Examination of MMPI-2-RF Substantive Scales as Indicators of Acute Suicidal Affective Disturbance Components.

A new suicide-specific diagnostic entity, acute suicidal affective disturbance (ASAD), was recently proposed to fill a void in the nomenclature. Although several studies have examined the reliability, validity, and potential clinical utility of ASAD, no studies have examined personality indicators of ASAD. This study sought to examine the association between personality and psychopathology factors, as assessed by the Minnesota Multiphasic Personality Inventory-2-Revised Form (MMPI-2-RF), and constructs that comprise ASAD in a sample of 554 psychiatric outpatients who completed all measures prior to their intake appointments. A smaller subset of patients (N = 58) also completed a measure designed to assess lifetime ASAD symptoms. Results indicated that ASAD symptoms were associated with traits characterized by emotional turmoil and atypical cognitive processes. Further, suicide-related criteria that comprise ASAD were related to low positive emotionality and hopelessness, whereas the overarousal criteria were associated with somatic symptoms and an inability to tolerate frustration and stress. These findings expand on previous research that examines the convergent and discriminant validity of ASAD and could inform clinical treatment by providing insight into personality traits that might be associated with acute suicide risk.

An investigation of the interactive effects of the capability for suicide and acute agitation on suicidality in a military sample.

BACKGROUND: According to the interpersonal theory of suicide (1, 2), the difficulties inherently associated with death by suicide deter many individuals from engaging in suicidal behavior. Consistent with the notion that suicide is fearsome, acute states of heightened arousal are commonly observed in individuals immediately prior to lethal and near-lethal suicidal behavior. We suggest that among individuals who possess elevated levels of the capability for suicide, the heightened state of arousal experienced during periods of acute agitation may facilitate suicidal behavior in part because it would provide the necessary energy to approach a potentially lethal stimulus. Among individuals who are low on capability, the arousal experienced during agitation may result in further avoidance. METHODS: In the present project we examine how acute agitation may interact with the capability for suicide to predict suicidality in a large military sample (n = 1,208) using hierarchical multiple regression. RESULTS: Results were in line with a priori hypotheses: among individuals high on capability, as agitation increases, suicidality increases whereas as agitation increases among individuals low on capability, suicidality decreases. Results held beyond the effects of thwarted belongingness, perceived burdensomeness, and suicidal cognitions. CONCLUSIONS: Beyond further substantiating the link between agitation and suicide, findings of the present study provide evidence for the construct validity of the acquired capability as well as offer initial evidence for moderating role of capability on the effect of agitation on suicide. Limitations of the current study highlight a need for future research that improves upon the techniques used in the present study. Implications for science and practice are discussed.

Development and validation of a brief self-report measure of agitation: the Brief Agitation Measure.

Emerging evidence indicates that agitation is an ominous precursor to imminent death by suicide, yet measures of it are few, and to our knowledge, no self-report measure of agitation exists. To fill this gap, we have developed the Brief Agitation Measure (BAM), which is designed as a brief measure to assess agitation. In this article, we provide preliminary evidence from 2 studies examining the reliability and validity of the BAM in an undergraduate sample as well as a clinical sample. We close with a discussion of the limitations of the studies and implications of our findings.

Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults.

The interpersonal-psychological theory of suicidal behavior (T. E. Joiner, 2005) proposes that an individual will not die by suicide unless he or she has both the desire to die by suicide and the ability to do so. Three studies test the theory's hypotheses. In Study 1, the interaction of thwarted belongingness and perceived burdensomeness predicted current suicidal ideation. In Study 2, greater levels of acquired capability were found among individuals with greater numbers of past attempts. Results also indicated that painful and provocative experiences significantly predicted acquired capability scores. In Study 3, the interaction of acquired capability and perceived burdensomeness predicted clinician-rated risk for suicidal behavior. Implications for the etiology, assessment, and treatment of suicidal behavior are discussed.

Gender specific gene-environment interactions on laboratory-assessed aggression.

