Archives of Suicide Research
ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20
Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters Hanna Sahlin-Berg, Tomas Moberg, Tatja Hirvikoski & Jussi Jokinen To cite this article: Hanna Sahlin-Berg, Tomas Moberg, Tatja Hirvikoski & Jussi Jokinen (2015): Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters, Archives of Suicide Research, DOI: 10.1080/13811118.2015.1004487 To link to this article: http://dx.doi.org/10.1080/13811118.2015.1004487
Accepted online: 16 Apr 2015.
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Date: 14 October 2015, At: 14:05
Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters Hanna Sahlin-Berg1 , Tomas Moberg1, Tatja Hirvikoski2, Jussi Jokinen1 1
Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet Karolinska University Hospital, Solna, Stockholm, Sweden, 2Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Address for correspondence: Jussi Jokinen, Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet, R5, Karolinska University Hospital/Solna, SE-171 76 Stockholm, Sweden. E-Mail: [email protected]
Abstract Objectives: The current study compared characteristics of suicidal behaviour and interpersonal violence in suicide attempters with and without a history of non-suicidal self-injury (NSSI).
Methods: A total of 100 suicide attempters were assessed with Karolinska Interpersonal Violence Scale (KIVS) and Karolinska Suicide History Interview concerning interpersonal violence and NSSI.
Results: There was a high degree of comorbid NSSI in suicide attempters (44%). Suicide attempters with NSSI-history reported more interpersonal violence as adults and more severe suicidal behaviour compared to suicide attempters without NSSI. Comorbid NSSI was related to severity of suicidal behaviour in gender specific manner.
Conclusion: Comorbid NSSI in suicide attempters may increase suicide and violence risk
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KEYWORDS: Suicide attempt, non-suicidal self-injury, interpersonal violence, gender difference
1. INTRODUCTION Non-suicidal self-injury (NSSI) has been defined as self-directed deliberate destruction of
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bodily tissue in the absence of suicidal intent, whereas suicidal behaviour has been defined as an act of intentionally terminating one’s own life (Nock, 2010). Although NSSI and suicidal behaviour differ in several ways regarding intent, frequency and lethality (Muehlenkamp, 2005), there is increasing evidence for NSSI as a risk factor for future suicidal behaviour (Victor & Klonsky, 2014; Whitlock, Muehlenkamp, Eckenrode, et al., 2013)
NSSI is listed in the DSM-5 (American Psychiatric Association, 2013) as a criterion of Borderline personality disorder (BPD) and has until recently mainly been associated with that disorder as both suicidal and non-suicidal self-injurious behaviour is highly prevalent among individuals with BPD (Yen, Shea, Sanislow, et al., 2004). A growing body of research suggests that NSSI is common among individuals who do not fulfill criteria for BPD, and that NSSI in itself is associated with comorbid depression, anxiety and functional impairment (Selby, Bender, Gordon, et al., 2012).
Research involving both clinical and non-clinical populations suggests that there is a high comorbidity between NSSI-behaviour and suicide attempts (SA) and that individuals who engage in both NSSI and SA have more complex psychopathology, lower psychosocial
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functioning and more aggression and impulsivity than individuals with NSSI alone or SA alone (Hamza, Stewart & Willoughby, 2012; Swahn, Ali, Bossarte, et al., 2012; Stanley, Gameroff, Michalsen, et al., 2001). Among adult inpatients both with and without BPD, a history of NSSI has been associated with earlier suicide attempts (SA), greater lethal intent – or underestimation of lethality of SA – and as NSSI frequency increased, the
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number of SA increased (Andover & Gibb, 2010; Stanley, Gameroff, Michalsen, et al., 2001).
Similar patterns have been found for adolescents with a history of NSSI (Whitlock, Muehlenkamp, Eckenrode, et al., 2013; Asarnow, Porta, Spirito, et al., 2011; Wilkinson, Kelvin, Roberts, et al., 2011). The reason for this association is still unclear but Joiner (Joiner, 2005)has proposed that NSSI and other fear-inducing and aggressive acts may habituate the individual for the pain and fear associated with a suicide attempt, a theory that has gained increasing support over the years (Van Orden, Witte, Cukrowicz, et al., 2010).
There is a strong link between suicidal behaviour and aggression. A history of violence and aggressive behaviour is associated with higher frequency of SA, more violent SA and probability of lifetime suicidal thoughts and behaviours (Gvion & Apter, 2011). These findings seem to be explained by co-occurring Cluster-B personality disorders, mainly BPD and Antisocial personality disorder. BPD has been associated with impulsive aggression and violent acts (Fountoulakis, Leucht & Kaprinis, 2008), as well as more suicidal behavior, especially if combined with antisocial personality disorder (Howard,
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McCarthy, Huband, et al., 2013; McGirr, Paris, Lesage, et al., 2007), but the connection may not be evident in all groups of BPD patients (Allen & Links, 2012).
Both exposure to interpersonal violence as a child and expressed violent behaviour as an adult are risk factors for completed suicide in suicide attempters as reported in a long-
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term follow-up study (Jokinen, Forslund, Ahnemark, et al., 2010). Another risk factor for suicide is the choice of a violent SA method (Runeson, Tidemalm, Dahlin, et al., 2010). It is theorized that partly the same biological mechanisms may be involved in aggression and violent suicidal behaviour (Placidi, Oquendo, Malone, et al., 2001).
The current study compares characteristics of suicidal behaviour in suicide attempters with and without a history of NSSI. We hypothesized that suicide attempters with a history of NSSI would report more interpersonal violence and have more serious suicidal behavior in form of choice of suicide attempt method or repetition of suicide attempts. Since many studies of suicidal behaviour have shown gender differences (Hawton, 2000), we also assessed men and women separately.
2. METHODS 2.1. Study Setting Patients having their clinical follow-up after attempted suicide at the Suicide Prevention Clinic of the Karolinska University Hospital were invited to participate in the study of biological and psychological risk factors for suicidal behaviour. Inclusion criteria were a recent SA (time limit of 1 month), fair capacity to communicate verbally and in writing in
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the Swedish language and age 18 years or older. Exclusion criteria were schizophrenia spectrum psychosis, dementia, mental retardation and intravenous drug abuse. A suicide attempt was defined as a self-destructive act with some degree of intent to die. Patients were recruited during 2001—2005. The Regional Ethics Review Board in Stockholm approved the study protocol (Dnr. 00-194) and the participants gave their written
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informed consent to participate.
