Combining the Suicide Intent Scale and the Karolinska Interpersonal Violence Scale in suicide risk assessments.

BACKGROUND: High suicide intent, childhood trauma, and violent behavior are risk factors for suicide in suicide attempters. The aim of this study was to investigate whether the combined assessment of suicide intent and interpersonal violence would provide a better prediction of suicide risk than an assessment of only suicide intent or interpersonal violence. METHODS: This is a cohort study involving 81 suicide attempters included in the study between 1993 and 1998. Patients were assessed with both the Suicide Intent Scale (SIS) and the Karolinska Interpersonal Violence Scale (KIVS). Through the unique personal identification number in Sweden, patients were linked to the Cause of Death Register maintained by the Swedish National Board of Health and Welfare. Suicides were ascertained from the death certificates. RESULTS: Seven of 14 patients who had died before April 2013 had committed suicide. The positive predictive value for the Suicide Intent Scale alone was 16.7 %, with a specificity of 52 % and an area under the curve of 0.74. A combined assessment with the KIVS gave higher specificity (63 %) and a positive predictive value of 18.8 % with an AUC of 0.83. Combined use of SIS and KIVS expressed interpersonal violence as an adult subscale gave a sensitivity of 83.3 %, a specificity of 80.3 %, and a positive predictive value of 26 % with an AUC of 0.85. The correlation between KIVS and SIS scores was not significant. CONCLUSIONS: Using both the the SIS and the KIVS combined may be better for predicting completed suicide than using them separately. The nonsignificant correlation between the scales indicates that they measure different components of suicide risk.

High interleukin-6 and impulsivity: determining the role of endophenotypes in attempted suicide.

The dysregulation of inflammation has been associated with depression and, more recently, with suicidal behaviors. The reports regarding the relationship between interleukin-6 (IL-6) and suicide attempts are inconsistent. Personality traits such as impulsivity and aggression are considered endophenotypes and important factors that underlie suicidal behaviors. The aim of the current study was to assess whether plasma and cerebrospinal fluid (CSF) levels of IL-6 are associated with personality traits among suicide attempters. We assessed the relationships among personality traits, IL-6 and violent suicide attempts. The plasma and CSF levels of IL-6 were measured in suicide attempters (plasma=58, CSF=39) using antibody-based immunoassay systems. Personality domains were assessed using the Karolinska Scale of Personality (KSP). IL-6 levels in plasma and CSF were used to predict personality domains via regression models. Plasma IL-6 was significantly and positively correlated with extraversion as well as the KSP subscales impulsivity and monotony avoidance. CSF IL-6 was positively correlated with monotony avoidance. Violent suicide attempts tended to be associated with high plasma IL-6 levels. Plasma and CSF levels of IL-6 were not significantly associated with each other. These results indicate that impulsivity and the choice of a violent suicide attempt method might be related to higher levels of IL-6 in individuals who attempt suicide. The neuroinflammation hypothesis of suicidal behavior on the basis of elevated IL-6 levels might be partly explained by the positive association between IL-6 and impulsivity, which is a key element of the suicidal phenotype.

Low vascular endothelial growth factor and interleukin-8 in cerebrospinal fluid of suicide attempters.

A dysregulated immune system influencing pathways for cytokine regulation and growth factor expression is implicated in the pathophysiology of several neuropsychiatric disorders. Here, we analyzed cerebrospinal fluid (CSF) cytokines and growth factors with an ultra-sensitive immunoassay system in 43 medication-free suicide attempters and 20 healthy male volunteers. CSF vascular endothelial growth factor (VEGF) and CSF interleukin-8 (IL-8) levels were significantly lower in suicide attempters compared with healthy controls. Further, CSF VEGF showed a significant negative correlation with depression severity. CSF IL-6 levels did not differ between suicide attempters and healthy controls. Low CSF levels of VEGF may represent a lack of trophic support to neurons and downregulation of neurogenesis in the hippocampus reflecting more severe depressive states. IL-8 has also been reported as important in neuroprotection as well as having chemokine activity in the innate immune response. The results support a role for an impaired innate immunity and dysregulation of neuroprotection in the pathophysiology of depression and suicidal behavior.

CSF 5-HIAA and exposure to and expression of interpersonal violence in suicide attempters.

