A Cross-Sectional Study of Major Repeaters: A Distinct Phenotype of Suicidal Behavior

A Cross-Sectional Study of Major Repeaters: A Distinct Phenotype of Suicidal Behavior

Hilario Blasco-Fontecilla, MD, PhD; Isabelle Jaussent, PhD; Emilie Olié, MD, MsC; Severine Béziat, MSc; Sebastien Guillaume, MD, PhD; Paula Artieda-Urrutia, MD; Enrique Baca-Garcia, MD, PhD; Jose de Leon, MD; and Philippe Courtet, MD, PhD

Every year, 10 to 20 million people attempt suicide.1 Suicide attempts are between 10 and 40 times more frequent than completed suicides.2 Repetition of suicide attempts is frequent, and its study is important at least for 2 reasons. First, a history of suicide attempts is the strongest predictor of future suicidal behavior.3 Indeed, the estimated rate of nonfatal suicide attempt repetition among suicide attempters is up to 40% after 3 to 8 years of follow-up.4-6 Second, suicide attempts represent a major source of economic burden.7

The repetition of suicide attempts has been related to various risk factors: (1) sociodemographic (age and low educational level),8 unemployment,9 or being unmarried10; (2) personal history, particularly childhood abuse11; and (3) psychopathological (personality disorders,12 anxiety disorders,13 and addictions,14 among others). Moreover, repetition of suicide attempts has been related to a greater severity of suicidal symptoms.15 Although the literature comparing multiple suicide attempters versus single attempters is vast,16,17 the characterization of major repeaters (individuals with ≥ 5 lifetime suicide attempts) is particularly poor.18 Major repeaters represent about 10%-15% of all suicide attempters.18-20 They are heavy consumers of health resources, pose a challenge to clinicians,18 and are at higher risk of suicide completion.21,22

Unfortunately, apart from the study by Kreitman and Casey,18 there are no further methodologically sound studies considering this subcategory of multiple suicide attempters. In their seminal article, Kreitman and Casey18 studied over 3,000 individuals admitted to the Regional Poisoning Treatment Center, Edinburgh, Scotland, for parasuicide. They arbitrarily divided individuals into those with no previous parasuicide (“first-evers”), those with a lifetime history of 2-4 parasuicides (“minor repeaters”), and those with ≥ 5 lifetime parasuicides (“major or grand repeaters”). Interestingly, they warned that the variables associated with an increased risk of repetition of parasuicide were not necessarily the same as those related to major repetition.18

In sum, there has been little research regarding the clinical profile of major repeaters. The identification of major repeaters as a distinctive suicidal phenotype is important because specific prevention plans could help to reduce the economic burden and suicide risk of this subpopulation. The main objective of the present study was to better characterize major repeaters and to test whether or not they represent a distinctive suicidal phenotype. We expected to find that major repeaters are more likely (1) to be diagnosed with childhood trauma (abuse/neglect), (2) to have pathological personality traits (impulsivity, novelty seeking, harm avoidance, and anger), and (3) to have a more severe suicide profile when compared with non-major suicide attempters (individuals with 1 to 4 lifetime suicide attempts).

METHOD

Sample

The study included 372 suicide attempters. The mean patient age was 40.3 years (SD = 13.3; range, 18-83). The prevalence of female gender was 71% (264/372), of higher education (> 12 years) was 45% (166/372), and of married status was 38% (140/372).

Procedure

All participants were assessed using a protocol designed to collect information regarding sociodemographic (age, gender, marital status, years of education, number of children) and clinical variables (prematurity, history of childhood abuse/neglect, family history of suicidal behavior, Mini-International Neuropsychiatric Interview [MINI] diagnoses, and personality traits) following a guideline for suicide assessment.23 Data were obtained cross-sectionally from suicide attempters consecutively hospitalized after a suicide attempt in a unit of the Montpellier University Hospital, Montpellier, France, which specializes in treating suicide, between October 12, 2000, and June 10, 2010. A suicide attempt was defined as a self-destructive behavior with intent to end one’s life independent of resulting damage.24,25 To be included, patients had to be aged ≥ 18 years, to be French-speaking, and to have all 4 biological grandparents from Western European countries, as the present study is based on an ongoing genetic study of suicide attempt. More information can be found elsewhere.26 All participants signed an informed consent form after the explanation of the study objective and procedures. The local Ethics Committee (CPP Sud Mediterranée IV, CHU Montpellier, France) approved the study.

