revista romana de psihiatrie

8/20/2019 Revista Romana de Psihiatrie

1/38

REVISTAROMÂNĂ

dePSIHIATRIE

Vol XVI Nr. 4 December 2014

QUARTERLY

CNCSIS B+ p-ISSN: 1454-7848 e-ISSN: 2068-7176

COMITET DE REDACŢIERedactor şef: Dan PRELIPCEANURedactor-şefidjuncți: Dragoş MARINESCU

Aurel NIREŞTEANCOLECTIV REDACŢIONALDoina COZMANiana DEHELEAN

Marieta GABOŞ GRECUMaria LADEA

Cristinel ŞTEF ĂNESCUCătălina TUDOSE

Secretari de redacţie: Elena C ĂLINESCUValentin MATEI

CONSILIU ŞTIINŢIFICVasile CHIRIŢĂ (membru de onoare

al Academiei de Ştiinţe Medicale,Iaşi)

Michael DAVIDSON (Professor, SacklerSchool of Medicine Tel Aviv Univ.,Mount Sinai School of Medicine,New York)

Virgil EN ĂTESCU (membru al Academiei deŞtiinţ e Medicale, Satu Mare)

oana MICLUŢIA (UMF Cluj-Napoca)Şerban IONESCU (Universitatea

Paris VIII, Universitatea Trois-Rivieres, Quebec)

Mircea L ĂZĂRESCU (membru de onoare al Academiei de Ştiinţ e Medicale,Timisoara)

uan E. MEZZICH (Professor of Psychiatryand Director, Division of PsychiatricEpidemiology and InternationalCenter for Mental Health, MountSinai School of Medicine, New YorkUniversity)

Sorin RIGA (cercetător principal gr.I)

Eliot SOREL (George WashingtonUniversity, Washington DC)

Maria GRIGOROIU-ŞERB ĂNESCU

(cercetător principal gr.I)Tudor UDRIŞTOIU (UMF Craiova)

Teodor T. POSTOLACHE, MD (Director,Mood and Anxiety Program,Department of Psychiatry,University of Maryland School ofMedicine, Baltimore)

Dan RUJESCU (Head of Psychiatric Genomics and Neurobiologyand of Division of Molecular andClinical Neurobiology, Departmentof Psychiatry, Ludwig- Maximilians-University, Munchen)

ARPP

ASOCIAŢIA ROMÂNĂE PSIHIATRIE ŞI PSIHOTERAPIE

www.romjpsychiat.ro

ROMANIAN JOURNAL OF PSYCHIATRY


2/38

CUPRINS


3/38

109

PROF. DR. FLORIN TUDOSE

(5 octombrie 1952 - 12 octombrie 2014)


4/38

110

SPECIAL ARTICLES

SOMATIC CO-MORBIDITIES AND FRAILTY INPATIENTS WITH MENTAL DISORDERS

1 MD, PhD student, Assistant Professor, Physiology II – Neurosciences Department, Faculty of Medicine, Carol Davila University of Medicine and

Pharmacy, Bucharest, Romania. Contact adress: Mihai Viorel Zamfir, Str. Matei Basarab, Nr. 22, Bl. 100, Sc. A, Ap. 3, Bl. 100, Sc. A, Ap. 3, Rm. Vâlcea,

Jud. Vâlcea. Email: [email protected] MD, PhD, Assistant Professor, Psychiatry Department, Clinical Psychiatry Hospital “Prof. Dr. Alex. Obregia“, Faculty of Medicine, Carol DavilaUniversity of Medicine and Pharmacy, Bucharest, Romania3 MD, PhD, Geriatrics and Gerontology Professor at Faculty of Medicine, Carol Davila University of Medicine and Pharmacy; Head of Geriatrics andGerontology Department at Ana Aslan National Institute of Gerontology and Geriatrics, Bucharest, Romania Received May 16, 2014, Revised June 13, 2014, Accepted July 18, 2014

Abstract: Far from being an exception, presence of somatic co-morbidities represents the rule in patients with chronicmental disorders. Co-morbidities can delay diagnosis, caninfluence treatment, are related to complications andaffect survival. From these reasons assessment of co-morbidities become a necessity in clinical research. Oneassessment method is represented by co-morbidity indices.These instruments used mainly in research offer a globalassessment of associated diseases' severity and are usedespecially for mortality prediction. Co-morbidity indicesexclude the primary disease from impact analysis and focus only on cumulated effect of coexistent diseases. Co-morbidity indices are not, however, direct methods ofassessment on health state, for this purpose performance scales are used. Frailty, a new concept useful in researchand also in clinical practice, aims to explain the differentevolution of patients with comparable co-morbidity load. Frailty describes a state of global vulnerability to stressorsthat determines an unfavorable prognosis. Studiedespecially in elderly, frailty is considered a consequence ofmultisystemic physiologic decline encountered in thesecategory of patients. The defining characteristics of frailty

concept are global physiological impairment andunfavorable answer to stressors. Proposed modalities for frailty assessment are multiple, reflecting the lack ofconsensus on defining frailty. Some assessmentinstruments are centered on identification of a clinical pattern, others use clinical global impression, and othersuse a multidimensional approach (including domains likemobility, physical activity, nutritional state, cognition, social support, patient's perception on his own health) orquantifies the number of deficits. Existence of anassociation between mental disorders, somatic co-morbidities and frailty remains to be established by future studies, such studies requiring existance of standardizedinstruments.

Key words: polipathology, frail, assessment.


5/38

111

Somatic co-morbidities in patient with mentaldisorders represent an important public health issue due totheir negative impact on quality of life and life expectancy,and also to high costs associated to care. Far from being anexception, presence of somatic co-morbidities representthe rule in patients with chronic mental disorders.Prevalence of chronic somatic disorders in patients with

severe mental disorders reaches up to 74% (1). Factorscontributing to association between mental and somaticdisorders are multiple: stress, high prevalence of mooddisorders, unhealthy behaviors and life-styles, high

prevalence of smoking, alcohol dependence and drugsaddictions, sedentariness, adverse reactions to drugs,

particularly to antipsychotics (that present a high risk fordeveloping metabolic syndrome and diabetes mellitus) (2-4).

Patients with schizophrenia present high risk ofsomatic morbidity and mortality (5). Life expectancy for

patients with schizophrenia is 20-25 years smaller than forsubjects in general population, and the excess of mortality

cannot be explained only by increased incidence ofsuicide (6). Diabetes mellitus and metabolic syndrome areimportant complications in patients with schizophrenia.Prevalence of diabetes mellitus in these patients isestimated between 9-14%, and the risk of developingdiabetes mellitus is 2-3 times higher in patients withschizophrenia as compared to general population (7).Incidence of diabetes mellitus following treatments withconventional (7.7/1000 years-patient) or atypical(9.8/1000 years-patient) antipsychotics was higher incomparison to general population (3.3/1000 years-

patient) in a cohort from Great Britain (8). Adults orelderly patients with schizophrenia present a 79% increasein cardiovascular risk as compared to general population(9). Increased cardiovascular risk is due not only todiabetes mellitus, but also to dyslipidemia and smoking(10). Respiratory disorders, including chronic obstructive

pulmonary disease and decreased values of pulmonarycapacity are frequently encountered in patients withschizophrenia, that present an Odds Ratio for developingCOPD of 1.88 in comparison to general population (11).