BACKGROUND: Serotonin is implicated in impaired impulse control, aggression and suicidal behaviour. Low cerebrospinal fluid (CSF) concentrations of the serotonin metabolite 5-hydroxyindoleacetic acid (5-HIAA) have been found in violent suicide attempters, suicide victims and in violent offenders. CSF 5-HIAA concentrations have both genetic and environmental determinants. Childhood trauma may have an effect on central monoamine function as an adult. AIM: The aim of this study was to assess the relationship of CSF 5-HIAA and the exposure to and the expression of violence in childhood and during adult life measured with the Karolinska Interpersonal Violence Scale (KIVS). METHOD: 42 medication free suicide attempters underwent lumbar puncture and were assessed with the Karolinska Interpersonal Violence Scale (KIVS) to assess history of childhood exposure to violence and lifetime expressed violent behaviour. RESULTS: In women, but not in men, CSF 5-HIAA showed a significant negative correlation to exposure to violence during childhood. Furthermore, suicide attempters with low CSF 5-HIAA were more prone to commit violent acts as an adult if exposed to violence as a child compared to suicide attempters with high CSF 5-HIAA. In the non-traumatized group, CSF 5-HIAA showed a significant negative correlation to expressed violent behaviour in childhood. CONCLUSIONS: Although central serotonergic function has important genetic determinants, exposure to childhood trauma may also affect serotonergic function. Low serotonergic function may facilitate impaired aggression control in traumatized suicide attempters.

The serotonin transporter gene polymorphism (5-HTTLPR) and affective symptoms among women diagnosed with borderline personality disorder.

Gene variants of the serotonin transporter have been associated with vulnerability to affective disorders. In particular, the presence of one or two copies of the short (s) allele of the 5-HTTLPR polymorphism has been associated with reduced serotonin transporter expression and function, and vulnerability to affective disorders. To test for an association between variants of the serotonin transporter gene polymorphism (5-HTTLPR) and relevant clinical features of borderline personality disorder (BPD), a psychiatric disorder with symptoms characteristic for serotonin dysfunction, 77 women with BPD were genotyped in the 5-HTTLPR polymorphism. They rated their subjective experience of borderline-specific, depressive, anxious and obsessive-compulsive symptoms, and were interviewed about lifetime incidence of suicide attempts and self-harming acts. Carriers of two s alleles of the 5-HTTLPR reported more symptoms of borderline, depression, anxiety and obsessive-compulsive behaviours, but not of suicidal and self-injury behaviour, compared to carriers of a long (l) allele. This indicates that the 5-HTTLPR ss homozygous genotype might influence serotonin function affecting susceptibility to both borderline-specific, depressive, anxious and obsessive-compulsive symptoms in BPD, and leading to a more severe symptomatology related to these clinical features. Further, this suggests that 5-HTT gene variants may not be as influential on suicidal and self-injury behaviour in BPD.

Gingival inflammation, increased periodontal pocket depth and elevated interleukin-6 in gingival crevicular fluid of depressed women on long-term sick leave.

BACKGROUND AND OBJECTIVE: The aim of this work was to investigate periodontal status, in relation to inflammatory markers and cortisol, in the gingival crevicular fluid and saliva of a homogenous group of women on long-term sick leave for job-stress related depression in comparison to nondepressed women. MATERIAL AND METHODS: The participants comprised 20 women with depression (DSM-IV) (mean age 48.5 +/- 6.9 years) and 29 healthy controls (mean age 54.5 +/- 2.9 years). Clinical examination was performed. Gingival crevicular fluid was collected by an intracrevicular washing technique. Interleukin-1 beta, interleukin-6, matrix metalloproteinase (MMP)-8 and MMP-9 were determined with enzyme-linked immunosorbent assay and cortisol was determined by using a radioimmunoassay. One-way analysis of covariance was used as the statistical method. RESULTS: The depressed patients had significantly higher gingival inflammation (p < 0.001), and deeper pockets (p < 0.003), than the healthy controls, after adjusting for age and smoking. The levels of interleukin-6 in the gingival crevicular fluid were significantly higher in the patients than in the controls: 3.84 +/- 1.58 pg per site and 0.79 +/- 1.83 pg per site, respectively, p < 0.003. There were no significant differences in the levels of interleukin-1 beta, MMP-8 and MMP-9. The patients had lower cortisol values in gingival crevicular fluid than the controls, whereas the levels of cortisol in saliva were similar in both groups. CONCLUSION: Women on long-term sick-leave for depression had more severe periodontitis and higher concentrations of interleukin-6 in gingival crevicular fluid than healthy controls. An alteration of the immune system in these patients might be interpreted as reflecting the consequences of long-term stress exposure and might contribute to worse periodontal conditions in these particular patients.

Stress and burnout in psychiatric professionals when starting to use dialectical behavioural therapy in the work with young self-harming women showing borderline personality symptoms.