• Major repeaters appear to be a distinctive suicidal phenotype characterized by a distinctive sociodemographic and clinical profile.
• Major repeaters are more likely to be diagnosed with any type of childhood maltreatment.
• Specific preventive plans should be tailored to major repeaters.

Measures

Psychiatric diagnoses using the MINI27 were provided by trained psychiatrists or clinical psychologists. They held consensus meetings and were regularly monitored by the experienced psychiatrists who were investigators in the study (E.O., S.G., P.C.).

Childhood abuse was assessed with the validated French version of the 28-item Childhood Trauma Questionnaire (CTQ).28,29 The CTQ is a self-report questionnaire with good reliability and validity for screening diagnoses of physical, sexual, and emotional abuse and emotional and physical neglect.30 The CTQ has demonstrated excellent test-retest reliability and convergent validity.31 Each item is rated from 1 (never) to 5 (very often), and scores range from 5 to 25 for each type of trauma. According to Bernstein and Fink,28 thresholds or cutoff scores have been set for each type of trauma at 4 levels of maltreatment: none, low, moderate, and severe. The different cutoffs have been shown to have good specificity and sensibility.28

Personality traits were studied with 3 scales. The French version of the Tridimensional Personality Questionnaire is a 100-item true/false questionnaire that measures novelty seeking, harm avoidance, and reward dependence.32 The French version of the Barratt Impulsiveness Scale Version 10 was used to evaluate impulsivity traits.33 The scale includes 34 self-report items scored 1 to 4 (rarely/never, occasionally, often, and almost always/always), with a score of 4 indicating the highest impulsivity.34 The French version of the State-Trait Anger Expression Inventory was used to measure anger.35 This 44-item questionnaire has 5 subscales measuring anger as an emotional state (state anger), a trait (trait anger), and 3 facets of anger expression: (1) anger expressed outward (anger-out), (2) anger that is experienced but suppressed (anger-in), and (3) control of angry feelings (anger-control).36

Finally, a series of questionnaires was used to explore the severity of suicidal behavior. The Risk-Rescue Rating Scale (RRRS) is a 10-item, interviewer-administered scale designed to evaluate lethality of a suicide attempt, measuring the risk of death derived from the attempt and the likelihood of a rescue intervention at the time of the attempt.37 The Suicidal Intent Scale is a semistructured 15-item rating scale that measures the severity of suicidal intent.38 We used the global score and the “planning factor” score derived from a factor analysis of the Suicidal Intent Scale.39 The Scale for Suicidal Ideation is a 19-item interviewer-rated questionnaire40 with items rated on a 3-point scale. The total score can range between 0 and 38.41

Age at first suicide attempt was classified as < 26 years versus ≥ 26 years; 26 years of age was the best cutoff point to separate between early onset and late-onset first suicide attempt subgroups.42 According to the categories of Asberg et al,43 hanging, jumping from heights, use of firearms or knives, and throwing oneself under a train were considered violent suicide attempts, while drug overdose and superficial wrist cutting were classified as nonviolent.

