Comparison of non-suicidal self-injurious behavior and suicide attempts in patients admitted to a psychiatric crisis unit

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Abstract

The aim of the current study was to examine differences in personality, coping skills, and select psychopathology symptoms in psychiatric patients with and without non-suicidal self-injury and/or suicide attempts. We collected data in a sample of 128 psychiatric patients by means of self-report questionnaires measuring self-harm, psychological symptoms, personality and coping skills. Results support a continuum of self-harm such that patients with both non-suicidal self-injury and suicide attempts exhibit significantly greater levels of psychopathology and lower levels of adaptive personality traits and coping skills. The findings point to the clinical importance of making a distinction between non-suicidal self-injury and suicide attempts, and offers additional variables to consider outside of intent when appraising suicide risk.

Introduction

Non-suicidal self-injury (NSSI) is any socially unaccepted behavior involving deliberate and direct injury to one’s own body surface without suicidal intent (Claes & Vandereycken, 2007a). It is estimated that 4.3–20% of adult psychiatric inpatients engage in NSSI and these percentages increase to 40% for adolescent psychiatric inpatients (Klonsky & Muehlenkamp, 2007). Suicide attempts are defined as self-injurious behaviors with intent to die and it has been estimated that approximately 4.6% of individuals have made at least one suicide attempt (Nock & Kessler, 2006). Researchers have noted a high co-occurrence between NSSI and suicide attempts (Jacobson & Gould, 2007) leading some to question the need to differentiate the behaviors. Many argue that self-injuring patients with suicidal intent clearly differ from those without such intent (Nock & Kessler, 2006), with the former being more likely to have potentially lethal injuries and greater psychopathology (Joiner, 2005).

Important differences have been identified between persons reporting NSSI and/or suicide attempts in regards to depressed mood, hopelessness, psychological distress, reasons for living, aggressive symptoms, and functions served by the behavior (Brown et al., 2002, Klonsky, 2007, Muehlenkamp and Gutierrez, 2004, Muehlenkamp and Gutierrez, 2007, Nock and Kazdin, 2002, Nock and Kessler, 2006, Whitlock and Knox, 2007, Whitlock et al., 2008). Significant limitations to these studies are that many used non-clinical populations of adolescents and they failed to examine whether there are clinically meaningful differences in actual coping skills and personality characteristics.

Both suicide attempts and NSSI have been associated with impulsiveness and borderline personality disorder (Andover et al., 2005, Brown et al., 2002, Nock et al., 2006). Persons with suicide attempts have also scored significantly higher than controls on personality characteristics of neuroticism, harm avoidance, and lower on extraversion (Brezo et al., 2006, Calati et al., 2008). Similarly, within a sample of eating disordered patients with(out) NSSI, Claes et al. (2004) found higher levels of neuroticism and lower levels of extraversion among patients with NSSI. While these are valuable results, the studies indicating differences between NSSI and suicide attempt groups are based on predominantly higher functioning, non-clinical, adolescent populations and those with adults are largely restricted to examining BPD features.

The same is true in regards to coping skills. While there is a larger body of literature documenting that persons with suicide attempts have less adaptive problem-solving skills (Speckens & Hawton, 2005), there is only one known study examining specific coping skills in NSSI (Andover, Pepper, & Gibb, 2007) and the sample included relatively high functioning college students. It is important for research to identify whether meaningful differences in core personality traits and coping skills exist between these self-harming groups within psychiatric adult populations to further inform clinical practice.

The purpose of the current study was to compare four groups of psychiatric patients with(out) NSSI and suicide attempts (SA) on personality traits, coping strategies, and clinical symptoms. It was hypothesized that patients without NSSI or SA would show less psychopathology, more adaptive and active coping strategies, and higher levels of extraversion and conscientiousness than the other groups. Furthermore, we expected that patients with both NSSI and SA would show the highest levels of psychopathology and neuroticism, less adaptive coping strategies, and the lowest levels of extraversion and conscientiousness among the self-harm groups.

Section snippets

Participants and procedures

Participants were recruited from 200 admissions to an inpatient psychiatric crisis unit in Belgium between September 2006 and June 2007. The crisis unit is part of a university general hospital and admits patients who are referred by psychiatrists working in the first aid unit of the hospital or, by psychiatrists treating psychiatric outpatients. Patients admitted to the crisis unit suffer from severe psychopathology and are a danger to themselves or others, and/or are unable to remain at home

NSSI and SA

Of the total sample, 36.7% (n = 47) reported at least one type of NSSI. There were no significant gender differences with respect to the presence/absence of NSSI (χ(1)2 = 0.10, ns); 34.4% (N = 11) of the male patients and 37.5% (N = 36) of the female patients reported at least one type of NSSI. A total of 45 patients endorsed at least one suicide attempt, and there were no significant gender differences in the proportion of males and females reporting suicide attempts: 28.1% (N = 9) of the male patients

Discussion

In general the major differences between the four patient groups are congruent with the hypotheses, and consistent with a continuum of severity within self-harm behaviors. Patients without NSSI and SA are at one end of the spectrum showing less psychopathology, less pronounced “pathological” personality traits and more adequate coping strategies. At the opposite end are NSSI + SA patients, who showed the highest levels of psychopathology and relied more on depressive reaction patterns when

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      Individuals who have engaged in NSSI have been shown to be at increased risk of suicidal behaviour (Hamza et al., 2012) and suicide risk among self-harm patients is estimated to be hundreds of times higher than in the general population (Owens et al., 2002). Self-harm behaviour can occur at any age (Hawton et al., 2014; Preyde et al., 2012), yet there are very few studies on NSSI in psychiatric adult populations (Claes et al., 2010). We did not find any studies exploring the co-occurrence of NSSI and suicide ideation across all diagnostic categories in large clinical samples.

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