The aim of the study was to investigate how starting to use dialectical behavioural therapy (DBT) in the work with young self-harming women showing symptoms of borderline personality disorder affected the psychiatric professionals (n = 22) experience of occupational stress and levels of professional burnout. The study was carried out in relation to an 18-month clinical psychiatric development project, and used a mix of quantitative and qualitative research methods [a burnout inventory, the Maslach burnout inventory-General Survey (MBI-GS), free format questionnaires and group interviews]. The result confirms previous reports that psychiatric health professionals experience treatment of self-harming patients as very stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients. The teamwork and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some therapists felt also improved their handling of other work stressors not related to DBT. The inventory for professional burnout, the MBI-GS, showed no significant changes over the 18-month period, although there was a tendency for increased burnout levels at the 6-month assessment, which had returned to baseline levels at 18 months.

Psychological factors in irritable bowel syndrome: a population-based study of patients, non-patients and controls.

BACKGROUND: It has been suggested that psychopathology in irritable bowel syndrome (IBS) patients is a function of patient status rather than of the disease. Although there are many studies comparing IBS patients, IBS non-patients, and controls with each other, no previous study has recruited all three groups from a representative community sample and had all subjects diagnosed by a physician. In the present study we aimed to compare psychological factors in IBS patients, IBS non-patients, and normal controls in a sample recruited from the population. METHODS: Subjects aged 18-45 years were recruited from a random sample of the normal population. Seventeen (2 M and 15 F) IBS patients were matched by sex and age with IBS non-patients and normals. Measures of personality traits, interpersonal distress, and temporary psychological distress were used. A physician diagnosed all 51 subjects in order to exclude possible gastrointestinal diagnoses other than IBS. RESULTS: Controls often differed from IBS non-patients and patients on the personality, interpersonal, and psychological distress measures, while IBS non-patients and patients very rarely differed from each other. All three groups were non-alexithymic. CONCLUSIONS: The results indicate that there are psychopathological differences between normals and IBS persons (patients and non-patients), but they could not confirm that psychopathology was a function of patient status. Whether this psychopathology is a vulnerability factor for IBS, or a consequence of it, remains to be studied.

Psychological Factors in Irritable Bowel Syndrome: a Population-based Study of Patients, Non-patients and Controls.

BACKGROUND: It has been suggested that psychopathology in irritable bowel syndrome (IBS) patients is a function of patient status rather than of the disease. Although there are many studies comparing IBS patients, IBS non-patients, and controls with each other, no previous study has recruited all three groups from a representative community sample and had all subjects diagnosed by a physician. In the present study we aimed to compare psychological factors in IBS patients, IBS non-patients, and normal controls in a sample recruited from the population. METHODS: Subjects aged 18-45 years were recruited from a random sample of the normal population. Seventeen (2 M and 15 F) IBS patients were matched by sex and age with IBS non-patients and normals. Measures of personality traits, interpersonal distress, and temporary psychological distress were used. A physician diagnosed all 51 subjects in order to exclude possible gastrointestinal diagnoses other than IBS. RESULTS: Controls often differed from IBS non-patients and patients on the personality, interpersonal, and psychological distress measures, while IBS non-patients and patients very rarely differed from each other. All three groups were non-alexithymic. CONCLUSIONS: The results indicate that there are psychopathological differences between normals and IBS persons (patients and non-patients), but they could not confirm that psychopathology was a function of patient status. Whether this psychopathology is a vulnerability factor for IBS, or a consequence of it, remains to be studied.

No association between a promoter dopamine D(4) receptor gene variant and schizophrenia.

The dopamine D(4) receptor has been implicated in the pathogenesis of schizophrenia. An association between a putative functional promoter polymorphism (-521C/T) in the dopamine D(4) receptor gene (DRD4) and schizophrenia was recently reported. In the present study, patients with schizophrenia (n = 132) and control subjects (n = 388) were analyzed with respect to the DRD4 - 521C/T polymorphism. No significant case control differences emerged. The present results do not support a major role for DRD4 in the etiology of schizophrenia among Caucasians from Sweden.

No association between serotonin 2A receptor gene variants and personality traits.

Among theories of biological underpinnings to personality traits, different mechanisms of the serotonergic system are perhaps the most common factors suggested to influence individual differences in personality traits. We have investigated two frequent variants in the serotonin 2A receptor gene (5-HT2A) and personality traits. Healthy Swedish subjects (n = 304) were assessed with the Karolinska Scales of Personality (KSP) inventory. After correction for multiple testing, no significant differences were found. We conclude that the investigated 5-HT2A gene variants do not significantly influence personality as assessed by the KSP in the present population.

Androgen receptor trinucleotide repeat polymorphism and personality traits.