Statistical Analyses

As the hypothesis of a normal distribution was rejected (Shapiro-Wilk test), the number of suicide attempts was categorized as follows. Patients were divided into those with total lifetime suicide attempts ≥ 5 (major repeaters) and those with total suicide attempts < 5 (non-major repeaters). Five suicide attempts correspond approximately to the lowest decile of our distribution. Univariate analyses of the associations between major repeaters and patient characteristics (sociodemographic characteristics, personal and familial history, MINI psychiatric diagnoses, and personality traits) were quantified with odds ratios (ORs) and their 95% confidence intervals (CIs) using regression logistic models. Explored continuous variables such as personality traits were divided into terciles with the lowest or highest tercile compared to the remaining 2, the linearity assumption being rejected for most variables. Variables associated with being a major suicide repeater (P < .10) were then introduced into a multivariable logistic regression model. Significance level was set at P < .05. Another set of univariate analyses of the associations between major repeaters with suicide severity was calculated. SAS statistical software, version 9.2 (SAS, Inc, Cary, North Carolina) was used for the statistical analyses.

RESULTS

The frequency of major repeaters was 10% (37/372) in the total sample, 2.8% (3/108) in men, and 12.8% (34/264) in women. When compared with non-major suicide attempters, major repeaters displayed significant differences in (1) sociodemographic characteristics including preponderance of women (92%; OR = 5.17; 95% CI, 1.55-17.2) and lower frequency of higher education (OR = 0.36; 95% CI, 0.17-0.80) (Table 1) and (2) personal variables including almost all CTQ dimensions (Table 2). No significant association was found between familial history of suicidal behavior and major repeaters.

When compared with non-major suicide attempters, major repeaters displayed significant differences in (1) psychiatric diagnoses, including significantly higher frequency of anorexia nervosa (OR = 2.90; 95% CI, 1.09-7.71), bulimia nervosa (OR = 3.03; 95% CI, 1.26-7.24), and substance dependence (OR = 2.75; 95% CI, 0.96-7.91; borderline significance) (Table 3) and (2) personality traits, including higher frequency of trait anger (OR = 2.10; 95% CI, 1.05-4.16) (Table 4).

We carried out a logistic regression including all significant univariate sociodemographic, personal and familial history, and psychiatric diagnosis variables with P ≤ .10 (Table 5). In this model, female gender, low education level, anorexia nervosa, substance dependence, high trait anger, and low level of anger expressed outward remained significant and were independently associated with major repeaters.

We also explored in another set of univariate analyses whether major repeaters were a particular subgroup of suicide attempters characterized by a more severe suicide profile. Major repeaters had significantly higher frequency of earlier onset at first suicide attempt (OR = 2.23; 95% CI, 1.12-4.45; P = .02) and of being in the highest tercile of the RRRS risk score (OR = 2.14; 95% CI, 1.08-4.23; P = .03). There was also a borderline significance for rescue RRRS (OR = 1.88; 95% CI, 0.94-3.74; P = .07), violent suicide attempts (OR = 2.06; 95% CI, 0.96-4.41; P = .06), and expectancy of lethality (OR = 1.88; 95% CI, 0.94-3.72; P = .07) (Table 6).

DISCUSSION

Here, we have further refined the concept of repetition of suicidal behavior by suggesting that major repeaters may represent a distinctive suicidal phenotype of individuals characterized by female gender, a lower level of education, childhood maltreatment, higher trait anger and lower level of anger expressed outward, and the presence of anorexia nervosa and substance dependence. Moreover, major repeaters had an older age at onset of suicidal behavior than the remaining suicide attempters. Furthermore, major repetition of suicidal behavior was not related to major depression, bipolar disorder, anxiety disorders, or a family history of suicidal behavior. Our results demonstrate, importantly, some risk factors characteristic of female major repeaters. However, in order to give a more reliable characterization of major repeaters, future studies should combine neurobiological (eg, genetic, epigenetic, neuroimaging) and clinical information.

The prevalence of major repeaters in our study (10%) was consistent with available literature (4.5%-16%).18,44,45 Furthermore, major repeaters were almost exclusively women (91.9%). The literature agrees that women attempt suicide 2 to 3 times more frequently than men.46 Less clear is to what extent female gender poses increased risk for major suicide repetition.18 Furthermore, major repeaters were more likely to be diagnosed with any type of childhood maltreatment in the univariate analyses. Childhood or adolescence victimization has been associated with several addictions,47 substance use disorders in adolescents,48 and suicidal behavior,49 including repetition of suicide attempts.11 Interestingly, the greater the number of different types of CTQ-measured abuse or neglect, the higher the likelihood of being diagnosed as a major repeater.

