive interpersonal schemas as sensitive and specific markers of borderline personality disorder among psychiatric inpatients.

Diagnostic criteria for borderline personality disorder (BPD) and mood and psychotic disorders characterized by major mood episodes (i.e., major depressive, bipolar and schizoaffective disorder) share marked overlap in symptom presentation, complicating differential diagnosis. The current study tests the hypothesis that maladaptive interpersonal schemas (MIS) are characteristic of BPD, but not of the major mood disorders. One hundred psychiatric inpatients were assessed by SCID I, SCID II and the Young Schema Questionnaire (YSQ-S2). Logistic regression analyses tested the association between MIS (measured by the YSQ-S2) and BPD, bipolar, major depressive and schizoaffective disorder. Receiver operator characteristic (ROC) curve analyses assessed the sensitivity and specificity of MIS as a marker of BPD. After covariation for comorbidity with each of the 3 mood disorders, BPD was robustly associated with 4 out of 5 schema domains. In contrast, only one of fifteen regression analyses demonstrated a significant association between any mood disorder and schema domain after covariation for comorbid BPD. ROC analyses of the 5 schema domains suggested Disconnection/Rejection had the greatest power for identification of BPD cases. These data support the specific role of maladaptive interpersonal schemas in BPD and potentially contribute to greater conceptual clarity about the distinction between BPD and the major mood disorders.

Disturbed self concept mediates the relationship between childhood maltreatment and adult personality pathology.

BACKGROUND: Despite a robust literature documenting the relationship between childhood maltreatment and personality pathology in adulthood, there is far less clarity about the mechanism underlying this relationship. One promising candidate for such a linking mechanism is disturbance in the sense of self. This paper tests the hypothesis that disturbances in the sense of self mediate the relationship between childhood maltreatment and adult personality pathology. Specifically, we assess the self-related traits of stable self-image, self-reflective functioning, self-respect and feeling recognized. METHODS: The sample included 113 non-psychotic psychiatric inpatients. Participants completed the Child Trauma Questionnaire (CTQ), the Personality Diagnostic Questionnaire-4 (PDQ-4+), and the self-reflexive functioning, stable self image, self-respect, and feeling recognized scales from the Severity Indices of Personality Problems (SIPP-118). A series of linear regressions was then performed to assess the direct and indirect effects of childhood trauma on personality disorder traits (PDQ-4+ total score), as mediated by self concept (SIPP-118 scales). Aroian tests assessed the statistical significance of each mediating effect. RESULTS: There was a significant mediating effect for all SIPP self concept variables, with a full mediating effect for the SIPP composite score and for SIPP feeling recognized and self-reflexive functioning, such that the direct effect of childhood trauma on personality did not retain significance after accounting for the effect of these variables. There was a partial mediating effect for SIPP stable self image and self-respect, such that the direct effect of the CTQ retained significance after accounting for these variables. SIPP feeling recognized had the strongest mediating effect. CONCLUSIONS: Multiple facets of self concept, particularly the degree to which an individual feels understood by other people, may mediate the relationship between childhood maltreatment and adult personality pathology. This underscores the importance of attending to disturbances in the sense of self in patients with personality pathology and a history of childhood maltreatment. These findings also support the centrality of disturbed self concept to the general construct of personality pathology.

Assessment of Sexual Fantasies in Psychiatric Inpatients With Mood and Psychotic Disorders and Comorbid Personality Disorder Traits.

INTRODUCTION: Sexuality is an important aspect of quality of life and sexual fantasies comprise a normal part of human sexuality. However, the nature of sexuality and sexual fantasies of patients with mental illness remains an understudied area. AIM: To investigate the nature and frequency of sexual fantasies in psychiatric patients, the present study compared the frequency of four types of sexual fantasies across four different mood and psychotic diagnoses and three personality disorder clusters. METHODS: Study participants included 133 psychiatric inpatients recruited from an urban hospital. Sexual fantasies were compared across patients with schizophrenia, bipolar disorder, schizoaffective disorder, major depressive disorder and three nonclinical samples from the literature and then correlated with personality cluster scores. MAIN OUTCOME MEASURES: Subjects were administered the Structured Clinical Interview for DSM-IV for Axis I and for Axis II Disorders. Sexual fantasies were assessed by the Wilson Sexual Fantasies Questionnaire, which measures four types of sexual fantasies (exploratory, intimate, impersonal, and sadomasochistic). RESULTS: Within the entire sample, there were significant differences across sexual fantasy types, with subjects scoring highest on intimate sexual fantasies and then exploratory, impersonal, and sadomasochistic. There were no significant differences across mood and psychotic diagnostic groups for any of the sexual fantasy scales and the scores were within the normative range of nonclinical samples. Patients with high cluster B scores scored significantly higher on all four fantasy scales than those without. Patients with high cluster A scores scored lower on intimate fantasies, but there was no association between cluster C scores and sexual fantasies. The association between cluster B and sexual fantasies remained consistent across Structured Clinical Interview for DSM-IV for Axis I diagnoses (no interaction effect). CONCLUSION: Patients with severe mental illness report sexual fantasies that are largely affiliative in nature and consistent with normative patterns. This suggests that assessment and treatment of sexual issues in the mentally ill should be part of the clinical routine as it is in healthy individuals.