We examined gene-environment interactive effects on aggressive behavior among men and women genotyped (short versus long alleles) for the serotonin transporter gene. Aggressive behavior was indexed via a laboratory paradigm that measured the intensity and duration of shocks delivered to a putative "employee". Half of the participants were exposed to a physical stressor during the procedure (stress) and half were not (no-stress). Participants' physiological responses were gauged via acoustic startle eyeblink reactions (startle reactivity). Results were that men with the homozygous short (s/s) genotype showed increased aggression only under stress, whereas women and men carrying the long allele did not show differences in aggression in stress versus no-stress. However, although stress exposure produced increases in startle reactivity, there were no genotype or gender differences in physiology. These results replicate longitudinal research findings confirming the interactive effects of genes and environment on behavioral reactivity and on the development of externalizing psychopathological syndromes, at least in men.

Fearlessness about death: the psychometric properties and construct validity of the revision to the acquired capability for suicide scale.

The Interpersonal Theory of Suicide proposes that suicidal behavior is so frightening that in order for an individual to engage in suicidal behavior, desire for suicide must be accompanied by the capability to do so. The capability for suicide is characterized by both a sense of fearlessness about death and elevated physiological pain tolerance. The primary aim of the current project was to reevaluate and revise the Acquired Capability for Suicide Scale (ACSS; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and offer a revision to the scale. Expert review of the scale items resulted in retaining 7 items assessing fearlessness about death. The recommendation is made to refer to the revised scale as the ACSS-Fearlessness About Death (ACSS-FAD) to reflect its content more specifically. A model with the 7 retained items provided good fit to the data across 3 independent samples of young adults. Multiple-group analyses examining measurement invariance across men and women found that the latent structure of the scale is comparable across gender. Data are also presented demonstrating convergent and discriminant validity for the scale in young adults and an inpatient psychiatric sample. Findings support the viability of the ACSS-FAD, indicating the scale has a replicable factor structure that generalizes across males and females and is substantively related to the construct of fearlessness about death. Taken together, the present work extends knowledge of the psychometrics of the ACSS-FAD in particular and the nature of fearlessness about death in general.

Post-therapy functional impairment as a treatment outcome measure in non-suicidal self-injury disorder using archival data.

There have been calls for the creation of a non-suicidal self-injury (NSSI) disorder, and a recent DSM-5 work group has delineated potential diagnostic criteria for the proposed disorder. Preliminary research comparing NSSI disorder to Axis I disorders and its closest diagnostic 'neighbor', borderline personality disorder (BPD), suggests that impairment at intake, patient history of associated features and diagnostic co-occurrence rates set NSSI disorder apart from existing DSM-IV-TR disorders. However, few studies have examined the treatment course of NSSI disorder relative to other disorders. The purpose of this study was to distinguish potential treatment outcome differences between a potential NSSI disorder, BPD and Axis I. Archival data (N = 571), which included ratings of functioning at therapy intake and termination, were analysed to determine between-group differences. Although no significant differences in the number of months in therapy or number of sessions attended were found, findings suggest that the NSSI group made strong gains in therapy, as evidenced by improvements in clinician ratings of functional impairment from intake to termination. These findings suggest that NSSI disorder may have a positive prognosis with treatment.

Non-suicidal self-injury (NSSI) disorder: a preliminary study.

Non-suicidal self-injury (NSSI) disorder has been suggested for inclusion into the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, in preparation), yet there is concern that NSSI is primarily a function of high borderline personality disorder (BPD) symptoms. The purpose of this study was to examine the characteristics of NSSI disorder and compare it to BPD and other DSM Axis I diagnoses commonly seen in clinical practice to aid in the determination of whether NSSI should be considered a separate, valid diagnostic entity. Chart data were analyzed from the screening, intake, and termination information of 571 treatment-seeking patients in a general practice clinic. Patients were classified into one of three groups: NSSI without BPD, BPD (with and without NSSI) or a comparison condition for those who did not meet criteria for the first 2 groups. Participants in these 3 groups were compared on functioning at intake, psychopathology, and diagnostic co-occurrence. Results indicated important group differences regarding diagnostic co-occurrence rates, patient history of associated features, and impairment at intake. The NSSI group displayed similar levels of functional impairment as the BPD group, including on indices of suicidality. The BPD group reported increased experiences with abuse and fewer men relative to the NSSI group. Most in the NSSI group did not exhibit subthreshold BPD symptoms or personality disorder not otherwise specified. In conclusion, a potential NSSI disorder may be characterized by high levels of depressive symptoms, anxiety, suicidality, and low functioning relative to other Axis I diagnoses.