2.2. Patients During the study period, 258 patients (169 women and 89 men) from the catchment area made a suicide attempt and came into contact with the Suicide Prevention Clinic. 61 patients were excluded due to exclusion criteria above, 50 patients did not want to participate in the study and 47 patients were not proposed to participate due to reasons like initial refusal to have a clinical follow-up, holiday period, or moving to another part of the country. A total of 100 suicide attempters (67 women and 33 men) were enrolled in the study. The mean age of the patients was 34 years (SD=12.4; range 18—67). The mean age did not differ between men and women. Eighteen patients had used a violent SA method, according to the criteria proposed by Träskman and colleagues (Träskman, Asberg, Bertilsson, et al., 1981). These criteria include the use of all violent methods (e.g., hanging, firearm, jumping from a high place, car exhaust) whereas suicide attempts involving drug overdose or superficial phlebotomy are classified as non-violent. Information of NSSI and earlier SA could be obtained in 80 patients. 32 patients had made an earlier SA, the mean number of earlier attempts was 2.5, range=2 -4. The mean age of onset of suicidal behaviour (age at first attempt) was 24 years (SD=11.8; range 12-
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51) in suicide attempters with earlier SA compared to mean age of onset of 36 years (SD=13.3; range 18-63) in suicide attempters without earlier SA. Of the 80 patients, 16 had used a violent attempt method. The participants were interviewed by a trained psychiatrist using the SCID I research version interview to establish the diagnosis assessed by DSM-IV (First, Spitzer, Gibbon, et al., 1996). Trained clinical psychologists
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established Axis II diagnoses by DIP-I-interviews (Ottosson, Bodlund, Ekselius, et al., 1995). All self-rating scales were completed under the supervision of a research nurse.
86% of the participants had at least one current Axis I psychiatric diagnosis.
Among the Axis I diagnoses, 71% of patients met the criteria for mood disorders (unipolar major depressive disorder, single episode or recurrent, bipolar disorder, depressed or dysthymic disorder), 5% for adjustment disorder, 6% for anxiety disorders, 4% for diagnosis of alcohol abuse. Twenty-five patients had a comorbid anxiety disorder, 12% had a comorbid substance-related disorder (mostly alcohol dependence) and 4% had a comorbid eating disorder (bulimia nervosa). Among the Axis II diagnoses, 28% of the patients met the criteria for a personality disorder.
2.3. Assessments The Karolinska Suicide History Interview (KSH). NSSI was assessed with the Karolinska Suicide History, a semi-structured interview collecting information on suicide attempts and NSSI. NSSI is assessed through four questions assessing intent (i.e. “Have you ever harmed yourself on purpose, without intent to die?”), methods, reasons for self-harm and
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degree of planning (i.e. “Do you usually plan your self-harm episodes?”). The Karolinska Interpersonal Violence Scale can be seen in the Appendix.
The Freeman scale (Freeman, Wilson, Thigpen, et al., 1974) is a measure of reversibility and interruption probability of the SA. A high score in the first part of the scale indicates
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‘low reversibility of suicidal method' (i.e. serious attempt, for example, a gunshot in head or trunk of body) and a low score indicates ‘high reversibility' (i.e. non-serious attempt), based on the type and quantity of drugs used or the extent of self-injury inflicted. In the second part of Freeman scale, the likelihood that someone would interrupt the attempt is rated (Freeman interruption probability). The rating ranges from certain intervention, (eg. act committed in presence of other), to remote chance of being interrupted, (eg. act committed in isolated setting without the possibility to call help). Individual responses are coded on a 1–5 scale and the total Freeman range is between 2 and 10.
The Karolinska Interpersonal Violence Scale, KIVS (Jokinen, Forslund, Ahnemark, et al., 2010) contains four subscales assessing exposure to violence and expressed violent behaviour in childhood (between 6-14 years of age) and during adult life (15 years or older). The ratings are based on a semi-structured interview.
2.4. Data Analysis Initial analyses were carried out to evaluate skewness and kurtosis of the distributions with Shapiro Wilk test. In continuous variables, group differences were analysed using Student’s t-test in normally distributed data (corrected for unequal variance when
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appropriate according to Levene’s Test for Equality of Variances) or with Mann-Whitney in non-normally distributed data. χ2 was used for cross tabulations of categorical variables, except in cases of less than 5 in any cell where Fisher’s exact test was used. Tests of non-parametric or parametric correlations were performed using Spearman rho or Pearson's r, respectively. A standard multiple regression analysis was conducted to
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determine whether lifetime violent behaviour could be predicted by NSSI status corrected for age, comorbid borderline personality disorder and comorbid substance abuse.
3. RESULTS 3.1 Frequency Of Non-Suicidal Self-Harm In Suicide Attempters, Clinical Comparisons Information on NSSI from KSH was available in 80 patients (52 women, 28 men).
The clinical characteristics did not differ between 80 patients with NSSI data compared to those who did not have NSSI assessed with the structured interview KSH. Nearly half (44%, n=35) of the suicide attempters reported a history of NSSI. Concerning the frequency of NSSI, 51.4% (n=18) reported that they had harmed themselves less than 5 times, whereas 40% (n=14) of those who reported NSSI history had harmed themselves more than 10 times. The most commonly reported method of NSSI was cutting 74% (n=26), 23% (n=8) had used several different methods of self-harm.
There were no gender differences in the reported history of NSSI (p=0.72) or the frequency of NSSI (p=0.81). Suicide attempters with NSSI were younger (mean age 29 years, SD=8.4, range 18-48 years) than those without NSSI (mean age 40 years,
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SD=13.7, range 19-67 years), t (1, 74.45) =4.37, p < 0.0001, d=0.96. The frequency of NSSI showed a significant negative correlation with age (rho=-0.34, p=0.002).
Comorbidity with any Axis 2 diagnosis was significantly higher in suicide attempters with NSSI (χ2=12.1, p=0.0005, Cramer’s V=0.41), 76% (16/21) of suicide attempters
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with any Axis 2 diagnosis reported NSSI compared to 31% (16/51) of suicide attempters without Axis 2 comorbidity. As expected, all patients with comorbid borderline personality disorder reported NSSI. Presence of NSSI did not differ in suicide attempters with and without comorbidity with substance abuse (p=0.62). The depression severity did not differ in suicide attempters with and without NSSI (p=0.72).