Human family and twin studies have established considerable heritable components influencing individual differences in personality traits as assessed by self-report questionnaires. We have investigated a trinucleotide repeat polymorphism in the androgen receptor gene and personality traits. Healthy Swedish subjects (n = 335) were assessed with the Karolinska Scales of Personality inventory. There were tendencies (P > or = 0.006) in some scales indicating possible relationships between the androgen receptor allele length and personality traits related to dominance and aggression. However, after correction for multiple testing, no significant differences were found. We conclude that no significant association could be found between the androgen receptor polymorphism investigated and any personality trait, although the tendencies found are worthwhile subjects for replication attempts.

Excess tryptophan hydroxylase 17 779C allele in surviving cotwins of monozygotic twin suicide victims.

OBJECTIVE: To evaluate the relationship of the tryptophan hydroxylase (TPH) genotype to suicidality by the study of surviving monozygotic (MZ) cotwins of twins who committed suicide. METHOD: Twenty-four surviving Swedish MZ twins whose MZ cotwins had committed suicide were compared to 158 demographically sampled Swedish general population controls for TPH alleles. We also examined serotonin transporter alleles. RESULTS: The living MZ cotwins of suicide victims had a significantly higher TPH 17 779C allele frequency than controls. No significant difference was observed for serotonin transporter alleles. CONCLUSION: These results, in a small sample, suggest the possibility that the 17 779C allele of the TPH gene may be associated with an increased risk of suicide. Further studies in larger samples are needed.

A comparison between the Beck Depression Inventory (BDI) and the self-rating version of the Montgomery Asberg Depression Rating Scale (MADRS).

BACKGROUND: The Beck Depression Inventory BDI is the most often used self-rating instrument for depressive symptoms. In the present study, the BDI was compared with a self-rating version of the Montgomery Asberg Depression Rating Scale (MADRS-S) in 86 psychiatric patients with mainly affective and anxiety disorders. METHODS: The patients were interviewed with the SCID-I Interview for a DSM-IV Major depression, and self-assessed the BDI and the MADRS. They were rated to have either mild, moderate or severe depressive symptomatology. After recovery, criteria for DSM-IV Personality disorders were self-assessed. RESULTS: The instruments were about equal in differentiating between different Axis-I diagnoses and did not differ according to sensitivity to change during antidepressive treatment. Although the scales were highly intercorrelated (r=0.869), the BDI was demonstrated to tap more maladaptive personality traits compared to the MADRS-S. LIMITATIONS: Because the sample consisted of psychiatric patients with prominent psychiatric symptomatology, the discriminative power of the BDI and the MADRS-S should be further evaluated in a sample with milder symptoms. CONCLUSIONS: The MADRS-S is equivalent to the BDI as a self-assessment instrument for depression, but the MADRS-S focuses on core depressive symptoms, and is less influenced by maladaptive personality traits.

The genotype of human transcription factor AP-2beta is associated with platelet monoamine oxidase B activity.

Platelet monoamine oxidase B (MAO; EC 1.4.3.4.) activity is stable in the individual and is mainly genetically regulated. Levels of MAO-B in platelets have repeatedly been shown to be associated with personality traits. We have recently also demonstrated an association between the genotype of AP-2beta to a variety of personality traits as well as binge-eating disorder. In the present study we have analysed blood samples from 158 males and 64 females with regard to platelet MAO activity and genotype of transcription factor AP-2beta. In both sexes homozygotes for the long allele [CAAA](5) were significantly associated with low platelet MAO activity P<0.0001 (males) and P=0.0158 (females). This study represents a novel approach to increase the understanding about the molecular mechanisms for how the MAOB gene is regulated in blood cells and how this regulation is linked to personality traits.

Psychiatric care as seen by the attempted suicide patient.

Psychiatric care as seen by the attempted suicide patient This study highlights the experiences of patients during in-patient psychiatric care in Sweden following a suicide attempt. Eighteen patients were interviewed as close to being discharged as possible. Each respondent was asked to narrate his/her experiences of the care received. An interview guide concerned the following areas: admission to the hospital, feelings and reactions, and positive as well as negative experiences during the hospital stay. The interviews were transcribed verbatim and a qualitative content analysis concerning the meanings, intuitions, consequences and the context of the data was performed. Three central categories were identified: being a psychiatric patient, patients' perceptions of the caregivers and the care provided, as well as important aspects of the psychiatric care received. The importance of being well cared for and receiving understanding and confirmation was emphasized. Lack of confirmation may have contributed in some cases to a feeling of being burdensome, demands for discharge or even another suicide attempt. Verbal contacts with the staff were seen as essential for the process of healing and for the desire to go on living.

