A chronological perspective on suicide--the last days of life.

A combined psychological autopsy and narrative approach was used to study the completed suicides of 67 Israeli soldiers. Three issues were addressed. First, the authors examined the typology of the life narratives of suicide completed during active army duty. Second, focusing on the last 3 weeks of the soldiers' lives, they sought to examine their triggers for suicide, emotional state of mind, army duty functioning, and communication of suicidal intent. Finally, they examined military responses to communication of intent, help provision, and help acceptance. Four types of narratives were identified: regressive, stable, tragic (progression and sudden collapse), and romantic (ups and downs). During the last days of life, suicide completers exhibited a split between an emotional state of mind (evidencing an emotional deterioration) and a behavioral military functioning, which was mostly stable. The analysis also revealed a resistance to receive help and a resistance to provide help, both of which impeded intervention. The gap between functioning and emotional distress in suicidal individuals and the incongruence between crisis and help are highlighted. The need to educate military personnel to look beyond duty functioning and the need to develop clear guideline about referrals to professional helps are discussed.

Eating-related concerns, mood, and personality traits in recovered bulimia nervosa subjects: a replication study.

OBJECTIVE: Limited data suggest that eating-related concerns and behaviors, disturbances in mood, and altered temperament persist following recovery from bulimia nervosa (BN). METHOD: In order to replicate and extend such findings, 11 women who were long-term recovered from BN (>1 year with no binging, purging, or restricting behaviors, normal weight, and regular menstrual cycles) were compared with 15 healthy volunteer women on the Eating Disorders Invertory-2 (EDI-2), the Beck Depression Inventory, the State Trait Anxiety Inventory, and the Multidimensional Personality Questionnaire (MPQ). RESULTS: Compared with the control women, the recovered BN women showed elevated levels of the EDI-2 subscales of Drive for Thinness, Body Dissatisfaction, Ineffectiveness, Perfectionism, and Social Insecurity, greater depression and anxiety, elevated levels of the MPQ Stress Reaction dimension and the higher-order factor of Negative Emotionality, and lower levels of the MPQ Well Being and Closeness dimensions. DISCUSSION: Core eating and weight-related concerns, dysphoric affect, social discomfort, and personality traits indicative of perfectionism persist following long-term recovery from BN.

Body attitudes and body experiences in suicidal adolescents.

The relationships between cognitive and affective attitudes toward the body, body experiences (dissociation, insensitivity, and lack of control), and suicidal tendencies were examined as a derivative of the hypothesis that bodily attitudes and experiences may facilitate suicidal acting out. Three groups of adolescents (aged 14-18), including suicidal (made a suicide attempt) and nonsuicidal inpatients and controls, were compared with regard to suicidal tendencies, various body aspects, and depression and anxiety. A series of MANOVAs, discriminant analysis, Pearson correlations, and regressions were employed. The results show that the suicidal group differed from the two nonsuicidal groups in feelings toward the body, body protection, and body dissociation. Some aspects of bodily measures discriminated between suicidal and nonsuicidal subjects. In addition, various bodily measures were associated with and statistically predicted suicidal tendencies. The discussion focuses on the web of associations between body attitudes and experiences and their role in suicidal behavior.

Therapeutic empathy with the suicidal wish: principles of therapy with suicidal individuals.

Several principles of therapeutic work with suicidal individuals are described. These principles represent different aspects of therapeutic empathy with the suicidal wish. They are based on a theoretical model that presents suicide as an end result of unbearable mental pain. Mental pain is believed to emerge from reciprocal interactions between biochemical imbalances, life stress, personality factors, pain-producing inner patterns (e.g., self-hate, sense of being dispensable), and facilitators and inhibitors of self-destructive behavior. The therapeutic approach is characterized by an empathic experiential encounter with the death wish, the pain-producing inner patterns, self-destructive tendencies, and the exploration of the most dreadful and frightening inner experiences. An empathic attitude toward the wish to die, coupled by an uncompromised confrontation of self-destructiveness, can provide the hope of discovering a path of compromise with life's difficulties.

Human figure drawings in the evaluation of severe adolescent suicidal behavior.