3.2. Suicidal Behaviour 32 suicide attempters (40%) had made an earlier SA. Suicide attempters with NSSI showed a trend to report more often prior SAs (18/35 vs 14/45; χ2=3.4, p=0.07). Broken down by gender, only female suicide attempters with a history of NSSI reported more often prior SAs (13/22 vs 8/30; p=0.02, Fisher exact 2-sided). The number of earlier SAs showed a significant positive correlation with frequency of NSSI (rho=0.22, p=0.049). Broken down by gender, the number of earlier SAs showed a significant positive correlation with frequency of NSSI in female suicide attempters (rho=0.32, p=0.02), but not in males (p=0.81).
History of NSSI showed a trend to be more frequent in suicide attempters who had used a violent SA method when included in the study (10/35 vs 6/45; χ2=2.9, p=0.09). Broken
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down by gender, history of NSSI was significantly associated with a choice of a violent SA method in male suicide attempters (7/13 vs 2/15; p=0.04, Fisher exact 2-sided), but not in females (3/22 vs 4/30; p=0.99).
Suicide attempters who had used a violent SA method reported significantly higher
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frequency of NSSI (Z=2.1, p=0.04, Mann-Whitney). Broken down by gender, only male suicide attempters who had used a violent SA method reported significantly higher frequency of NSSI (Z=2.1, p=0.04, Mann-Whitney).
The Freeman rating (total, reversibility and interruption probability, Table 1) did not differ between suicide attempters with and without NSSI (p=0.91; p=0.85; p=0.75) or correlate significantly with NSSI frequency (p=0.57; p=0.51; p=0.99).
3.3 Interpersonal Violence And Trauma History Suicide attempters with NSSI reported significantly more expressed interpersonal violence as an adult (mean=1.5, median=2, SD=1.2, range=0-4) compared with suicide attempters without NSSI (mean=0.7, median=0, SD=1.1, range=0-5) (Z=3.0, p=0.003), Figure 1. The mean exposure to interpersonal violence as a child did not differ between suicide attempters with NSSI (mean=2, median=2, SD=1.5, range=0-5) compared to suicide attempters without NSSI (mean=1.7, median=2, SD=1.4, range=0-4) (Z=0.77, p=0.44).
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A standard multiple regression analysis based on the results in correlation analyses was conducted with NSSI status, comorbid borderline personality disorder, comorbid substance abuse and age as predictors of expressed interpersonal violence as an adult, entered simultaneously as predictors. The regression model was significant, RSq=0.15, DF=4, p=0.03. The history of NSSI was the only significant predictor of expressed
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interpersonal violence in the regression model, Table 2.
4. DISCUSSION In this cohort of suicide attempters, 44% reported a history of NSSI, which is somewhat lower than earlier reported prevalence rates between 57%-65% for comorbid NSSI in adults with previous SA (Andover & Gibb, 2010; Stanley, Gameroff, Michalsen, et al., 2001). Interestingly one third of the suicide attempters without comorbid Axis 2 diagnosis reported NSSI indicating that both behaviours have a high degree of comorbidity even in suicide attempters without personality disorder diagnosis, which is in line with recent research on NSSI as a proposed separate diagnostic entity (Glenn & Klonsky, 2013; Selby, Bender, Gordon, et al., 2012).
We found a history of NSSI to be related to more severe suicidal behaviour. Female suicide attempters with NSSI-history reported significantly more often prior SAs and the number of earlier SAs showed a significant positive correlation with frequency of NSSI, which is in line with the finding of Andover and Gibb (2010). Interestingly, both history of NSSI and frequency of NSSI were significantly associated with a choice of a more violent SA method in male suicide attempters indicating that comorbid NSSI is
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associated with higher severity of suicidal behaviour and that there may be a gender difference. Suicide attempt and suicide differ in age and gender pattern and in the choice of method of suicidal behaviour, men using more often violent SA methods (Hawton, 2000). However, the reversibility of suicide attempt method and interruption probability measured with the Freeman scale did not differ between suicide attempters with and
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without NSSI. Our finding of relationship between comorbid NSSI and the severity of suicidal behaviour is in line with Joiner’s theory on NSSI as a gateway (Whitlock, Muehlenkamp, Eckenrode, et al., 2013) to increased severity of suicidal behaviours through habituation to self-inflicted pain and reduction of fear associated with self-harm.
There was also a significant association between NSSI and expressed interpersonal violence as adults in suicide attempters. Further, a history of NSSI was the only significant predictor of expressed interpersonal violence as adults even after controlling for borderline personality disorder, substance abuse and age. However, the level of exposure to interpersonal violence as a child did not differ between suicide attempters with and without NSSI.
This finding contributes to the already existing association between interpersonal violence and suicidality, and extends this finding to NSSI. Expressed interpersonal violence as an adult may be a marker for increased severity and differentiate individuals with NSSI at increased risk for SA.
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The connection between interpersonal violence and NSSI has not been explored although elevated self-reported ratings of impulsivity and aggression as well as both self- and other- directed hostility have been found in studies of individuals with NSSI and suicidal behaviour (Andover & Gibb, 2010; Dougherty, Mathias, Marsh-Richard, et al., 2009; Guertin, Lloyd-Richardson, Spirito, et al., 2001; Ross & Heath, 2003; Stanley, Gameroff,
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Michalsen, et al., 2001; Swahn, Ali, Bossarte, et al., 2012; Taliaferro, Muehlenkamp, Borowsky, et al., 2012). Individuals with NSSI may represent a group with more impaired self-control (Wilkinson & Goodyer, 2011), which in turn may constitute an increased risk factor for both interpersonal violence and future SA. The association between NSSI and adult expressed interpersonal violence may be seen in relation to earlier reports of link between suicidal and violent behaviors.
In conclusion, history of NSSI was frequent in suicide attempters, related to severity of suicidal behaviour in a gender specific manner and associated with expressed interpersonal violence as an adult. Taken together, suicide attempters need to be assessed concerning NSSI history and early intervention is warranted since comorbidity of both behaviours may be related to a worse outcome through higher propensity to interpersonal violence.
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Guertin, T., Lloyd-Richardson, E., Spirito, A., et al. (2001) ‘Self-mutilative behavior in adolescents who attempt suicide by overdose’, Journal of the American Academy of Child & Adolescent Psychiatry 40(9), 1062–1069. Gvion, Yari and Apter, Alan (2011) ‘Aggression, Impulsivity, and Suicide Behavior: A Review of the Literature’, Archives of Suicide Research 15(2), 93–112.