Suicide attempts and impulse control disorder are related to low cerebrospinal fluid 5-HIAA in mentally disordered violent offenders.

OBJECTIVE: The aim of this study was to investigate the relationship between low cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA) and aggressive acts in mentally disordered violent offenders. METHOD: CSF concentrations of 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid and 4-hydroxy-3-methoxyphenyl glycol were measured in 35 drug-free men convicted of homicide and currently undergoing forensic psychiatric investigation in a high security hospital. RESULTS: The mean metabolite concentrations in the homicide offenders did not differ from those of age- and body-height matched male control subjects. One-third of the murderers had made one or several suicide attempts, and their mean concentration of spinal fluid 5-HIAA was significantly lower than that of the remaining murderers. Subjects with impulse control disorder also had lower mean CSF 5-HIAA. A consistent pattern of higher CSF 5-HIAA in subjects with more self-reported anxiety traits was observed. CONCLUSION: The association between serotonin and suicidal behaviour holds for yet another subject group. Determining CSF 5-HIAA might be worth while in the routine assessment of psychiatrically ill homicide offenders.

Season of birth variations in dimensions of functioning evaluated by the diagnostic interview for borderline patients.

In view of recent reports showing that cerebrospinal fluid (CSF) levels of monoamine metabolites exhibit season of birth variations, and that they are also associated with section II (impulse action patterns) of the diagnostic interview for borderline patients (DIB), we analyzed two samples of data to investigate the relationship between the season of birth and the DIB. The first sample comprised 202 patients participating in psychobiological research in Stockholm, and the second sample comprised 130 patients who had committed suicide in Västerbotten in northern Sweden. Those with intermediate score for section II (impulse action patterns) were significantly more likely to have been born during the season October to January in the pooled data, and this tendency persisted in separate analyses for the two samples and for the two diagnostic groups mood disorders and schizophrenia, respectively. Those with high score for section IV (psychosis) were significantly more likely to have been born during February to April in the pooled sample and in the nonschizophrenic group. In the group with schizophrenia, those born during February to April had significantly high scores for section III (affects). These results throw further light on the role of season of birth in suicidology and in psychiatric morbidity.

A population study on irritable bowel syndrome and mental health.

BACKGROUND: Irritable bowel syndrome (IBS) is commonly thought to be associated with psychologic distress. However, in some studies only persons who had sought medical care for IBS (IBS patients) showed an increased frequency of psychiatric symptoms, and nonpatients did not differ significantly from normal subjects. Our aims were 1) to estimate the prevalence of IBS in the population aged 18-45 years, 2) to find the proportion seeking medical care for IBS, and 3) to compare IBS subjects with normals, and IBS patients with IBS nonpatients with regard to mental health. METHODS: Questionnaires on IBS symptoms and the General Health Questionnaire (GHQ) were mailed to 5000 randomly sampled persons aged 18-45 years. The response rate was 58%. RESULTS: IBS was found in 7.4% of the men and 13.3% of the women. Those who had sought medical attention had more severe symptoms. The Likert mean score on the GHQ was 4.7 (95% confidence interval, 4.4-5.0) points higher for the IBS group than for normals (P < 0.001). There was no difference in GHQ scores between IBS patients and nonpatients. CONCLUSIONS: The results indicate that IBS per se is associated with more psychiatric distress, regardless of medical care-seeking. Seeking medical care is associated with more severe IBS symptoms.

Associations between plasma glucose and DSM-III-R cluster B personality traits in psychiatric outpatients.

Associations between personality traits, measured with the Karolinska Scales of Personality, the Impulsiveness subscale from the Impulsiveness, Venturesomeness and Empathy (IVE) Inventory, and with self-assessed personality traits and disorders (SCID-II Screen Questionnaire), and plasma insulin, glucagon and glucose, respectively, were explored in a sample of 101 psychiatric outpatients of both sexes. No relationships between the peptide hormones and personality measures were found. However, fasting glucose values, which were all essentially within the normal biological variation, were significantly related to several personality measures. For males, a low blood glucose was associated with low stable general level of functioning, with high IVE Impulsiveness, and with self-assessed histrionic and narcissistic traits. High number of self-assessed personality traits for all cluster B personality disorders was strongly associated with high IVE Impulsiveness. The results of the present study support the generalizability of earlier findings from alcoholic impulsive offenders: in males, low blood glucose is associated with an extrovert and impulsive, acting-out behavior that includes the breaking of societal norms and rules. In contrast, for females a positive relationship between fasting glucose and self-assessed histrionic personality traits was found. Because no association between global level of functioning and glucose was found in women, these personality traits may not necessarily be maladaptive, as was the case for males.