OBJECTIVE: To evaluate the reliability of using certain indicators derived from human figure drawings to distinguish between suicidal and nonsuicidal adolescents. METHOD: Ninety consecutive admissions to an adolescent inpatient unit were assessed. Thirty-nine patients were admitted because of suicidal behavior and 51 for other reasons. All subjects were given the Human Figure Drawing (HFD) test. HFD was evaluated according to the method of Pfeffer and Richman, and the degree of suicidal behavior was rated by the Child Suicide Potential Scale. RESULTS: The internal reliability was satisfactory. HFD indicators correlated significantly with quantitative measures of suicidal behavior; of these indicators specifically, overall impression of the evaluator enabled the prediction of suicidal behavior and the distinction between suicidal and nonsuicidal inpatients (p < .001). A group of graphic indicators derived from a discriminant analysis formed a function, which was able to identify 84.6% of the suicidal and 76.6% of the nonsuicidal adolescents correctly. Many of the items had a regressive quality. CONCLUSIONS: The HFD is an example of a simple projective test that may have empirical reliability. It may be useful for the assessment of severe suicidal behavior in adolescents.

The subjective experience of problem irresolvability and suicidal behavior: dynamics and measurement.

This article presents the dynamics and measurement of a relatively unstudied concept in children's and adolescents' suicidal behavior: the subjective experience of problem irresolvability (SEPI). This concept relates to the youngsters' sense of lack of control due to being pressured to resolve irresolvable problems within the family circle. The first study describes the construction and factor analysis of the SEPI scale as well as its relationship to suicidal tendencies, perceived parental care, and self-esteem. The second study presents a repeated factor analysis and the association between the SEPI scale and suicidal tendencies, hopelessness, depression, anxiety, and commitment to parents. The results suggest that the scale has a 4-factor structure with sound psychometric properties that distinguish successfully between suicidal adolescents on the one hand, and psychiatric and normal adolescents on the other. The SEPI was also found to be associated with the various studied variables.

Adult attachment style and affect regulation: strategic variations in subjective self-other similarity.

Six studies examined the link between adult attachment style and subjective self-other similarity. In Studies 1-3, data were collected on representations of self-other similarity in the realms of traits and opinions. Studies 4-5 examined the effects of affective inductions on the link between attachment and self-other similarity. Study 6 examined the cognitive maneuvers people differing in attachment style use for changing self-other similarity upon distress arousal. Whereas avoidant persons underestimated self-other similarity and anxious-ambivalent persons overestimated it, secure persons provided more accurate similarity scores. These differences were exacerbated by negative affect and mitigated by positive affect. Insecure persons' distortions resulted from transformations they made in representations of the self and others. Results are discussed in terms of attachment theory.

Self-representation of suicidal adolescents.

This study focused on the self-representations of suicidal adolescent. Twenty-six Israeli suicidal inpatients, 24 nonsuicidal inpatients, and 24 control participants completed scales on suicidal tendencies, the hedonic value of self-representations, the complexity (differentiation, integration) of these self-representations, and the discrepancies among self domains (actual, ideal, ought). Suicidal adolescents showed more negative self-representations, a less differentiated and less integrated organization of self-attributes, and more discrepancies between the 3 assessed domains of the self than did control participants. In addition, compared with psychiatric nonsuicidal participants, suicidal adolescents showed a less complex organization of self-attributes and a higher discrepancy between ideal self and ought self. Results were discussed in terms of the vulnerable self of suicidal adolescents, characterized by uneven processing of positive and negative information, confusion, and simplicity.

Suicidal adolescents and ego defense mechanisms.

OBJECTIVES: To identify defense mechanisms that characterize adolescents with a range of suicidal behaviors and to differentiate them from nonsuicidal adolescents. METHODS: Fifty-five suicidal adolescent inpatients admitted for a definite suicide attempt were compared with 87 adolescent inpatients who had no history of suicide attempt or ideation and 81 nonpatients. Defense mechanisms were assessed by the Ego Defense Scale (EDS) which is part of a larger semistructured interview, the Child Suicide Potential Scale (CSPS), and by a self-report questionnaire, the Life Style Index (LSI). The CSPS was also used to quantity violent and suicidal behaviors. RESULTS: On the LSI suicidal adolescent patients scored higher on denial, displacement, repression, and total defenses than the nonpatients. On the EDS they scored higher on regression, denial, projection, introjection, repression, and total defenses and lower on sublimation. LSI scores on displacement (higher) and on compensation (lower) distinguished suicidal from nonsuicidal inpatients. Denial and regression correlated positively and sublimation correlated negatively with both suicidal and violent behaviors. Introjection and repression correlated with suicidal behavior only. CONCLUSIONS: Overuse of displacement is connected with increased risk for suicidal and aggressive behaviors, while sublimation is probably a protective factor. In addition, several immature ego defenses possibly amplify aggression, which then is directed against the self by the maladaptive overuse of introjection, displacement, and repression.