Majority of patients with type I or II bipolardisorder present at least one somatic co-morbidity andmany present multimorbidity (3). Prevalence ofcardiovascular disorders is increased in these patients.Higher prevalence of arterial hypertension represents animportant risk factor for coronary and cerebro-vascular

ischemic events (12). Prevalence of obesity, metabolicsyndrome and diabetes mellitus are significantlyincreased in patients with bipolar disorder (13). Also

patients with bipolar disorder present increased prevalence of various pulmonary disorders (bronchitis,COPD, asthma, thromboembolism), situations that can beexplained by aggregation of risk factors for pulmonarydisorders (smoking, obesity, sedentariness, musculo-skeletal trauma, hypercoagulability, diabetes mellitus,drugs addictions) (13, 14). Increasing weight is a sideeffect associated with most new generationantipsychotics, being present especially for olanzapineand clozapine and more moderate for risperidone and

quetiapine (15). More than half of patients with bipolardisorders present different forms of addictions, between 6-69% alcohol dependence and between 14-60% drugaddictions (16, 17), with important impact on somaticstate.

Although existence of co-morbidities in patientswith depression represents the rule, most of therapeutictrials usually exclude patients with associated medicaldisorders. This situation raises questions on thegeneralization of the results of these types of studies (4).On the other hand, in the study WHO World Health Survey

between 9-23% of patients with chronic disorders

presented also depression, values significantly higher incomparison to persons with no chronic disorders (18). InSTAR*D, with a design that tried to reflect the real profileof co-morbidities, more that 2/3 patients with depression

presented an associated somatic disorders (19). Theseverity of depression is correlated to the level of somaticco-morbidities (20), and the degree of somatic impairmentis correlated to response to antidepressive treatment and tothe incidence of relapses (21, 22). Older patients withhigher number or severity of somatic co-morbidities,indicated by the score of Cumulative Illness Rating Scalefor Geriatrics (CIRS-G), presented increased prevalenceof depression and reduced response to the treatment with

paroxetine in comparison to patients with less severedisorders (22). Depression presents an increased risk foroccurrence and worsening of cardiac disorders. In a meta-analysis, depressive symptoms constituted a significantrisk factor for incident ischemic heart disease with aRelative Risk (1.64) smaller than that of active smoking(2.5) but higher than passive smoking (1.25) (23). Alsodepressive symptoms present after an acute myocardialinfarction are a risk factor for cumulated mortality (24)and depression post acute myocardial infarction isassociated with a 2.25 times higher risk for unfavorablecardiovascular prognosis (25). Anxiety symptoms are alsoassociated with increased incidence and with progressionof cardiac impairment (26, 27).

Between 10% to 20% of patients with diabetesmellitus present depression and the percentage rises to30% for patients with depression diagnosed prior todiabetes (28). Association of diabetes mellitus withdepression determines a reduced compliance to treatmentand increased risk of macro- and microvascularcomplications (29).

The relation between diabetes mellitus anddepression is bidirectional. Presence of depressionconstitutes a risk factor for occurrence of diabetes mellitusand depression treatment is associated with decreasedresistance to insulin, independent of other risk factors(obesity, alcohol abuse, smoking, family history) (30).

Presence of complications of diabetes mellitus isassociated with decreased answer to cognitive - behavioraltherapy and persistence of depression is associated withincreased levels of HbA1c (31). Similar studies supportthe connection between the depression or anxiety andstroke, Parkinson Disease, irritable bowel syndrome,cancer, fibromyalgia and pain syndromes (32).All these data show the association between mental andsomatic co-morbidities and support the fact thatsystematic approach of somatic co-morbidities can bedecisive for the prognosis of patients with mentaldisorders.

ASSESSMENT OF IMPACT OF CO-MORBIDITIESCo-morbidities can delay diagnosis, caninfluence treatment, are related to occurrence ofcomplications and can influence survival (33). Due tothese reasons the quantifying of co-morbidities is

Romanian Journal of Psychiatry, vol. XVI, No. 4 2014


6/38

112

becoming a necessity both in research andclinical practice.

One method for assessment of co-morbidities isrepresented by co-morbidity indices. Co-morbidityindices reduce all coexistent disorders to a singlenumerical score and allow comparison between patients

with different disorders. These scores offer a globalassessment of severity of coexistent disorders in one

patient. Co-morbidity indices are research instrumentused in prospective or retrospective studies that needstratifying patients in risk groups. They have threecomponents in their structure: items represented by co-morbidities, a severity scale for assessment of co-morbidities and a scoring system.

There are many co-morbidity indices used inclinical research, depending on the destination they have

been developed for (33,34). Cumulative Illness RatingScale (CIRS) was developed to assess co-morbidities loadand probability of survival (35). Kaplan-Feinstein

Classification is an index developed in a group of adultswith diabetes mellitus to prove the impact of co-morbidities on prognosis (36). Charlson Co-morbidityIndex is an index used for prediction of short termmortality (37) and INDEX of Coexistent Disease (ICED)is an index developed to prove that disorders other then the

primary disorder influence prognosis (38). As a generalrule, co-morbidity indices exclude the primary disorderfrom the analyses of impact and are limited to assessmentof cumulated effects of coexistant disorders, that is co-morbidities. Co-morbidity indices are not, however, directmethods of assessment for the impact of disorders onhealth status, performance scales (Activities of DailyLiving, Karnofsky etc.) being used for these purposes. In

addition co-morbidity indices are quite coarse to replaceclinical reasoning for specific cases.

THE CONCEPT OF FRAILTY Numerous studies show that social demographic

parameters and co-morbidities cannot fully explain thedifferent prognosis of elderly patients. The concept offrailty aims to reflect different evolutions in patients withcomparable co-morbidity load (39). Frailty is referring toa state of global vulnerability to stressors, vulnerabilitywhich determines an unfavorable prognosis. Frailty, amajor research theme in geriatrics, is considered aconsequence of multi-systemic physiologic decline

encountered in elderly, representing a transitional stateduring a dynamic process of progression from functionalfitness to dependency and death (40). Frail patients arecharacterized by functional decline, disabilities, increasedincidence of fractures, frequent hospital admissions andincreased mortality (39).

Currently frailty is distinguished from co-morbidities or disabilities, which can coexist with frailty

but are considered distinct phenomena. This situation isillustrated in Cardiovascular Health Study, in which the

presence of frailty phenotype is partially superposed to the presence of co-morbidities or disabilities. (41)

The link between frailty, co-morbidities anddisability is complex. Both frailty and co-morbidities

predict onset of disability, disability may worsen frailtyand co-morbidities and co-morbidities can contribute tofrailty onset (42). Similarly, the onset of progression ofchronic disorders and poly-pathology may represent

symptoms of frailty (41), (43).The defining characteristics of frailty concept are

global-multi-systemic physiological impairment andincreased vulnerability to stressors (39). Frailty representsa multi-systemic vulnerability associated withaccumulation of deficits (dysfunctions), which can be

quantified by a frailty index with predictive value fordifferent types of outcomes (44).