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Hamza, Chloe A., Stewart, Shannon L. and Willoughby, Teena (2012) ‘Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model’, Clinical Psychology Review 32(6), 482–495. Hawton, K (2000) ‘Sex and suicide. Gender differences in suicidal behaviour’, The British Journal of Psychiatry: the Journal of Mental Science 177, 484–485. Howard, Rick, McCarthy, Lucy, Huband, Nick, et al. (2013) ‘Re-offending in forensic patients released from secure care: the role of antisocial/borderline personality disorder co-morbidity, substance dependence and severe childhood conduct disorder’, Criminal behaviour and mental health: CBMH 23(3), 191–202. Joiner, T. E. (2005) Why People Die by Suicide. Cambridge, MA: Harvard University Press. Jokinen, J., Forslund, K., Ahnemark, E., et al. (2010) ‘Karolinska Interpersonal Violence Scale predicts suicide in suicide attempters’, The Journal of Clinical Psychiatry 71(8), 1025–1032. McGirr, Alexander, Paris, Joel, Lesage, Alain, et al. (2007) ‘Risk factors for suicide completion in borderline personality disorder: a case-control study of cluster B comorbidity and impulsive aggression’, The Journal of clinical psychiatry 68(5), 721– 729.
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Muehlenkamp, J. J. (2005) ‘Self-injurious behavior as a separate clinical syndrome’, The American Journal of Orthopsychiatry 75(2), 324–333. Nock, M. K. (2010) ‘Self-Injury’, Annual Review of Clinical Psychology 6(1), 339–363. Van Orden, Kimberly A., Witte, Tracy K., Cukrowicz, Kelly C., et al. (2010) ‘The interpersonal theory of suicide.’, Psychological Review 117(2), 575–600.
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THE KAROLINSKA INTERPERSONAL VIOLENCE SCALE
The steps of this scale are defined by short statements about violent behaviour. Based on an interview with the subject; use the highest score where one or more of
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the statements apply.
A. Used violence.
As a child (6 - 14 years)
0
No violence.
1
Occasional fights, but no cause for alarm among grown-ups in school or in the
family. 2
Fighter. Been in fights a lot.
3
Often started fights. Hit a comrade who had been bullied. Continued hitting when
the other had surrendered. 4
Initiated bullying. Often hit other children, with fist or object.
5
Caused serious physical injury. Violent toward adult(s). Violent behaviour that led
to intervention by social welfare authorities.
As an adult (15 years or older) 0
No violence.
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1
Slapped or spanked children on occasion. Shoved or shook partner or another
adult. 2
Occasionally smacked partner or child. Fought when drunk.
3
Assaulted partner drunk or sober. Repeated corporal punishment of child. Frequent
fighting when drunk. Hit someone when sober.
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4
Instance of violent sexual abuse. Repeated battering/physical abuse of child or
partner. Assaulted/attacked other persons frequently, drunk or sober. 5
Killed or caused severe bodily harm. Repeated instances of violent sexual abuse.
Convicted of crime of violence.
B. Victim of violence. Childhood (6 - 14 years) 0
No violence.
1
Occasional slaps. Fights in school, of no great significance.
2
Bullied occasionally for short period(s). Occasionally exposed to corporal
punishment. 3
Often bullied. Frequently exposed to corporal punishment. Beaten by drunken
parent. 4
Bullied throughout childhood. Battered/beaten up by schoolmates. Regularly
beaten by parent or another adult. Beaten with objects. Sexually abused. 5
Repeated exposure to violence at home or in school that resulted at least once in
serious bodily harm. Repeated sexual abuse, or sexual abuse that resulted in bodily harm.
Adulthood (15 years or older)
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0
No violence.
1
Threatened or subjected to a low level of violence on at least one occasion.
2
Beaten by partner on occasion. Victim of purse snatching. Threatened with object.
3
Threatened with a weapon. Robbed. Beaten by someone other than partner.
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Frequently beaten by partner. 4
Raped. Battered.
5
Repeatedly raped. Repeatedly battered. Severely battered, resulting in serious
bodily harm.
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Table 1. The Freeman scale ratings in suicide attempters Ratings
Mean
Median
S.D.
Range
Freeman reversibility
2.8
3
0.8
1-5
2.6
2
1.0
1-5
5.4
5
1.5
2-10
of the suicide attempt method (N=80)
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Freeman interruption probability (N=80) Freeman total(N=80)
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Table 2. NSSI as a predictor of expressed interpersonal violence as an adult in suicide attempters. t ratio p value
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NSSI+
2.30
0.025*
Borderline personality disorder 0.16
0.88
Comorbid substance abuse
1.20
0.25
age
-0.69 0.49
* p
ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: http://www.tandfonline.com/loi/usui20
Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters Hanna Sahlin-Berg, Tomas Moberg, Tatja Hirvikoski & Jussi Jokinen To cite this article: Hanna Sahlin-Berg, Tomas Moberg, Tatja Hirvikoski & Jussi Jokinen (2015): Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters, Archives of Suicide Research, DOI: 10.1080/13811118.2015.1004487 To link to this article: http://dx.doi.org/10.1080/13811118.2015.1004487
Accepted online: 16 Apr 2015.
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Date: 14 October 2015, At: 14:05
Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters Hanna Sahlin-Berg1 , Tomas Moberg1, Tatja Hirvikoski2, Jussi Jokinen1 1
Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet Karolinska University Hospital, Solna, Stockholm, Sweden, 2Department of Molecular Medicine and Surgery, Centre for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Address for correspondence: Jussi Jokinen, Department of Clinical Neuroscience/Psychiatry, Karolinska Institutet, R5, Karolinska University Hospital/Solna, SE-171 76 Stockholm, Sweden. E-Mail: [email protected]
Abstract Objectives: The current study compared characteristics of suicidal behaviour and interpersonal violence in suicide attempters with and without a history of non-suicidal self-injury (NSSI).
Methods: A total of 100 suicide attempters were assessed with Karolinska Interpersonal Violence Scale (KIVS) and Karolinska Suicide History Interview concerning interpersonal violence and NSSI.