Thresholds and tolerance of physical pain in suicidal and nonsuicidal adolescents.

It was hypothesized that suicidal inpatient adolescents (n = 38) will exhibit a higher tolerance for physical pain than nonsuicidal inpatients (n = 29) and control participants (n = 34). Participants provided self-reports of hopelessness, dissociation, suicidal tendencies, depression, and anxiety and were administered a series of thermal pain stimuli by means of a Thermal Sensory Analyzer (TSA). The suicidal participants significantly differed from the 2 controls in pain thresholds and tolerance and in most self-report measures, even after controlling for motivation, medication, diagnosis, and length of hospitalization. Significant correlations were found between pain measures and self-report measures. The results were discussed in terms of the role that body experiences play in suicidal behavior.

Repressive coping style and the architecture of emotion-related memories: is their relationship that simple?

The present study re-examines the relationship between repressive coping style and the architecture of emotion-related memories by introducing methodological improvements in the elicitation of these memories. Participants were classified into four repressive coping groups according to the Taylor Manifest Anxiety scale and the Marlowe-Crowne Social Desirability scale. They were then asked to recall personal experiences related to five core relational themes attempting to elicit positive and negative emotions and to rate how they felt in each situation. Results indicated that differences in the architecture of emotion-related memories among the four repressive coping groups depended on the type of the elicited memory. The discussion emphasizes the complexity of the relationship between repressive coping style and the architecture of emotion-related memories and suggests an expansion of the concept of repression.

Perception of physical pain in accident and suicide attempt patients: self-preservation vs self-destruction.

The perception of physical pain and its relationship to psychological variables were examined in emergency-room (ER) patients who were admitted following suicide attempts or accident injuries, and in a control group of community subjects. Two pain measures, involving electric shocks, were administered to the subjects. Psychological variables included hardiness, body image, body satisfaction feelings about the body, stressful events, anxiety and depression. Suicidal subjects endured the highest number of shocks, scored lowest on the appraisal of pain, and scored lowest on psychological hardiness. Moreover, it was found that, among the suicidal subjects, the more negative the scores of psychological variables, the higher the endurance of pain. In accident victim subjects, the relationships were exactly opposite. These results were interpreted as reflecting two different core attitudes towards life under stressful circumstances: a life-destroying tendency in the suicidal subjects vs. a life-preserving tendency in the accident-victim subjects. These two core attitudes indicate different modes of defense: defensive detachment in the suicidal patients and avoidance of stress in the accident victims.

Tolerance for physical pain in suicidal subjects.

This study investigated the tolerance for physical pain in suicidal subjects. Suicidal, psychiatric nonsuicidal, and normal young males and females were administered pain measures including electric shocks, appraisal of shocks, and a measure of thermal pain. Additional study variables included diagnosis, past suicide attempts, severity of suicidal intent, and length of hospitalization. Suicidal individuals showed higher tolerance for pain and appraised the pain as less intense than the other groups, regardless of diagnosis, length of hospitalization, and motivation to participate in the study. These findings were explained as a result of dissociative processes inherent in the development of suicidal tendencies and in terms of pain management strategies.

Defense mechanisms in severe adolescent anorexia nervosa.

OBJECTIVE: To compare ego defense mechanisms in adolescents with anorexia nervosa and other major psychiatric disorders, to defenses in healthy adolescents. METHOD: Thirty-seven patients with anorexia nervosa, 30 with major depressive disorder, 20 with obsessive-compulsive disorder, 53 with borderline personality disorder, 60 with schizophrenia, and 81 healthy controls were assessed with Pfeffer's Ego Defense Scale. RESULTS: Regression, denial, projection, repression, introjection, and total defenses were common to all psychiatric patients and distinguished them from normal adolescents. In addition to these defenses, anorectic patients also used intellectualization more frequently than normal adolescents and psychiatric patients. They used sublimation more than other psychiatric patients. Patients with disorders, apart from obsessive-compulsive disorder, that are considered to be often comorbid with anorexia did not have different defense than schizophrenic patients. CONCLUSIONS: Anorectic adolescents overutilize relatively more mature defenses than do psychiatrically ill adolescents, and they overutilize immature defenses compared with normal adolescents. This combination of mature and immature defenses may be related to the uniquely heterogeneous ego functioning seen in anorectic patients, and it may provide insight into the nature of the psychopathology of anorexia nervosa. It also could have important psychotherapeutic and prognostic value.

Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients.

OBJECTIVE: To determine the relative importance of aggression and depression in adolescent suicide within different diagnostic categories. METHOD: One hundred sixty-three consecutive admissions to an adolescent psychiatric inpatient unit were assessed using a semistructure diagnostic instrument, the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Scores for depression, suicidal behaviors, and violent behaviors were calculated from this assessment. RESULTS: Anorexia nervosa and conduct disorder patients had the highest suicidal behavior scores. In addition, patients with conduct disorder were significantly more violent than patients with major depressive disorder, and scores on the Violent Behavior Scale correlated with suicidal symptoms but not with depressive symptoms. CONCLUSION: Aggression may be as important in some kinds of suicidal behaviors as is depression. Thus it seems that there are hypothetically at least two types of suicidal behaviors during adolescence: a wish to die (depression) and a wish not to be here for a time (impulse control). The first type of suicidal behavior characterizes that seen in disorders with prominent depression such as major depressive disorder and anorexia nervosa, and the second characterizes disorders of impulse control such as conduct disorder.

Attachment styles and repressive defensiveness: the accessibility and architecture of affective memories.

One hundred and twenty Israeli students were classified into secure, avoidant, and anxious-ambivalent attachment groups. They completed scales that tap the construct of repressive defensiveness and recalled early personal experiences of anger, anxiety, sadness, and happiness. Secure people reported moderate defensiveness and low anxiety and had easy access to negative memories without being overwhelmed by the spreading of the dominant emotional tone to nondominant emotions. Anxious-ambivalent people were unable to repress negative affects, reported high anxiety, had easy access to negative memories, and could not inhibit emotional spreading. Avoidant people reported high levels of defensiveness and anxiety and showed low accessibility to negative memories. The discussion emphasizes the parallel between a person's interaction with the social world and the makeup of his or her inner world.

Attitudes toward the body in suicidal, depressed, and normal adolescents.

Our purpose was to investigate the hypothesis that suicidal adolescents, compared with depressed nonsuicidal and nonsuicidal normal adolescents, display a more negative attitude toward their bodies. Scales for suicidal tendencies, dissociative tendencies, perception of actual versus ideal body features, and feelings toward the body were administered to the subjects. The suicidal subjects showed a larger perceived discrepancy between actual versus ideal body features and a more negative feeling toward the body, and scored higher on some aspects of dissociation than the normal group. The suicidal group also displayed more negative feelings toward the body and scored higher on some aspects of dissociation than the depressed group. A series of correlations showed that the higher the suicidal tendency, the higher the dissociation, the larger the discrepancy, and the stronger the negative feelings toward the body. The findings were explained as reflecting unique characteristics of suicidal individuals that develop from early trauma and sadomasochistic relationships. These characteristics may facilitate suicidal behavior.

Dissociation, physical pain, and suicide: a hypothesis.

The hypothesis of this paper states that at least some suicidal individuals are characterized by a disposition toward dissociation manifested in relative insensitivity to physical pain and indifference to their bodies. Three main topics are discussed: dissociation and suicide, psychological aspects of pain, and pain and suicide. Various theoretical and experimental studies suggest that certain stress conditions lead to the development of dissociative tendencies, and that once these tendencies are established, they become an integral part of suicidal behavior. Psychological variables that affect pain tolerance are presented and they include perception, motivation, emotions, and behavioral and cognitive strategies of pain control. These can increase tolerance of pain in suicidal individuals, making the suicidal act possible. The specific relationships of pain and suicide are then introduced through an examination of pain analgesia in the phenomenon of self-harm. The integration of the material suggests that early and continuous stress lead to the simultaneous development of dissociative tendencies (including indifference to the body and pain) and heightened vulnerability to stress. These dispositions may facilitate suicidal behavior in the face of mounting intolerable stress, helplessness, and hopelessness. Preliminary empirical support for the present hypothesis is cited. This hypothesis shifts the focus of attention from the question of what causes suicide to what facilitates suicide, and in so doing suggests new directions for research and therapy.