Multi-systemic impairment translates into aglobal alteration of homeostasis and into the occurrence ofdecompensation in the presence of reduced level ofstressors (39). It is important to note that frailtycharacterizes patients with limited functional reserves,fact that could explain why relative minor burdens (stress,infections, dehydration, extreme temperature) are poortolerated by these patients.

Among the symptoms of frailty are mobilitydecline, increased prevalence of falls, loss of capacity ofself care and functional impairment, poor nutritional state,

sensory deficits, fatigue, decline of muscular strength (39,42, 43, 44). There is still a debate regarding the inclusionof cognitive function impairment among the domains offrailty, some authors emphasizing the physical aspects offrailty while other having a multidimensional approach(45, 46).

The consequences of frailty are usuallydiscussed in terms of mortality, morbidity,institutionalization, incidence of dependency, sarcopenia,decrease in quality of life and frequent hospitaladmissions (39, 42, 43). Frailty represents a risk factor forincident Alzheimer's dementia and cognitive decline (47,48). Other cross-sectional studies show the existence of a

positive correlation between frailty and mood disorders

(43).The presumed cause of frailty is physiological

decline that occurs in some older people. Multiplemechanisms are incriminated in frailty occurrence (49):hormonal deficits, inflammation, oxidative stress,sarcopenia (decline of muscular mass and strengthassociated with ageing). Interestingly, these pathogenicmechanisms are also present in patients with mentaldisorders.

Beyond the debate regarding frailty concept,today it is accepted that frailty represents an increased riskstate for mortality and other types of poor outcomes:functional decline, dependency, fracture, hospital

admission (39).The modalities proposed for frailty assessment aremultiple, reflecting the lack of consensus on definingthis concept (46). Some instruments are focused on theidentification of a clinical pattern (Fried phenotype),others use global clinical impression (Clinical FrailtyScale); and others use a multidimensional approach(including domains like mobility, physical activity,nutritional status, cognition, social support, patient's

perception on his health) or quantify the number ofdeficits (Frailty Index) (45).The Frailty Phenotype proposed by Fried, an assessmentinstrument frequently used in research, is focused on

parameters of physical functionality. Fried phenotype is aconstruct that comprises five dimensions:1. Involuntary weight loss (>5% weight loss in last year);2. Decreased grip strength;3.Exhaustion, assessed by questions derived from a


7/38

113

depression questionnaire (Center for EpidemiologicStudies Depression Scale);4. Decreased walking speed at a normal pace on 5mdistance (=3 criteria patients are

considered frail, pre-frail at 1-2 criteria, absence of anycriterion defining fit patients. These criteria have beenderived from Cardiovascular Health Study (CHS) andthereafter validated in numerous studies, frail patients

presenting an increased risk of mortality, functionaldecline, dependency and hospitalizations (50).Clinical Frailty Scale (CFS) is a simple instrumentdeveloped for use by clinicians (51). Clinical Frailty Scaleuses clinician's reasoning on co-morbidities, cognitiveimpairment and disability. Patients are divided in sevencategories: fit, well (without signs of active disease); wellwith treated co-morbidities; apparently vulnerable(symptomatic co-morbidities); mildly frail (partial

dependency in instrumental activities of daily living –IADL); moderately frail (partial dependency in activitiesof daily living -ADLs- and instrumental activities of dailyliving - IADLs); severely frail (total dependency). CFS iseasy to administer and from this point of view it has anadvantage over other more complex instruments. Hence,clinical judgment on frailty can bring useful informationon patient`s prognosis. In Canadian Study of Health andAging, CFS has been proved to be a useful instrument for

prediction of mortality and institutionalization at fiveyears, having performances comparable to Frailty Indexand Cumulative Illness Rating Scale (51). In the samestudy, in a multivariate analysis, every increase with onestage on CFS presented an increase in middle term (70months ) o f mor ta l i ty w i th 21 ,2% and o finstitutionalization with 23,9% (51).Frailty Index . Rockwood et al (51, 52), developed afrailty index based on identification of deficits in domainslike cognition, mood, ability to communicate, balance,continence, activities of daily living (ADLs), presence ofco-morbidities. These deficits have been identified duringa population study that selected a group of prognosticfactors (70 factors) for mortality and institutionalization.Frailty Index is expressed as a ratio between number ofidentified deficits and maximum number of possibledeficits. Frailty Index is an argument in favor of the theoryof accumulation of deficits as mechanism for frailty

occurrence, mortality increasing proportionally to thenumber of deficits. Useful in research, Frailty Index isdifficult to use in practice due to its complexity.

MODELS WITH MULTIPLE DOMAINS Many investigators describe a broader frailty model,including domains like cognition, functionality and socialfactors. Most of these models with multiple domains arethe result of statistical analysis and do not propose

pathophysiological explanations for the relationship between measured parameters at the beginning of thestudy and prognostic parameters (45, 46). In addition,correlation between the results of these models is only

partial, sometimes even quite reduced, which can beexplained by the different instruments used and also by thefact that they detect different groups of frail patients withdifferent evolution trajectories (53). There is also the

problem of inclusion of disability in the structure of

instruments for frailty assessment, disability beingconsidered by expert groups a complication of frailty andnot one of its components.Among the models with multiple domains, we mentionFrailty Index – Comprehensive geriatric Assessment (FI-CGA), a frailty index based on comprehensive geriatricassessment (54). Comprehensive geriatric assessment is a

multidimensional, multidisciplinary diagnostic process,used for assessment of medical, functional and psycho-social problems encountered in older patients. Severalcomponents of comprehensive geriatric assessment aredescribed in the specialty literature: biological, nutritionalstate, polymedication, functionality, risk of falls, mood,cognition, social network and social support, quality oflife and spirituality. FI–CGA is an instrument that includesthese components and co-morbidi t ies in amultidimensional scale for assessment of frailty.Increased levels of frailty assessed by FI-CGA areassociated with an increased risk of mortality andinstitutionalization.

CONCLUSIONSIn the present review we presented a series of data thathighlight the somatic dimension of mental disorders,classically represented by somatic co-morbidities. A newcategory of somatic impairment described especially inolder patients is represented by frailty. The existence of anassociation between mental disorders, somatic co-morbidities and frailty remains to be established by futurestudies, such studies assuming the utilization ofstandardized instruments.

ACKNOWLEDGEMENTThis paper is supported by the Sectorial OperationalProgramme Human Resources Development (SOP HRD)2007-2013, financed from the European Social Fund and

by the Romanian Government under the contract numberPOSDRU/107/1.5/S/82839.

REFERENCES1. Jones DR, Macias C, Barreira PJ et al. Prevalence, severity, and co-occurrence of chronic physical health problems of persons with seriousmental illness. Psychiatr Serv 2004;55: 1250-1257.2. Balf G, Stewart DT, Whitehead R, Baker RA. Metabolic adverseevents in patients with mental illness treated with antipsychotics: a primary care perspective. Prim Care Companion J Clin Psychiatry 2008;10: 15-24.3. Krishnan KR. Psychiatric and medical comorbidities of bipolardisorder. Psychosom Med 2005;67(1): 1-8.