After correcting for confounders, anorexia nervosa, substance dependence, and trait anger were independently associated with major repeater status. Individuals diagnosed with anorexia nervosa, particularly purging, are more likely to attempt suicide.50-52 In suicide attempters diagnosed with eating disorders, suicide attempts are not only frequent, but also more serious and related to a higher expectation that they will die from the attempt compared to other suicide attempters.53 As for the relationship between substance dependence and major repetition, individuals with substance-related disorders are at increased risk for suicidal behavior, including repetition of suicidal behavior.16,54-57 With regard to personality traits, major repeaters were more likely to manifest higher scores of trait anger, but were not able to express this anger outward. Anger can be expressed toward other persons/objects (“externalized”), suppressed/directed inward (“internalized”), or controlled.58 Our study suggests that major repeaters appear to direct inward the excess of anger. High anger has traditionally been suggested to contribute to suicide risk.59 Our results are in keeping with a recent study with 748 inpatients aged 18-40 years.60 In this study, the authors reported that facets of anger predicted suicide attempts following hospital discharge for patients with a history of childhood sexual abuse.60 Our intuition that major repeaters had more severe suicide attempts was also confirmed. Indeed, repetition of deliberate self-harming has previously been associated with continuing suicide risk.61 Finally, another fact that further supports the theory that major repeaters are a characteristic suicidal phenotype is our finding that they had an older age at onset of suicidal behavior. This is in contradiction with most of the studies published so far, which report an association between repetition of suicidal behavior61,62 and either a younger age or an earlier onset of suicidal behavior.42 Our results displaying that major repeaters had an older age at onset of suicidal behavior represent a new finding and might help emergency room personnel in evaluating suicide attempters.

Our results could also be interpreted as bringing some support to the addictive hypothesis of suicidal behavior.63 Goodman64 suggested that addictive disorders may include not only substance use disorders, but also behavioral addictions. In this context, Tullis65 proposed that suicidal individuals showing childhood abuse/neglect, affective disorders, and multiple addictions could get addicted to suicidal behavior. We recently refined the theory of addiction to suicidal behavior by proposing that major repeaters may be the individuals addicted to suicidal behavior.63 Suicidal behavior produces relief from negative emotions, reduces mental pain, and raises social support. Therefore, we suggested that the likely release of endogenous opioids might underlie the addiction to suicidal behavior. Literature compatible with this hypothesis includes the cathartic effect of suicidal behavior,66 defined as a sudden decrease in the symptoms associated with suicidal behavior following a suicidal crisis,67 and Beck’s “sensitizing” suicidal behavior hypothesis.68 Beck suggested that previous suicidal behavior sensitizes suicidal thoughts and behaviors, such that they become more autonomous and easily precipitated.68 In any case, currently, there is no direct evidence for the addictive hypothesis of suicidal behavior.

Another putative interpretation is that major repeaters in our sample are female patients diagnosed with borderline personality disorder. Patients with borderline personality disorder are frequently diagnosed with substance use disorders, eating disorders,69 and multiple suicide attempter status.70 Our study had no tool to diagnose borderline personality disorder, so we cannot rule out this possibility. However, research showed that multiple suicide attempters display greater psychopathology than single suicide attempters even after controlling for borderline personality disorder diagnosis.16 Furthermore, major repeaters in our sample were not characterized by higher levels of impulsivity, a frequent criterion of borderline personality disorder.

