Recent Life Events Preceding Suicide Attempts in a Personality Disorder Sample: Findings From the Collaborative Longitudinal Personality Disorders Study Journal of Consulting and Clinical Psychology Vol 73. No. 1,

Introduction 2

Suicides and suicide attempts are often precipitated by particularly stressful life events. Few studies have examined the relationship between life events, suicidal behaviors, and personality disorders. Whether individuals with PDs are particularly vulnerable to suicidal behaviors in the face of recent, stressful life events? Studies that have focused on the relationship between life events, suicidal behaviors, and PDs have reported mixed findings. 3

It remains uncertain as to whether life events are predictive of suicidal behavior in the context of severe psychopathology, such as BPD, and whether life events may have differential effects for different types of suicide behaviors. Although negative events frequently found to precede suicidal behaviors, the impact of value-neutral or even positive life events on suicidal behavior is inconclusive. Different type of life events may also exert differential effects on factor that may affect the relationship between life events and suicidal behaviors. Furthermore, different types of life events may have different effects depending on diagnosis. 4

Many questions remain as to whether the association between life events and suicidal behaviors is general or specific to the type of life event, whether it is influenced by the social desirability of the life event, and whether it is a significant risk factor beyond psychiatric and other risk factors. Most studies of suicide behavior and life events have been retrospective and have often been based on informant accounts. The Collaborative Longitudinal Personality Disorders Study (CLPS) is an ongoing longitudinal follow-up study. 5

The design of the CLPS holds several significant advantages: a large, representative sample of individuals with PDs samples have been carefully diagnosed on the basis of structured clinical interviews prior to suicidal behavior(s); the administration of a wide rang of assessments; a prospective design. 6

Hypotheses Participants in a PD sample who experienced a negative life event, particularly with regard to romantic relationships, would have a significant risk of imminent suicidal behaviors in the 1-2 months following the event; These negative life events would be significant predictors, even after we controlled for variables that have been strongly demonstrated to predict suicide attempts; Those with more severe psychopathology and/or functional impairment at baseline would demonstrate a greater vulnerability to suicide attempts when faced with stressful life events. 7

Models would be tested specific types of life events as predictors in a univariate model; the interaction of baseline GAF and life events; a full model containing significant life event(s) and/or significant GAF-life event interaction with covariates of BPD, MDD, alcohol and substance use disorders, and childhood sexual abuse. 8

Method 9

The CLPS is a multisite, naturalistic, prospective study of four PD groups: STPD, BPD, AVPD, OCPD, and a comparison group of MDD without PD. Participants Participants between the ages of 18 and 45 years were recruited from treatment clinics or recruited with fliers and advertisements. Individuals with (a) acute substance intoxication or withdrawal, (b) active psychosis, (c) cognitive impairment, or (d) a history of either schizophrenia, schizophreniform, or schizoaffective disorders were excluded. 10

Interviewers had master’s- or doctoral-level training (or equivalent clinical experience) in a mental health related discipline. The total CLPS study group consisted of 668 participants. Participants were interviewed at 6 months,1, 2, and 3 years following the baseline assessment. 65 participants made a suicide attempt. Of these, 59(91%) met full criteria for a study PD and MDD, 2(3%)met criteria for a PD only, and 4(6%)met criteria for MDD only. 11

Because of the skewed distribution, and the differences in enrollment criteria between the PD groups and the MDD comparison group, analyses were restricted to participants in the PD groups. Participants who only endorsed suicidal gestures were also excluded. In the present examination, we focused on the 489 participants with PDs (73% of the original sample) with at least 24 months of follow-up data (baseline, 6-month, and 1- and 2-year interviews). 12

Measures DIPD-IV SCID-I/P LIFE Life Events Assessment (LEA) 13

Data Analyses For each month of the follow-up period, a dichotomous variable was created to represent the onset of domain specific stressors occurring within that month, as assessed by the LEA. Using these scores for each targeted life event category, we conducted Cox’s proportional hazards regression (PHREG) analyses to determine whether experiencing a life event in the month preceding or during a suicide attempt was a significant predictor of the attempt. 14

For each model, a stepwise data analytic strategy was implemented in which the first PHREG analysis was aimed at determining whether valence of life event was predictive of suicidal behavior. The second step involved testing domain categories. If these were significant at p <.01, then specific life event items were tested. 15

Result 16

Of the 489 participants who had a PD diagnosis at baseline and had completed at least 2 years of follow-up evaluation, 61had made a suicide attempt. Of these, 37 had only one attempt, 24 had multiple attempts during 3-year follow-up period. To obviate the potential problem of correlated events, we analyzed only the first suicide attempt for each participant. There were no statistically significant differences between the attempters and nonattempters on the demographic variables. Similarly, there were no significant demographic differences between the present sample and the entire study sample of 668 participants. 17