4. Otte C. Incomplete remission in depression: role of psychiatric andsomatic comorbidity. Dialogues Clin Neurosci 2008;10(4): 453-60.5. Brown S, Inskip H, Barraclough B. Causes of the excess mortality ofschizophrenia. Br J Psychiatry 2000;177: 212-217.6. Saha S, Chant D, McGrath J. A systematic review of mortality inschizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007;64:1123–1131.7. Oud MJ, Meyboom-de Jong B. Somatic diseases in patients withschizophrenia in general practice: their prevalence and health care. BMC Fam Pract 2009;10: 32.8. Carlson C, Hornbuckle K, DeLisle F et al. Diabetes mellitus andant ipsychot ic t reatment in the Uni ted Kingdom. Eur Neuropsychopharmacol 2006; 16: 366-375.9. Jin H, Folsom D, Sasaki A et al. Increased Framingham 10-year risk ofcoronary heart disease in middle-aged and older patients with psychoticsymptoms. Schizophr Res 2011;125(2-3): 295-9.10. Osborn DPJ, Nazareth I, King MB. Risk for coronary heart disease in

people with severe mental illness. Cross-sectional comparative study in primary care. Br J Psychiatry 2006;188: 271-277.11. Carney CP, Jones L, Woolson RF. Medical comorbidity in women andmen with schizophrenia. J Gen Intern Med 2006;21: 1133-1137.12. Johannessen L, Strudsholm U, Foldager L et al. Increased risk of



8/38

114

hypertension in patients with bipolar disorder and patients with anxietycompared to background population and patients with schizophrenia. J Affect Disord 2006;95: 13-17.13. McIntyre RS, Konarski JZ, Soczynska JK et al. Medical comorbidityin bipolar disorder: implications for functional outcomes and healthservice utilization. Psychiatr Serv 2006; 57:1140-1144.14. Strudsholm U, Johannessen L, Foldager L et al. Increased risk for pulmonary embolism in patients with bipolar disorder. Bipolar Disord 2005;7: 77-81.15. McIntyre RS. Psychotropic drugs and adverse events in the treatmentof bipolar disorders revisited. J Clin Psychiatry 2002;63(suppl 3):15–20.16. Regier DA, Farmer ME, Rae DS et al. Comorbidity of mentaldisorders with alcohol and other drug abuse. Results from theEpidemiologic Catchment Area (ECA) Study. JAMA 1990;264: 2511–8.17. Cassidy F, Ahearn EP, Carroll BJ. Substance abuse in bipolardisorder. Bipolar Disord 2001;3: 181– 8.18. Moussavi S, Chatterji S, Verdes E et al. Depression, chronic diseases,and decrements in health: results from the World Health Surveys. Lancet 2007;370(9590): 851-8.19. Rush AJ. STAR*D: what have we learned? Am J Psychiatry 2007;164: 201-204.20. Iosifescu DV, Nierenberg AA, Alpert JE et al. The impact of medicalcomorbidity on acute treatment in major depressive disorder. Am J

Psychiatry 2003;160: 2122-2127.21. Corey-Lisle PK, Nash R, Stang P, Swindle R. Response, partialresponse, and nonresponse in primary care treatment of depression. Arch Intern Med 2004;164: 1197-1204.22. Reynolds CF, Dew MA, Pollock BG et al. Maintenance treatment ofmajor depression in old age. N Engl J Med 2006;354: 1130-1138.23. Wulsin LR, Singal BM. Do depressive symptoms increase the risk forthe onset of coronary disease? A systematic quantitative review. Psychosom Med 2003;65: 201–210.24. Frazure-Smith N, Lesperance F, Talajiic M. Depression followingmyocardial infarction. Impact on 6-month survival. JAMA 1993;270:1819–1825.25. van Melle JP, de Jonge P, Spijkerman TA et al. Prognostic associationof depression following myocardial infarction with mortality andcardiovascular events: a meta-analysis. Psychosom Med 2004; 66:814–822.26. Kubzansky LD, Cole SR, Kawachi I et al. Shared and unique

contributions of anger, anxiety, and depression to coronary heart disease:a prospective study in the normative aging study. Ann Behav Med 2006;31: 21–29.27. Strik JJ, Denollet J, Lousberg R, Honig A. Comparing symptoms ofdepression and anxiety as predictors of cardiac events and increasedhealth care consumption after myocardial infarction. J Am Coll Cardiol 2003;42: 1801–1807.28. Grigsby AB, Anderson RJ, Freedland KF et al. Prevalence of anxietyin adults with diabetes: a systematic review. J Psychosom Res 2002;53:1053–1060.29. Thomas AJ, Kalaria RN, O'Brien JT. Depression and vasculardisease: what is the relationship? J Affect Disord 2004;79(1-3): 81–95.30. Kawakami N, Takatsuka N, Shimizu H, Ishibashi H. Depressivesymptoms and occurrence of type 2 diabetes among Japanese men. Diabetes Care 1999;22: 1071–1076.31. Lustman PJ, Griffith LS, Freedland KE et al. Cognitive behaviortherapy for depression in type 2 diabetes mellitus. A randomized,

controlled trial. Ann Intern Med 1998;129: 613–621.32. Aina Y, Susman JL. Understanding comorbidity with depression andanxiety disorders. J Am Osteopath Assoc 2006;106(5 Suppl 2): S9-14.

33. Hall SF. A user's guide to selecting a comorbidity index for clinicalresearch. J Clin Epidemiol 2006;59(8): 849-55.34. Dobranici L, Tudose C. The assessment of medical comorbidity inthe elderly patients with dementia / Evaluarea comorbidităţii medicale avârstnicului cu demenţă. Rom J Psychiat 2010;2.35. Linn BS, Linn MW, Lee G. Cumulative Illness Rating Scale. J AmGeriatr Soc 1968;5: 622–6.36. Kaplan MH, Feinstein AR. The importance of classifying initial co-morbidity in evaluating the outcome of diabetes mellitus. J Chron Dis 1974;27: 387–404.37. Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method ofclassifying prognostic comorbidity in longitudinal studies: developmentand validation. J Chron Dis 1987;40: 373–83.38. Cleary PD, Greenfield S, Mulley HG et al. Variations in length of stayand outcomes for six medical and surgical conditions in Massachusetsand California. JAMA 1991;266: 73–9.39. Walston J, Hadley EC, Ferrucci L et al. Research agenda for frailty inolder adults: toward a better understanding of physiology and etiology:summary from the American Geriatrics Society/National Institute onAging Research Conference on Frailty in Older Adults. J Am Geriatr Soc 2006;54(6): 991-1001.40. Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state ina dynamic process. Gerontology 2009;55(5): 539-49.41. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence

for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56(3): M146-56.42. Fried LP, Ferrucci L, Darer J et al. Untangling the concepts ofdisability, frailty, and comorbidity: implications for improved targetingand care. J Gerontol A Biol Sci Med Sci 2004;59(3): 255-63.43. Pel-Littel RE, Schuurmans MJ, Emmelot-Vonk MH, Verhaar HJ.Frailty: defining and measuring of a concept. J Nutr Health Aging 2009;13(4): 390-4.44. Rockwood K, Mitnitski A. Frailty in relation to the accumulation ofdeficits. J Gerontol A Biol Sci Med Sci 2007;62(7): 722-7.45. van Kan AG, Rolland Y, Houles M et al. The assessment of frailty inolder adults. Clin Geriatr Med. 2010;26(2): 275-86.46. van Kan AG, Rolland Y, Bergman H et al. The I.A.N.A Task Force onfrailty assessment of older people in clinical practice. J Nutr Health Agin 2008;12(1): 29-37.47. Gray SL, Anderson ML, Hubbard RA et al. Frailty and incidentdementia. J Gerontol A Biol Sci Med Sci 2013;68(9): 1083-90.48. Buchman AS, Boyle PA, Wilson RS et al. Frailty is associated with

incident Alzheimer's disease and cognitive decline in the elderly. Psychosom Med 2007;69(5): 483-9.49. Fedarko NS. The biology of aging and frailty. Clin Geriatr Med 2011;27(1): 27-37.50. Vermeulen J, Neyens J, van Rossum E et al. Predicting ADLdisability in community-dwelling elderly people using physical frailtyindicators: a systematic review. BMC Geriatr2011;11: 33.51. Rockwood K, Song X, MacKnight C et al. A global clinical measureof fitness and frailty in elderly people. CMAJ 2005;173(5): 489-95.52. Searle SD, Mitnitski A, Gahbauer EA et al. A standard procedure forcreating a frailty index. BMC Geriatr 2008;8: 24.53. Rockwood K, Andrew M, Mitnitski A. A comparison of twoapproaches to measuring frailty in elderly people. J Gerontol A Biol Sci Med Sci 2007;62(7): 738-43.54. Jones DM, Song X, Rockwood K. Operationalizing a frailty indexfrom a standardized comprehensive geriatric assessment. J Am GeriatrSoc 2004;52(11): 1929-33.

***


9/38

REVIEW ARTICLES

DIMENSIONAL PERSONOLOGICALPERSPECTIVE ON SUICIDAL BEHAVIOUR

Individual existence is delimitated by twoextremes – birth and death. The dynamics of theindividual's ages after birth – including childhood,adolescence, adulthood and aging – confirms the cyclicalcontinuity between life's beginning and end. At a certainstage in its history, psychoanalysis even hypothesized theexistence of two fundamental instincts – of life and ofdeath, respectively of Eros and Thanatos (1). The lastwould represent the inherent tendency of organic lifereturning to a preceding state, the inorganic state ofexistence.

An individual's attitude towards death hasalways been historically and culturally conditioned. In ananimated universe – according to the concept of animism –fear of death began as a fear of the dead since it was

believed that they could harm the living (2). On the otherhand – and in a later period – death was considered„happy” according to its significances and to theindividual's situation at that moment. That is why theVikings were striving to die with the sword in their hand sothat they could enter Wahalla. The manner in which human

beings view death depends on their preservation instinct,

but also on the stage of life they are going through, so that,for example, at an advanced age death could be looked atin a detached manner, like a fatality. On the whole, theindividual's attitude towards death swings between aserene balance – cultivated by the ancient Greeks – and a

particular fear or sensibility. (3).The contemporary individual refuses or

accepts death depending on its meanings. Fear of deathrepresents in the first place fear of the unknown and theirreversible. Because of social mores death has become anexternal „show” for the individual – frightening most of

the time – not the intimate act it should have stayed. Napoleon said „priests and physicians made death painful”. On the other hand, not only death but also life isoften accompanied by suffering, and the fear of deathshould not be stronger than the fear of life. Moreover,taking into account the „birth trauma”, death has beencompared with birth, "sleep” and "oblivion” being thedominants (Barbarin quoted by 3).

In general, the way an individual relates tolife's roles and values influences in an obvious manner theattitude towards death (4). Thus, pragmatic individuals

MD Psychiatry resident, PhD Candidate, Psychiatry Clinic II, UMF Targu Mures MD, PhD, Professor, Chief of Psychiatry Department, UMF Targu Mures MD, PhD, Psychiatry Clinic II, UMF Targu Mures MD, PhD Candidate, Assistant, Psychiatry Clinic II, UMF Targu Mures MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures Received July 02, 2014, Revised August 29, 2014, Accepted September 26, 2014

Abstract:The existence of the human being is delimited by the twoextremes – birth and death. The individual's attitudetowards death is always historically and culturallyconditioned. It swings between a serene balance andrespectively a particular fear or sensibility. Nowadaysdeath is accepted or rejected according to its meanings. Human beings integrate temperamental, character,biographic, archetypal components, but also self-reflexive

abilities. These abilities lead to individual self-awarenessand an understanding of life's meanings which favor self-realization and a subjective well-being. Ideation and suicidal conducts are the supreme expression of the loss ofexistential meanings. Personality traits are among the personal factors that have major implications on suicidalbehavior. Having a dimensional perspective on thesetraits – including taking into account the dimensional facets of personality – leads to a more nuancedunderstanding of the suicidal phenomenon as well as theelaboration of early prevention and intervention strategies. Key words: suicidal behavior, personality, dimensional

perspective.

115


10/38

116

who are involved in different activities and roles, with pro-social aptitudes, and have a social support network whichis well represented quantitatively and qualitatively, ignorethe idea of death which is overwhelmed and diluted by theintensity with which they live their life. In their case„memento mori” is actually a reference to „carpe diem”.

Death may also be ignored, and by those for whom liferepresents a mean to achieve a value ideal, a goal, whoenjoy a supra-personal respect and appreciation. Theachievement of such a goal brings about great existentialsatisfaction and may lead to a reconciliation with deathwhich can often be manifested by an attitude ofdetachment and courage.

It may be considered that living intensely one'sown life – in a pragmatic or idealistic way – protects theindividual when confronting the eternity of death. On theother hand, the scarcity of interpersonal relationships andexistential motivations and values, as well as thedysfunction in various roles of life, disadvantage the

human being before death which appears with all thenegative connotations that may be attributed to it.It is a known fact that human beings are

products of self-determination and self-becoming.Biographical experiences, archetypes and self-reflexiveabilities are progressively integrated throughout a

person's life so that in adulthood one becomes self-awareand aware of one's relationships with others. Dominant

personality traits are both inherited and acquired throughinteraction with other people and with the natural world(5).

Individual self-awareness means implicitlyknowing one's own qualities and flaws, but also being ableto reflect upon the resemblance with people around you, as

well as the challenge of accessing common existentialvalues. It allows the creation of a feeling of self-realizationand the „access” to personal happiness. This not onlymeans the harmony between physical, mental andspiritual well-being, but a certain subjective well-beingwhich may result from this harmony and especially fromthe understanding of life's meanings.

The approach to life of the mature person mustharmonize the attitude towards himself with the attitudetowards others seen in their own existential context.Hence, one might learn that life should not be lived as if itwere eternal, and might be able to find and give meaning toits end.

The contemporary social culture has a particular dynamics dominated by the phenomena oftechnological advancements, urbanization and populationmigrations. The abundance and growing diversity ofmaterial goods and services, life models and lifestyles areoften assault the individual's adaptive expectations andcapacities. Old community traditions and customs areignored or presented distortedly, as are spiritual andreligious values and ideals (5).