Finally, major repetition of suicidal behavior was not related to bipolar disorder, major depression, anxiety disorders, or a family history of suicidal behavior. However, the prevalence of these disorders and familial history of suicidal behavior was frequent in either major repeaters or the remaining suicide attempters. In keeping with the literature, our results support that all of these factors—bipolar disorder, major depression, and anxiety—are risk factors for suicidal behavior, but they are not specific to major repetition of suicidal behavior.71-74

Strengths and Limitations

The major strengths of the current study are its large sample size and the unbiased representativeness of our sample of suicide attempters. Unfortunately, the sample size was not big enough to discuss differences in men (n = 3). Thus, our results might only be valid or important for female major repeaters. Furthermore, as all retrospective studies, this study provided only statistical associations, which cannot be interpreted as providing causal connections.57 However, retrospective analyses are useful for pointing out potential characteristics of major repeaters. Another limitation is that we collapsed single attempters and “minor repeaters” into one category to gain statistical power. Some authors have stressed that the differentiation between single and multiple suicide attempters at a single point in a given time might not be the best way to correctly identify major suicide attempters, since a significant proportion of single attempters will become major repeaters.16,17 It is possible that by refining the categorization of multiple suicide attempters we gain some insight into the mechanisms underlying suicidal behavior.16 Furthermore, our study relies on an inpatient sample, thus limiting the generalizability of our findings to larger community samples of people who may not seek treatment and/or hospitalization following a suicide attempt.

CONCLUSIONS

The present study suggests that major repeaters represent a subgroup of multiple suicide attempters who present a unique profile characterized by female gender; lower educational level; elevated trait anger, which is not expressed outward; and the presence of eating disorders and substance dependence. Our results demonstrate some risk factors characteristic of major repeaters of female gender. If our results are replicated, major repeaters may benefit from specific therapeutic strategies traditionally used for substance addictions. By implementing specific prevention plans tailored to those suicide attempters showing the clinical profile of major repeaters during their first suicide attempts, we might contribute to reducing the rates of suicidal behavior.

Author affiliations: Department of Psychiatry, IDIPHIM-Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain (Drs Blasco-Fontecilla and Artieda-Urrutia); CIBERSAM (Dr Blasco-Fontecilla), Madrid, Spain; Inserm, U1061 and Université Montpellier I (Drs Jaussent, Olié, Guillaume, and Courtet and Ms Béziat), Montpellier, France; Psychiatric Emergency and Post Emergency Department, Centre Hospitalier Regional Universitaire Montpellier, H×´pital Lapeyronie, Montpellier, France (Drs Guillaume, Olié, and Courtet); Department of Psychiatry, IIS-FJD, CIBERSAM, Madrid, Spain (Dr Baca-Garcia); and Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky (Dr de Leon).

Potential conflicts of interest: Dr Blasco-Fontecilla has served on the speakers’ or advisory boards of AB-Biotics, Eli Lilly, and Shire. Dr Guillaume has received grant/research support from Servier Laboratory and served on the speakers’ or advisory boards of Bristol-Myers Squibb, Janssen, Lundbeck, and Servier. Drs Jaussent, Olié, Artieda-Urrutia, Baca-Garcia, de Leon, and Courtet and Ms Béziat report no conflicts of interest related to the subject of this article.

Funding/support: This research was supported by grants from CHU Montpellier (PHRC UF 7653) and Agence Nationale de la Recherche (NEURO 2007—GENESIS). Dr Guillaume received a grant from l’ Institut Servier. Dr Blasco-Fontecilla acknowledges the Spanish Ministry of Health (Rio Hortega CM08/00170), Alicia Koplowitz Foundation, and Conchita Rabago Foundation for funding his post-doctoral stage at Centre Hospitalier Regional Universitaire, Montpellier, France.

Role of the sponsors: Sponsorship allowed for the collection and management of data and the preparation of the manuscript.

Previous presentation: An oral presentation of this article titled “On Pain, Suicide, and Addiction: the Addictive Hypothesis of Suicidal Behavior” was given at The International Academy of Suicide Research 2013 World Congress on Suicide; June 10-13 2013; Montreal, Canada.

Acknowledgments: The authors acknowledge Lorraine Maw, MA (Mental Health Research Center, Eastern State Hospital, Lexington, Kentucky), who helped in editing this article. Ms Maw reports no conflicts of interest related to the subject of this study.

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