Of the entire sample, 99.8% reported at least one negative life event, whereas 93.5% reported at least one positive life event. Among the 61 suicide attempters, all reported a negative life event, and 2 participants did not report a positive life event. Of the major categories of negative life events, the most frequently reported were work-related events. This was followed by family-household related events, health related events. Other events that were frequently endorsed included events related to love and marriage, social and recreation matters. Crime and legal events were endorsed at significantly bigger proportion in the suicide attempt group. 18

There were no significant differences between PD suicide attempters and PD nonattempters for any other class of events. Results from the proportional hazards regression analyses with the basic model that contained no covariates showed that negative events were predictive of suicide attempts in the following month(s) (HR=2.82, p<.001). Examinations of the eight life event categories yielded love-marriage (HR=3.55, p<.001) and crime-legal (HR=3.51, p<.001) were significant predictors of suicide attempt within the following 1-2 months. However the interaction term of Life Event * GAF Score was not significant for any of the life event categories. 19

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Discussion 22

Limitations The same life event may bring about different emotional consequences depending on the circumstances. The instrument used in this study did not assess participants subjective experiences of each of their significant life events, and this lack of distinction may have obscured some of our fingdings. The determination of positive and negative events was not instrument based but rather was made by a team of three investigators. We did not assess daily hassles or chronic stress, experiences that can also predict suicidal behaviors. 23

This study is the first to find significant associations between negative interpersonal events and suicidal behaviors in a PD sample with a prospective design and time-varying analyses. Our study design and statistical analyses enabled us to determine that specific events carry imminent risk for a suicide attempt in the month of, or the month following, the onset of the event. It was a robust finding that negative events pertaining to love-marriage and crime-legal matters remained even after controlling for numerous other risk factors for suicidal behavior. 24

Despite the robustness of the love-marriage event category as being a significant predictor of suicide attempts, no particular event in this category stood out as being significantly associated with suicide attempts. This is most likely a result of the relatively small cell sizes in each of there event categories. However it may be that the way in which an event affects an individual is more meaningful than the occurrence of such an event. In contrast to the love-marriage event category, analyses of specific types of crime-legal events determined that some specific events were associated with a significant risk factor. 25

The result of the present study clearly suggest that negative life events are significantly associated with suicide attempts. Individuals experiencing events relating to love-marriage are 3-times more likely to make a subsequent suicide attempt within the next 1-2 months compared with those who have not experienced a negative love-marriage event. Those who reported crime-legal events are 2.5 times more likely to make a suicide attempt compared with those who have not had such experiences. 26

Pathways that link stressful life events and suicidal behaviors most likely include mediating and moderating variables. Many have speculated that the relationship between life events and negative outcomes follows a diathesis stress model. Future longitudinal studies are needed to examine the process by which life events affect suicidal behavior and should examine cognitive and psychological processes that shape how an event is appraised and how individuals cope or respond to such events. 27

Comments 28

Advantages To find the associations between negative life events and suicidal behaviors in a PD sample with a prospective design Analyze predictability of negative life events to suicide attempts by Cox’s proportional hazards regression analyses 29

Questions Why chose samples with years old? Why chose such four PD group? Whether having suicide completes in this study or not? This study did not consider the relation between the number of negative life and suicide behavior. It is interesting only love-marriage and crime-legal were significant predictors of suicide attempt and no special event pertaining to love and marriage was significant. 30

Significances for our study The project on the role of impulsiveness and acute precipitating life events in attempted and completed suicide in China A case control study (retrospective study) Involved personality disorder and life events evaluation in suicide attempters, suicide completers, community residences and accidental deaths. Life events questionnaire include 9 event categories and 71 specific events. Whether generating negative effect from life events or not is decided by respondents. 31

We assess the beginning time and lasting time of life events, assess the effective days and effective degree of the life events to the subject, and whether having negative effect or not at the same time of suicidal behavior. It seems like that our evaluation about life events (including acute stress, chronic stress and daily hassles) is more reasonable. And we evaluate all 12 PDs by SCID-II. We should consider how to find potential mediating and moderating variables (eg. impulsive or aggressive characteristic) that link stressful life events and suicidal behaviors in our study. 32

Our study is a retrospective study but we have a twenty minutes interview to talk about the process of suicide behavior. One part of the interview content involve: What make him/her to have suicide ideation? How dose such problems affect him/her? Do you consider other method to resolve such problems? Is there anyone can help you to resolve such problems? We should consider: Are these questions enough if we want to examine the process that life events affect suicidal behavior ; to examine cognitive and psychological processes that shape how an event; and how individuals cope or respond to such events? 33

Thanks for your attention 34