These incessantly altering socio-culturalconditions have a negative influence on content andduration of the individual's developmental stages and mayfacilitate the development of dominant individualistictype traits. People who live for themselves prevail

numerically over those dedicated to certain meta-personalgoals.

The individual's attitude towards himself isdominated by narcissistic and egocentric arguments and

as a result is fragile and becomes vulnerable in relation tothe diversity and incisiveness of existential stimuli. In itsextreme version it may take a dramatic turn – that of thesuicidal behavior. Suicide is an act of an extreme severityof the individual towards himself with multiple

psychological, social, legal and moral meanings (3). Thus,

suicide may mean the cessation of any possibility to everagain have a conscious experience that precedes thegesture followed by physical death, it may be a „crime”, a„sin” or an expression of the subject's isolation from thesurrounding world or his marginalization.

The factors involved in the preparation andcourse of the suicidal act may be sub-divided into personaland extra-personal (6). In the first category a first rank

position is occupied by the individual's personalitystructure with its dominant traits. The presence of certain

pronounced or disharmonic personality traits – may favorthe attempts with both a high survival risk and those with alow survival risk. But suicidal behavior – in the diversityof its versions – may also often be encountered inharmoniously structured personalities, being caused bynon-personal factors.

Both from a categorical and qualitative perspective, the most common factors involved in thesuicidal act are, in a descendant order, the borderline type

pathological traits, and the antisocial, hysterical, avoidant,dependant and obsessive-compulsive types. Cluster Adisharmonic traits favor the so called „no prior history”suicides. Different personality types disadvantage thedifferentiation between real suicide attempts and thosewith a low risk of death. And so a categorical type of

personality prone to suicide cannot be pointed out.When looking at personality traits, the

dominants in cluster A and C pathological personalitiesseem to be the suicidal ideation, ruminations andrepresentations related to the preparation of the act itselfdue to a detachment from the practical, and to the triad of

perfectionism, rigidity and pride. In the case of cluster Btraits, actual suicidal behavior, with high or low survivalrisk, is favored by the instability of one's self-image, one'saffective instability, as well as by one's impulsive-aggressive potential.

The dimensional or quantitative perspectiveallows the establishment of more complex correlations

between normal personality, pathological personality andAxis I diseases by facilitating comparative comments. It

ensures a significantly increased accuracy of the diagnosisand a more nuanced comprehension of the psycho- behavioral anomalies (7). The most known and useddimensional models are the 5 factors model – the 'Big-Five' and Cloninger's 7 factors model – the psycho-

biological model.In case of the 5 factors model, each trait has six

corresponding facets which allow a much finerdimensional validation of the diagnosis. Thus, among thefacets of neuroticism – that is of the dimensioncorresponding to the affective stability - fear, pessimism,attitudinal fragility and shyness may favor suicidalideation and behavior. By the same token, the facets ofeither extroversion, activism and spirit of adventure or

solitude, resignation, passivity and anhedonia - inability toenjoy, may also play an enhancing role in suicidal ideationand behavior.

With respect to the conscientiousness or


11/38

117

perseverance dimension, its extreme components suchas perfectionism, sense of order and duty, reflexivity,respectively negligence, carelessness, unpredictability,lack of personal purposes and hedonism – whichexpress low levels related to it – may all favor self-suppressive behavior.

Agreeableness or charm through components

such as optimism, honesty, altruism, modesty or empathylower the risk of and preoccupation with suicidal acts. Thefacets of spiritual openness such as fantasy, esthetic sense,curiosity, sensations seeking, openness to novelty andfaith may be other factors non-conducive to suicidalideation and acts.

Overall, suicidal behavior is enhanced by highlevels of neuroticism and low levels of extroversion, andalso by extreme values – increased respectivelydiminished - of conscientiousness. It is disadvantaged byhigh values of agreeableness and spiritual openness. It is aconfirmed fact that the high level of impulsiveness,aggressiveness and affective lability as well as of

perfectionism and rigorousness may favor suicidal behavior. These traits corresponds to antisocial, borderline and obsessive-compulsive type personalities.

When relating dimensional personalityreference points to demographic factors one sees that the

pathological dimensions which favor the suicidal act suchas impulsiveness and affective-attitudinal instability

prevail at a young age, while perfectionism andrigorousness have the same influence at a more advancedage. In males, high-mortality risk suicide attempts are

prevalent, while in females the risk of mortality isdiminished.

From a dimensional perspective of the psycho- biological model of the seven factors – four oftemperament and three of character – the suicidal behaviormay be favored by the high values of dominant inheriteddimensions – novelty seeking, harm avoidance, rewarddependence and persistence. High values of characterdimensions such as self-directedness, cooperativenessand self-transcendence – are a protective factor as to the

suicidal phenomenon. This particularly complex personological model may allow a correlations withgenetic and biological factors by means of the integratedneuromediators – dopamine, serotonin, noradrenalin andgamma aminobutyric acid.

It can be stated that ideation and suicidalattempts are disadvantaged by the structuring quality of

the Self regarded as an individual strategic pole and by thecomplexity of interpersonal relationships, so by therelational social pole of the individual. The spiritualdimension or pole of the person has the same role,

particularly through the ability for self-transcendence.Any attempt at comprehending the suicidal

phenomenon and of elaborating prevention strategiesmust integrate a dimensional assessment of the personality

– inclusively according to its facets – that may offer data ofa particular value.

We cannot forget that the human being is theonly one who knows he is here on Earth just in passing, andthat is why he must – while seeking happiness and not the

end of life - dare, hope and believe. The individual canaccomplish this by cultivating self-esteem, inner harmony,with the surrounding people, nature and the cosmos.

REFERENCES1.Freud S. La psychopatologie de la vie quotidienne. Paris: Payrot, 1924.2.Eliade M. Fragmentarium. Bucharest: Ed.Vremea, 1939.3.Athanasiu A. Elemente de psihologie medical ă. Ed.Medicală,Bucharest, 1983.4.Baumgarten F. Der weltgelbundene und der lebensgebunkkiene Typus. Arbeit und Leistung 1966;20(7-8): 119.5.Lăzărescu M, Nireștean A. Tulburarea de personalitate. Iași:Ed.Polirom, 2007.6.Cosman D. Compendiu de suicidologie. Cluj Napoca: Ed.Casa Cărțiide Știință, 2006.7.Dehelean P, Dehelean M, Dehelean L. O problemă controversată:

modelul categorial versus dimensional al tulbur ărilor de personalitate.Perspectiva categorială și cea dimensională în cadrul tulbur ărilor de personalitate. In: Nireștean A (eds.) Personalitatea între anormalit ă țibiologice și interpret ări culturale. Tg.Mureș: Ed.University Press, 2005,43-72.

***



12/38

REVIEW ARTICLES

CLINICAL INSTRUMENTS FOR THE EVALUATIONOF SUICIDE RISK – AN OVERVIEW

1

Ana-Maria Exergian

INTRODUCTIONSuicide is a serious health-problem world-wide

and one of the main emergencies in psychiatric practice.Completed suicide is responsible of 1% of all deaths and isincluded, in most regions of the world, in the first tencauses of death (1). It is even higher in rank in adolescentsand young adults: in ages 15-29 it is the second cause ofdeath and in ages 30-49 the fifth (1). More than that,suicide and suicidal behaviour have serious social,economic and psychological influences impacting both the

persons who commit them, their families and other peopleclose to them.