Results: There was a high degree of comorbid NSSI in suicide attempters (44%). Suicide attempters with NSSI-history reported more interpersonal violence as adults and more severe suicidal behaviour compared to suicide attempters without NSSI. Comorbid NSSI was related to severity of suicidal behaviour in gender specific manner.
Conclusion: Comorbid NSSI in suicide attempters may increase suicide and violence risk
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KEYWORDS: Suicide attempt, non-suicidal self-injury, interpersonal violence, gender difference
1. INTRODUCTION Non-suicidal self-injury (NSSI) has been defined as self-directed deliberate destruction of
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bodily tissue in the absence of suicidal intent, whereas suicidal behaviour has been defined as an act of intentionally terminating one’s own life (Nock, 2010). Although NSSI and suicidal behaviour differ in several ways regarding intent, frequency and lethality (Muehlenkamp, 2005), there is increasing evidence for NSSI as a risk factor for future suicidal behaviour (Victor & Klonsky, 2014; Whitlock, Muehlenkamp, Eckenrode, et al., 2013)
NSSI is listed in the DSM-5 (American Psychiatric Association, 2013) as a criterion of Borderline personality disorder (BPD) and has until recently mainly been associated with that disorder as both suicidal and non-suicidal self-injurious behaviour is highly prevalent among individuals with BPD (Yen, Shea, Sanislow, et al., 2004). A growing body of research suggests that NSSI is common among individuals who do not fulfill criteria for BPD, and that NSSI in itself is associated with comorbid depression, anxiety and functional impairment (Selby, Bender, Gordon, et al., 2012).
Research involving both clinical and non-clinical populations suggests that there is a high comorbidity between NSSI-behaviour and suicide attempts (SA) and that individuals who engage in both NSSI and SA have more complex psychopathology, lower psychosocial
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functioning and more aggression and impulsivity than individuals with NSSI alone or SA alone (Hamza, Stewart & Willoughby, 2012; Swahn, Ali, Bossarte, et al., 2012; Stanley, Gameroff, Michalsen, et al., 2001). Among adult inpatients both with and without BPD, a history of NSSI has been associated with earlier suicide attempts (SA), greater lethal intent – or underestimation of lethality of SA – and as NSSI frequency increased, the
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number of SA increased (Andover & Gibb, 2010; Stanley, Gameroff, Michalsen, et al., 2001).
Similar patterns have been found for adolescents with a history of NSSI (Whitlock, Muehlenkamp, Eckenrode, et al., 2013; Asarnow, Porta, Spirito, et al., 2011; Wilkinson, Kelvin, Roberts, et al., 2011). The reason for this association is still unclear but Joiner (Joiner, 2005)has proposed that NSSI and other fear-inducing and aggressive acts may habituate the individual for the pain and fear associated with a suicide attempt, a theory that has gained increasing support over the years (Van Orden, Witte, Cukrowicz, et al., 2010).
There is a strong link between suicidal behaviour and aggression. A history of violence and aggressive behaviour is associated with higher frequency of SA, more violent SA and probability of lifetime suicidal thoughts and behaviours (Gvion & Apter, 2011). These findings seem to be explained by co-occurring Cluster-B personality disorders, mainly BPD and Antisocial personality disorder. BPD has been associated with impulsive aggression and violent acts (Fountoulakis, Leucht & Kaprinis, 2008), as well as more suicidal behavior, especially if combined with antisocial personality disorder (Howard,
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McCarthy, Huband, et al., 2013; McGirr, Paris, Lesage, et al., 2007), but the connection may not be evident in all groups of BPD patients (Allen & Links, 2012).
Both exposure to interpersonal violence as a child and expressed violent behaviour as an adult are risk factors for completed suicide in suicide attempters as reported in a long-
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term follow-up study (Jokinen, Forslund, Ahnemark, et al., 2010). Another risk factor for suicide is the choice of a violent SA method (Runeson, Tidemalm, Dahlin, et al., 2010). It is theorized that partly the same biological mechanisms may be involved in aggression and violent suicidal behaviour (Placidi, Oquendo, Malone, et al., 2001).
The current study compares characteristics of suicidal behaviour in suicide attempters with and without a history of NSSI. We hypothesized that suicide attempters with a history of NSSI would report more interpersonal violence and have more serious suicidal behavior in form of choice of suicide attempt method or repetition of suicide attempts. Since many studies of suicidal behaviour have shown gender differences (Hawton, 2000), we also assessed men and women separately.
2. METHODS 2.1. Study Setting Patients having their clinical follow-up after attempted suicide at the Suicide Prevention Clinic of the Karolinska University Hospital were invited to participate in the study of biological and psychological risk factors for suicidal behaviour. Inclusion criteria were a recent SA (time limit of 1 month), fair capacity to communicate verbally and in writing in
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the Swedish language and age 18 years or older. Exclusion criteria were schizophrenia spectrum psychosis, dementia, mental retardation and intravenous drug abuse. A suicide attempt was defined as a self-destructive act with some degree of intent to die. Patients were recruited during 2001—2005. The Regional Ethics Review Board in Stockholm approved the study protocol (Dnr. 00-194) and the participants gave their written
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informed consent to participate.
2.2. Patients During the study period, 258 patients (169 women and 89 men) from the catchment area made a suicide attempt and came into contact with the Suicide Prevention Clinic. 61 patients were excluded due to exclusion criteria above, 50 patients did not want to participate in the study and 47 patients were not proposed to participate due to reasons like initial refusal to have a clinical follow-up, holiday period, or moving to another part of the country. A total of 100 suicide attempters (67 women and 33 men) were enrolled in the study. The mean age of the patients was 34 years (SD=12.4; range 18—67). The mean age did not differ between men and women. Eighteen patients had used a violent SA method, according to the criteria proposed by Träskman and colleagues (Träskman, Asberg, Bertilsson, et al., 1981). These criteria include the use of all violent methods (e.g., hanging, firearm, jumping from a high place, car exhaust) whereas suicide attempts involving drug overdose or superficial phlebotomy are classified as non-violent. Information of NSSI and earlier SA could be obtained in 80 patients. 32 patients had made an earlier SA, the mean number of earlier attempts was 2.5, range=2 -4. The mean age of onset of suicidal behaviour (age at first attempt) was 24 years (SD=11.8; range 12-
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51) in suicide attempters with earlier SA compared to mean age of onset of 36 years (SD=13.3; range 18-63) in suicide attempters without earlier SA. Of the 80 patients, 16 had used a violent attempt method. The participants were interviewed by a trained psychiatrist using the SCID I research version interview to establish the diagnosis assessed by DSM-IV (First, Spitzer, Gibbon, et al., 1996). Trained clinical psychologists
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established Axis II diagnoses by DIP-I-interviews (Ottosson, Bodlund, Ekselius, et al., 1995). All self-rating scales were completed under the supervision of a research nurse.