Impulsivity and suicidality: the mediating role of painful and provocative experiences.

BACKGROUND: Multiple studies have reported a link between high levels of impulsivity and suicidal behavior. Joiner's (2005) explanation for this link is that impulsive individuals have a greater tendency to experience painful and provocative events that habituate them to fear and pain, which leads to an acquired capability for engaging in suicidal behavior. METHODS: Study 1 tested Joiner's (2005) hypothesis in a sample of 182 undergraduate students who completed self-report questionnaires on impulsivity, frequency of painful and provocative events, and acquired capability for suicide. In addition to self-report, pain tolerance (an aspect of acquired capability for suicide) was measured with a pressure algometer. Study 2 sought to replicate our findings from Study 1 in a sample of 516 clinical outpatients using a multi-faceted measure of impulsivity. RESULTS: Consistent with prediction, product of coefficients tests for mediation (MacKinnon et al., 2002) revealed that impulsivity has an indirect relationship with acquired capability for suicidal behavior, and that this relationship is mediated by painful and provocative events. LIMITATIONS: Data from our studies are cross-sectional in nature, which does not allow for conclusions about the temporal ordering of our variables. In addition, self-report was used to measure most variables. Future research may benefit from a longitudinal design and the inclusion of other modes of assessment (e.g., behavioral measures of impulsivity). CONCLUSIONS: Our findings suggest that the link between impulsivity and suicidal behavior occurs because impulsive people tend to have a greater capability for suicidal behavior, which they have acquired through experiencing painful and provocative events.

Sex and emotion in the acquired capability for suicide.

This article examined the impact of distress tolerance on sex differences in the acquired capability for suicide. Two hundred undergraduate participants filled out a series of questionnaires related to emotions and suicide risk. Males exhibited higher mean levels of the acquired capability than did women and distress tolerance interacted with sex to predict the acquired capability (ß = -.70, p < .02), such that males with high distress tolerance were at the greatest risk. These results indicate that the degree to which an individual can tolerate negative emotions impacts the strength of the relationship between sex and the acquired capability for suicide.

The reinforcing properties of repeated deliberate self-harm.

The current study tested hypotheses derived from Joiner's (2005) interpersonal theory of suicide, which proposes that deliberate self-harm (DSH) becomes increasingly more reinforcing with repetition. One hundred six participants with a history of DSH completed questionnaires about their emotions and experience of physical pain during their most recent DSH episode. Consistent with prediction, people with more numerous past DSH episodes felt more soothed, more relieved, and calmer following their most recent episode of DSH. Contrary to prediction, greater numbers of past DSH episodes were associated with more intense physical pain during the most recent episode. The findings suggest that the emotion regulation functions of DSH may become more reinforcing with repetition.

Overcoming the fear of lethal injury: evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide.

Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.

An exploration of the emotional cascade model in borderline personality disorder.

The emotional cascade model proposes that the emotional and behavioral dysregulation of individuals with borderline personality disorder (BPD) may be fundamentally linked through emotional cascades, vicious cycles of intense rumination and negative affect that may induce aversive emotional states. In order to reduce this aversive emotion, dysregulated behaviors such as non-suicidal self-injury may then be used as distractions from intense rumination. This study explored emotional cascades in a sample enriched with participants meeting diagnostic criteria for BPD. The first part of the study explored a structural equation model that examined the mediational effects of emotional cascades on the relationship between BPD symptoms and dysregulated behavior and found evidence for full mediation, even after controlling for symptoms of depression and other Cluster B disorders. The second part of the study examined the effects of a rumination induction conducted with the intention of eliciting emotional cascades in those diagnosed with BPD. The results demonstrated that individuals with BPD experienced greater reactivity and intensity of negative affect, but not of positive affect, following the procedure-even when controlling for current depressive symptoms. Future directions and clinical implications for the emotional cascade model are discussed.