In most instances, suicide is a complication of psychiatric disorders. Approximately 90% of those whodie by suicide have, at the time of death, a psychiatricdiagnosis (1, 2), most of them a diagnosis of mood disorder

(2, 3). Yet, most people who suffer from a mental illnessnever even attempt suicide. A study published in 2003estimated that the suicide rate of affective disorders is193:100.000, meaning that over 99.000 people sufferingfrom a mood disorder will never die by suicide (4).Therefore it is very important to be able to distinguishthose few who are at risk.

Up to date there is no available method that canaccurately distinguish those who will commit suicide fromthose who will not.

The importance and the difficulty of the task ofidentifying those who are at risk for suicide has lead to anextensive research on the subject, and to the elaboration of

numerous clinical instruments meant for this purpose.This review aims to describe some of those instruments,focusing on those that have proven psychometric

properties, in order to guide clinicians searching for an aidin evaluating suicide risk. The author does not presume to

be comprehensive in this review, since the number ofinstruments available is extensive and many of these arenot sustained by a significant evidence basis.

The instruments are presented in severalcategories: checklists, clinician-rated instruments, self-report instruments, combined administration instruments,measures of suicide attempt lethality, brief screeningmeasures and scales relating to protective factors. Noinstruments created for specific populations (adolescents,elderly etc.) were included.

CHECKLISTS

This type of instrument is the first to appear inclinical practice and, most of these early tools have littleor no documented reliability and validity. Among thesewe can include: the Scale for Predicting SubsequentSuicidal Behaviour (5), the Instrument for the Evaluationof Suicide Potential (6) and the Scale for AssessingSuicide Risk (7). At present, the existence of theseinstruments has more of a historical importance than aclinical one.

1 Psychiatry specialist MD, PhD Student, “Prof. Dr. Al. Obregia” Clinical Hospital of Psychiatry, No 10 Berceni Road, Bucharest, Romania. Assistant

Professor, Psychiatry department “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; tel: 0724.471.471; e-mail:

Received August 25, 2014, Revised October 06, 2014, Accepted October 31, [email protected]

Abstract:

Suicide and suicidality are serious health-problems world-wide. In most instances suicide is a complication of

psychiatric disorders, especially mood disorders. Yet, most people suffering from these disorders do not commit suicide. At present, there are no clinical or biologicalmeans that can accurately predict who will commit suicideand who will not. The importance of the subject and thedifficulty of assessing suicide risk have led to the creationof numerous clinical instruments meant to assist in this

endevour. The multitude of such instruments can make itdifficult for a physician to decide which scale or interviewto use in a particular instance. This overview aims to

present general characteristics and psychometric dataregarding some of the clinical instruments available forthe assessment of suicide risk.

Key words: suicide risk, mood disorders, clinical scales.

118

mailto:[email protected]:[email protected]


13/38

1.CLINICIAN-RATED INSTRUMENTS1.1 Scale for Suicide Ideation (SSI)

This is one of the most widely used instrumentsfor assessing suicide risk, partly due to its extensivedocumentation regarding validity and reliability.

It was published in 1979 by Beck et al. (8). It

contains 21 items, of which 5 are screening items (3regarding the wish to die – passive suicidal ideation and 2regarding the wish to attempt suicide – active suicidalideation) and 2 are additional items which assess theincidence and frequency of prior suicide attempts (theseitems are not scored). The total score is calculated byadding the scores of each item, ranging from 0 (none) to 2(moderate to strong).

Factorial analysis has determined 3 significantdimensions: active suicidal desire, specific plansregarding suicide and passive suicidal desire (8).

It has Cronbach coefficient alphas that showmoderately high internal consistency – 0.84 (9) to 0.89 (8).

It also has high interrater reliability, with a correlation ofup to 0.98 (8, 9).The validity of the SSI was established

repeatedly. In the original work, Beck et al found asignificant correlation with the self-harm items from theBeck Depression Inventory (BDI) (8). Other studies foundsignificant correlations with previous suicide attempts,severity of depression and daily self-monitoring ofsuicidal ideation (9, 10). It has been proven that the SSIcan discriminate suicide attempters from nonattempters(11).

It was found that a total score higher than 2includes the patient in a higher risk category and suggestsa likelihood of suicide that is 7 times higher than for those

with scores of 2 or less (12).Main advantages of this instrument are:

extensive use in research, well documented validity andreliability in a variety of populations, and, according tosome authors the fact that it is administered as an interview(13, 14) . One possible disadvantage is the fact that it has to

be administered by trained clinicians (14).1.2 Scale for Suicide Ideation – Worst (SSI-W)

This scale was published in 1999 by Beck et al.and contains 19 items scored 0 to 2, according to suicidalintensity. The SSI-W measures suicidality (behaviors,thoughts, emotions) at its worst point in the patient's life.As with SSI, the total score ranges from 0 to 38 (15).

Factorial analysis has found two factors: preparation and motivation (15).The Cronbach alpha was found to be 0.88,

representing moderately-high internal consistency (9).The instrument has high interrater reliability (9). Itsvalidity was established by correlation with the suicideitem from Hamilton Depression Rating Scale (HAM-D)and the suicide item of the BDI (9).

It was found that a score higher than 10delineated a group of patients who were 14 times morelikely to commit suicide, than those with lower scores(15).1.3 Suicide Intent Scale (SIS)

This instrument is comprised of 15 itemsdesigned to measure the seriousness of the intent to dieregarding the most recent suicide attempt. It rates

behaviour and communication prior to and during thissuicide attempt (preparation, execution, setting of the

attempt, whether or not there were attempts tocommunicate the intention – directly or indirectly,

purpose, expectations).Factor analysis have reported between 2 and 6

factors (16, 17).The Cronbach alpha showed high internal

reliability (0.95) (15).Predictive validity has been studied in two

prospective studies that had a 10 years follow-up period.In neither of these studies the SIS was able to predictcompleted suicide (18, 19).1.4 Suicide trigger scale (STS-3)

This is a 42-item clinician-administeredquestionnaire, with answers ranging from 0 (not at all) to 2(a lot). It was devised to assess a clinical entity named bythe authors “suicide trigger state” as a measure of acutesuicide risk (20).

It has demonstrated a high internal consistency(Cronbach alpha 0.94) (20).

Factor analysis lead to the identification of 3subscales: frantic hopelessness (12 items), ruminativeflooding (10 items) and near psychotic somatisation (7items) (20).

The STS-3 total score correlated with theseverity of current suicide ideation. Scores were alsohigher in those with a history of suicide (20).

A very recent study has shown that a transformedscoring (a distance from median of the initial scoring) wasable to predict suicide attempts following discharge in ahigh-risk group of suicidal inpatients (21).

2.SELF-REPORT INSTRUMENTS2.1 Beck Scale for Suicide Ideation (BSI)

This is a 21-item self-administered version of theSSI. It assesses the patient's suicidality during the week

prior to evaluation (22). As for the SSI, there are 19 scoreditems (0 to 2) which yield a total score of up to 38, and 2additional items which document the existence of

previous suicide attempts and the level of intent regardingthese attempts.