86% of the participants had at least one current Axis I psychiatric diagnosis.
Among the Axis I diagnoses, 71% of patients met the criteria for mood disorders (unipolar major depressive disorder, single episode or recurrent, bipolar disorder, depressed or dysthymic disorder), 5% for adjustment disorder, 6% for anxiety disorders, 4% for diagnosis of alcohol abuse. Twenty-five patients had a comorbid anxiety disorder, 12% had a comorbid substance-related disorder (mostly alcohol dependence) and 4% had a comorbid eating disorder (bulimia nervosa). Among the Axis II diagnoses, 28% of the patients met the criteria for a personality disorder.
2.3. Assessments The Karolinska Suicide History Interview (KSH). NSSI was assessed with the Karolinska Suicide History, a semi-structured interview collecting information on suicide attempts and NSSI. NSSI is assessed through four questions assessing intent (i.e. “Have you ever harmed yourself on purpose, without intent to die?”), methods, reasons for self-harm and
6
degree of planning (i.e. “Do you usually plan your self-harm episodes?”). The Karolinska Interpersonal Violence Scale can be seen in the Appendix.
The Freeman scale (Freeman, Wilson, Thigpen, et al., 1974) is a measure of reversibility and interruption probability of the SA. A high score in the first part of the scale indicates
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‘low reversibility of suicidal method' (i.e. serious attempt, for example, a gunshot in head or trunk of body) and a low score indicates ‘high reversibility' (i.e. non-serious attempt), based on the type and quantity of drugs used or the extent of self-injury inflicted. In the second part of Freeman scale, the likelihood that someone would interrupt the attempt is rated (Freeman interruption probability). The rating ranges from certain intervention, (eg. act committed in presence of other), to remote chance of being interrupted, (eg. act committed in isolated setting without the possibility to call help). Individual responses are coded on a 1–5 scale and the total Freeman range is between 2 and 10.
The Karolinska Interpersonal Violence Scale, KIVS (Jokinen, Forslund, Ahnemark, et al., 2010) contains four subscales assessing exposure to violence and expressed violent behaviour in childhood (between 6-14 years of age) and during adult life (15 years or older). The ratings are based on a semi-structured interview.
2.4. Data Analysis Initial analyses were carried out to evaluate skewness and kurtosis of the distributions with Shapiro Wilk test. In continuous variables, group differences were analysed using Student’s t-test in normally distributed data (corrected for unequal variance when
7
appropriate according to Levene’s Test for Equality of Variances) or with Mann-Whitney in non-normally distributed data. χ2 was used for cross tabulations of categorical variables, except in cases of less than 5 in any cell where Fisher’s exact test was used. Tests of non-parametric or parametric correlations were performed using Spearman rho or Pearson's r, respectively. A standard multiple regression analysis was conducted to
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determine whether lifetime violent behaviour could be predicted by NSSI status corrected for age, comorbid borderline personality disorder and comorbid substance abuse.
3. RESULTS 3.1 Frequency Of Non-Suicidal Self-Harm In Suicide Attempters, Clinical Comparisons Information on NSSI from KSH was available in 80 patients (52 women, 28 men).
The clinical characteristics did not differ between 80 patients with NSSI data compared to those who did not have NSSI assessed with the structured interview KSH. Nearly half (44%, n=35) of the suicide attempters reported a history of NSSI. Concerning the frequency of NSSI, 51.4% (n=18) reported that they had harmed themselves less than 5 times, whereas 40% (n=14) of those who reported NSSI history had harmed themselves more than 10 times. The most commonly reported method of NSSI was cutting 74% (n=26), 23% (n=8) had used several different methods of self-harm.
There were no gender differences in the reported history of NSSI (p=0.72) or the frequency of NSSI (p=0.81). Suicide attempters with NSSI were younger (mean age 29 years, SD=8.4, range 18-48 years) than those without NSSI (mean age 40 years,
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SD=13.7, range 19-67 years), t (1, 74.45) =4.37, p < 0.0001, d=0.96. The frequency of NSSI showed a significant negative correlation with age (rho=-0.34, p=0.002).
Comorbidity with any Axis 2 diagnosis was significantly higher in suicide attempters with NSSI (χ2=12.1, p=0.0005, Cramer’s V=0.41), 76% (16/21) of suicide attempters
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with any Axis 2 diagnosis reported NSSI compared to 31% (16/51) of suicide attempters without Axis 2 comorbidity. As expected, all patients with comorbid borderline personality disorder reported NSSI. Presence of NSSI did not differ in suicide attempters with and without comorbidity with substance abuse (p=0.62). The depression severity did not differ in suicide attempters with and without NSSI (p=0.72).
3.2. Suicidal Behaviour 32 suicide attempters (40%) had made an earlier SA. Suicide attempters with NSSI showed a trend to report more often prior SAs (18/35 vs 14/45; χ2=3.4, p=0.07). Broken down by gender, only female suicide attempters with a history of NSSI reported more often prior SAs (13/22 vs 8/30; p=0.02, Fisher exact 2-sided). The number of earlier SAs showed a significant positive correlation with frequency of NSSI (rho=0.22, p=0.049). Broken down by gender, the number of earlier SAs showed a significant positive correlation with frequency of NSSI in female suicide attempters (rho=0.32, p=0.02), but not in males (p=0.81).
History of NSSI showed a trend to be more frequent in suicide attempters who had used a violent SA method when included in the study (10/35 vs 6/45; χ2=2.9, p=0.09). Broken
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down by gender, history of NSSI was significantly associated with a choice of a violent SA method in male suicide attempters (7/13 vs 2/15; p=0.04, Fisher exact 2-sided), but not in females (3/22 vs 4/30; p=0.99).
Suicide attempters who had used a violent SA method reported significantly higher
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frequency of NSSI (Z=2.1, p=0.04, Mann-Whitney). Broken down by gender, only male suicide attempters who had used a violent SA method reported significantly higher frequency of NSSI (Z=2.1, p=0.04, Mann-Whitney).
The Freeman rating (total, reversibility and interruption probability, Table 1) did not differ between suicide attempters with and without NSSI (p=0.91; p=0.85; p=0.75) or correlate significantly with NSSI frequency (p=0.57; p=0.51; p=0.99).
3.3 Interpersonal Violence And Trauma History Suicide attempters with NSSI reported significantly more expressed interpersonal violence as an adult (mean=1.5, median=2, SD=1.2, range=0-4) compared with suicide attempters without NSSI (mean=0.7, median=0, SD=1.1, range=0-5) (Z=3.0, p=0.003), Figure 1. The mean exposure to interpersonal violence as a child did not differ between suicide attempters with NSSI (mean=2, median=2, SD=1.5, range=0-5) compared to suicide attempters without NSSI (mean=1.7, median=2, SD=1.4, range=0-4) (Z=0.77, p=0.44).
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A standard multiple regression analysis based on the results in correlation analyses was conducted with NSSI status, comorbid borderline personality disorder, comorbid substance abuse and age as predictors of expressed interpersonal violence as an adult, entered simultaneously as predictors. The regression model was significant, RSq=0.15, DF=4, p=0.03. The history of NSSI was the only significant predictor of expressed
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interpersonal violence in the regression model, Table 2.
4. DISCUSSION In this cohort of suicide attempters, 44% reported a history of NSSI, which is somewhat lower than earlier reported prevalence rates between 57%-65% for comorbid NSSI in adults with previous SA (Andover & Gibb, 2010; Stanley, Gameroff, Michalsen, et al., 2001). Interestingly one third of the suicide attempters without comorbid Axis 2 diagnosis reported NSSI indicating that both behaviours have a high degree of comorbidity even in suicide attempters without personality disorder diagnosis, which is in line with recent research on NSSI as a proposed separate diagnostic entity (Glenn & Klonsky, 2013; Selby, Bender, Gordon, et al., 2012).
We found a history of NSSI to be related to more severe suicidal behaviour. Female suicide attempters with NSSI-history reported significantly more often prior SAs and the number of earlier SAs showed a significant positive correlation with frequency of NSSI, which is in line with the finding of Andover and Gibb (2010). Interestingly, both history of NSSI and frequency of NSSI were significantly associated with a choice of a more violent SA method in male suicide attempters indicating that comorbid NSSI is
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associated with higher severity of suicidal behaviour and that there may be a gender difference. Suicide attempt and suicide differ in age and gender pattern and in the choice of method of suicidal behaviour, men using more often violent SA methods (Hawton, 2000). However, the reversibility of suicide attempt method and interruption probability measured with the Freeman scale did not differ between suicide attempters with and
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without NSSI. Our finding of relationship between comorbid NSSI and the severity of suicidal behaviour is in line with Joiner’s theory on NSSI as a gateway (Whitlock, Muehlenkamp, Eckenrode, et al., 2013) to increased severity of suicidal behaviours through habituation to self-inflicted pain and reduction of fear associated with self-harm.
There was also a significant association between NSSI and expressed interpersonal violence as adults in suicide attempters. Further, a history of NSSI was the only significant predictor of expressed interpersonal violence as adults even after controlling for borderline personality disorder, substance abuse and age. However, the level of exposure to interpersonal violence as a child did not differ between suicide attempters with and without NSSI.
This finding contributes to the already existing association between interpersonal violence and suicidality, and extends this finding to NSSI. Expressed interpersonal violence as an adult may be a marker for increased severity and differentiate individuals with NSSI at increased risk for SA.
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The connection between interpersonal violence and NSSI has not been explored although elevated self-reported ratings of impulsivity and aggression as well as both self- and other- directed hostility have been found in studies of individuals with NSSI and suicidal behaviour (Andover & Gibb, 2010; Dougherty, Mathias, Marsh-Richard, et al., 2009; Guertin, Lloyd-Richardson, Spirito, et al., 2001; Ross & Heath, 2003; Stanley, Gameroff,
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Michalsen, et al., 2001; Swahn, Ali, Bossarte, et al., 2012; Taliaferro, Muehlenkamp, Borowsky, et al., 2012). Individuals with NSSI may represent a group with more impaired self-control (Wilkinson & Goodyer, 2011), which in turn may constitute an increased risk factor for both interpersonal violence and future SA. The association between NSSI and adult expressed interpersonal violence may be seen in relation to earlier reports of link between suicidal and violent behaviors.
In conclusion, history of NSSI was frequent in suicide attempters, related to severity of suicidal behaviour in a gender specific manner and associated with expressed interpersonal violence as an adult. Taken together, suicide attempters need to be assessed concerning NSSI history and early intervention is warranted since comorbidity of both behaviours may be related to a worse outcome through higher propensity to interpersonal violence.
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Guertin, T., Lloyd-Richardson, E., Spirito, A., et al. (2001) ‘Self-mutilative behavior in adolescents who attempt suicide by overdose’, Journal of the American Academy of Child & Adolescent Psychiatry 40(9), 1062–1069. Gvion, Yari and Apter, Alan (2011) ‘Aggression, Impulsivity, and Suicide Behavior: A Review of the Literature’, Archives of Suicide Research 15(2), 93–112.
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Hamza, Chloe A., Stewart, Shannon L. and Willoughby, Teena (2012) ‘Examining the link between nonsuicidal self-injury and suicidal behavior: A review of the literature and an integrated model’, Clinical Psychology Review 32(6), 482–495. Hawton, K (2000) ‘Sex and suicide. Gender differences in suicidal behaviour’, The British Journal of Psychiatry: the Journal of Mental Science 177, 484–485. Howard, Rick, McCarthy, Lucy, Huband, Nick, et al. (2013) ‘Re-offending in forensic patients released from secure care: the role of antisocial/borderline personality disorder co-morbidity, substance dependence and severe childhood conduct disorder’, Criminal behaviour and mental health: CBMH 23(3), 191–202. Joiner, T. E. (2005) Why People Die by Suicide. Cambridge, MA: Harvard University Press. Jokinen, J., Forslund, K., Ahnemark, E., et al. (2010) ‘Karolinska Interpersonal Violence Scale predicts suicide in suicide attempters’, The Journal of Clinical Psychiatry 71(8), 1025–1032. McGirr, Alexander, Paris, Joel, Lesage, Alain, et al. (2007) ‘Risk factors for suicide completion in borderline personality disorder: a case-control study of cluster B comorbidity and impulsive aggression’, The Journal of clinical psychiatry 68(5), 721– 729.
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Muehlenkamp, J. J. (2005) ‘Self-injurious behavior as a separate clinical syndrome’, The American Journal of Orthopsychiatry 75(2), 324–333. Nock, M. K. (2010) ‘Self-Injury’, Annual Review of Clinical Psychology 6(1), 339–363. Van Orden, Kimberly A., Witte, Tracy K., Cukrowicz, Kelly C., et al. (2010) ‘The interpersonal theory of suicide.’, Psychological Review 117(2), 575–600.
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Ottosson, H., Bodlund, O., Ekselius, L., et al. (1995) ‘The DSM-IV and ICD-10 personality questionnaire (DIP-Q): Construction and preliminary validation’, Nordic Journal of Psychiatry 49(4), 285–292. Placidi, G. P., Oquendo, M. A., Malone, K. M., et al. (2001) ‘Aggressivity, suicide attempts, and depression: relationship to cerebrospinal fluid monoamine metabolite levels’, Biological Psychiatry 50(10), 783–791. Ross, S. and Heath, N. L. (2003) ‘Two Models of Adolescent Self-Mutilation’, Suicide and Life-Threatening Behavior 33(3), 277–287. Runeson, B., Tidemalm, D., Dahlin, M., et al. (2010) ‘Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study’, British Medical Journal 340, c3222–c3222. Selby, Edward A., Bender, Theodore W., Gordon, Kathryn H., et al. (2012) ‘Non-suicidal self-injury (NSSI) disorder: A preliminary study.’, Personality Disorders: Theory, Research, and Treatment 3(2), 167–175. Stanley, B., Gameroff, M. J., Michalsen, V., et al. (2001) ‘Are suicide attempters who self-mutilate a unique population?’, American Journal of Psychiatry 158(3), 427–432. Swahn, Monica H., Ali, Bina, Bossarte, Robert M., et al. (2012) ‘Self-Harm and Suicide Attempts among High-Risk, Urban Youth in the U.S.: Shared and Unique Risk and
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Träskman, L, Asberg, M, Bertilsson, L, et al. (1981) ‘Monoamine metabolites in CSF and suicidal behavior’, Archives of General Psychiatry 38(6), 631–636. Victor, Sarah E. and Klonsky, E. David (2014) ‘Correlates of suicide attempts among self-injurers: A meta-analysis’, Clinical Psychology Review 34(4), 282–297. Whitlock, Janis, Muehlenkamp, Jennifer, Eckenrode, John, et al. (2013) ‘Nonsuicidal Self-injury as a Gateway to Suicide in Young Adults’, Journal of Adolescent Health 52(4), 486–492. Wilkinson, P. and Goodyer, I. (2011) ‘Non-suicidal self-injury’, European Child & Adolescent Psychiatry 20(2), 103–108. Wilkinson, P., Kelvin, R., Roberts, C., et al. (2011) ‘Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT)’, American Journal of Psychiatry 168(5), 495–501. Yen, Shirley, Shea, M. Tracie, Sanislow, Charles A., et al. (2004) ‘Borderline Personality Disorder Criteria Associated With Prospectively Observed Suicidal Behavior’, American Journal of Psychiatry 161(7), 1296–1298.
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THE KAROLINSKA INTERPERSONAL VIOLENCE SCALE
The steps of this scale are defined by short statements about violent behaviour. Based on an interview with the subject; use the highest score where one or more of
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the statements apply.
A. Used violence.
As a child (6 - 14 years)
0
No violence.
1
Occasional fights, but no cause for alarm among grown-ups in school or in the
family. 2
Fighter. Been in fights a lot.
3
Often started fights. Hit a comrade who had been bullied. Continued hitting when
the other had surrendered. 4
Initiated bullying. Often hit other children, with fist or object.
5
Caused serious physical injury. Violent toward adult(s). Violent behaviour that led
to intervention by social welfare authorities.
As an adult (15 years or older) 0
No violence.
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1
Slapped or spanked children on occasion. Shoved or shook partner or another
adult. 2
Occasionally smacked partner or child. Fought when drunk.
3
Assaulted partner drunk or sober. Repeated corporal punishment of child. Frequent
fighting when drunk. Hit someone when sober.
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4
Instance of violent sexual abuse. Repeated battering/physical abuse of child or
partner. Assaulted/attacked other persons frequently, drunk or sober. 5
Killed or caused severe bodily harm. Repeated instances of violent sexual abuse.
Convicted of crime of violence.
B. Victim of violence. Childhood (6 - 14 years) 0
No violence.
1
Occasional slaps. Fights in school, of no great significance.
2
Bullied occasionally for short period(s). Occasionally exposed to corporal
punishment. 3
Often bullied. Frequently exposed to corporal punishment. Beaten by drunken
parent. 4
Bullied throughout childhood. Battered/beaten up by schoolmates. Regularly
beaten by parent or another adult. Beaten with objects. Sexually abused. 5
Repeated exposure to violence at home or in school that resulted at least once in
serious bodily harm. Repeated sexual abuse, or sexual abuse that resulted in bodily harm.
Adulthood (15 years or older)
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0
No violence.
1
Threatened or subjected to a low level of violence on at least one occasion.
2
Beaten by partner on occasion. Victim of purse snatching. Threatened with object.
3
Threatened with a weapon. Robbed. Beaten by someone other than partner.
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Frequently beaten by partner. 4
Raped. Battered.
5
Repeatedly raped. Repeatedly battered. Severely battered, resulting in serious
bodily harm.
20
Table 1. The Freeman scale ratings in suicide attempters Ratings
Mean
Median
S.D.
Range
Freeman reversibility
2.8
3
0.8
1-5
2.6
2
1.0
1-5
5.4
5
1.5
2-10
of the suicide attempt method (N=80)
Downloaded by [University of Nebraska, Lincoln] at 14:05 14 October 2015
Freeman interruption probability (N=80) Freeman total(N=80)
21
Table 2. NSSI as a predictor of expressed interpersonal violence as an adult in suicide attempters. t ratio p value
Downloaded by [University of Nebraska, Lincoln] at 14:05 14 October 2015
NSSI+
2.30
0.025*
Borderline personality disorder 0.16
0.88
Comorbid substance abuse
1.20
0.25
age
-0.69 0.49
* p