Factorial analysis has delineated 3 factors: desirefor death, preparation for suicide and actual suicide desire(23). There are two additional items that did not load anyfactor: deterrents to death and deception/concealment(23).

Cronbach alpha coefficients have been found to

be high (up to 0.97) (22, 23). Regarding validity, it has been found that it correlates highly with SSI (22), but onlymoderately with the suicide item in the BDI.

Predictive validity has not been studied.This instrument holds an advantage compared to

the SSI, for patients who are more comfortable answeringdifficult questions in self-report format than in aninterview (14).2.2 Beck Hopelessness Scale (BHS)

This instrument was created by Beck and Steerand includes 20 statements which are rated as true or false.It assesses negative beliefs (pessimism) about the future(24).

Factorial analysis has revealed 2 factors: pessimism about the future and resignation. A later studyhas found that many of the items are redundant, and mostof the variation of scores is due to a single statement: “Thefuture appears dark to me” (25).


119


14/38

120

The validity of the BHS has been proven by thefindings of higher scores in suicide attempters versusnonattempters (11, 26). Also, significant correlations werefound between BHS scores and SIS scores (27, 28).

The predictive validity of the scale has been welldocumented. Beck et al. found, in 1989, that a score of 9 or

above on the BHS suggested a suicide risk 11 times higherthan for scores below 8 (18). A study published in 1990 hasfound that BHS scores are the best predictors of eventualsuicide in the long term (over 1 year) (29).2.3 Self-Monitoring Suicide Ideation Scale (SMSI)

This instrument was developed by Clum andCurtin in 1993 (30). It consists of 3 items adapted from theSSI: “Today I have had thoughts of making an actualsuicide attempt” scored 0 (none) to 3 (strong), “Today Ihave thought about making an active suicide attempt”scored 0 (not at all) to 4 (continuously) and “Today I havefelt that the control I have over making an active suicideattempt was” scored (strong; no doubt I had control) to 3

(absent; no sense of control).It is designed to be used on a daily basis and todocument fluctuations in level of suicidal ideation (30).

The SMSI items were moderately correlated withscores on the SSI, and significantly correlated with theBeck Hopelessness Scale (BHS) (30).2.4 Suicide Probability Scale (SPS)

It was developed by Cull and Gill and publishedin 1988 (31). It consists of 36 items scored from 1 (“None,or a little of the time”) to 4 (“Most of the time”). It has 4subscales: hopelessness, suicidal ideation, negative self-evaluation and hostility.

Factor analysis has delineated 7 factors: ideation,hopelessness, positive outlook, interpersonal closeness,

hostility and angry impulsivity (31).Cronbach alpha coefficients shows high internal

reliability (0.93) (31).The authors have shown that the SPS can

differentiate among normals, psychiatric inpatients andsuicide attempters (31). The total score was significantlycorrelated with the BHS and the BDI (32).

Its predictive value has not been tested.2.5 Positive and Negative Suicide Ideation Inventory(PANSI)

This is an instrument that evaluates positive andnegative thoughts related to suicide attempts in the form ofa 20 item self-report. Each item is scored taking into

account symptoms present the previous 2 weeks, from 1(none of the time) to 5 (most of the time) (33).

Factorial analysis has proven the presence of twofactors: positive and negative ideation (33).

Coefficient alphas ranged from 0.80 to 0.93 for both factors, underlining a high internal reliability (33).

The authors have documented a generallymoderate correlation to items from the SuicideBehaviours Questionnaire, but the psychometric

properties of this scale need further research (33).2.6 Adult Suicidal Ideation Questionnaire (ASIQ)

This instrument was developed by Reynolds andwas published in 1991. It consists of 25 items scored from0 (never had the thought) to 6 (almost every day). Itmeasures frequency of suicidal thoughts and behaviour inthe month prior to evaluation and the perceived responseof others to a suicide attempt and, also, the degree of beliefin suicide as a solution to problems (34).

Factorial analysis has proven that this instrumentevaluates a single dimension of suicidality (35).

The ASIQ has high internal consistency –Cronbach alpha 0.96-0.98 (34, 35). Regarding validity, itwas shown that there is significant correlation with thesuicide item of HAM-D (34).

The predictive validity has been studied in 1999,and it was found that ASIQ significantly predictedsuicides in a sample of psychiatric inpatients (35).2.7 Suicide Ideation Scale (SIS)

This is a 10-item self-report scale that evaluatesseverity of suicidal ideation during the year precedingassessment. The total score ranges from 10 to 50, eachitem being scored from 1 (“Never or none of the time”) to5 (“Always or a great many times”) (36).

Cronbach alpha coefficient shows high level ofinternal consistency (0.86) (36).

SIS scores were moderately correlated with theBHS (36).

Psychometric properties of this scale haveinsufficiently been tested. Also there is no study regarding predictive value.2.8 Firestone Assessment of Self-Destructive Thoughts(FAST)

This is a 84 item instrument assessing currentfrequency of self-destructive thoughts. Each item is ratedfrom 0 (never) to 4 (most of the time). It contains 4subscales: self-defeating, addictions, self-annihilatingand suicide intent (37).

Factor analysis has found three factors: self-defeating (includes: self-depreciation, self-denial, cynicalattitudes, isolation, self-contempt), addictions (consists of8 addiction items) and self-annihilating (includes:

hopelessness, giving up, self-harm, suicide plans andsuicide injections) (37).

Cronbach's alpha coefficients have shown highinternal consistency of the total score and the foursubscales (0.84 to 0.97) (37).

Total scores and scores on subscales have beensignificantly correlated with BDI, BHS and BSI (37).

Further research is required to assess FAST's predictive ability.2.9 Suicide Behaviours Questionnaire (SBQ)

The current version of the SBQ is an abbreviatedversion of a 7-page clinician-rated interview (developed

by Linehan, unpublished), described by Cole in 1988 (38).

It consists of 4 items: “Have you ever thought about orattempted to kill yourself?” (scores 1-6); “How often haveyou thought about killing yourself in the past year?”(scores 1-5); “Have you ever told someone that you weregoing to commit suicide, or that you might do it?” (scores1-3) and “How likely is it that you will attempt suicidesomeday?” (scores 1-5).

Internal consistency is adequate (Cronbach alpha0.75-0.80) (39).Validity has been tested and it was shown that scorescorrelated significantly with the SSI scores (39). Also itwas shown that there was a significant inverse correlationwith RLI scores (14, 39).

There is no data available on predictive validity.A 34 item revised version of the SBQ (SBQ-14)

was created in 1996 by Linehan (unpublished). The SBQ-14 assesses 14 suicidal behaviours in 5 areas: past suicidalideation, future suicidal ideation, past suicide threats,

Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk – An Overview


15/38

121

future suicide attempts and likelihood of dying in a futuresuicide attempt. The questionnaire also evaluates: lifetimesuicidal behaviour, current suicide plan, availability oflethal methods, social deterrents, attitudes towards suicideand distress tolerance.

Factor analysis has shown that SBQ-14 is one-dimensional (39).

Internal reliability is high (Chronbach alpha0.73-0.92) and validity was proven by a significantcorrelation with the RLI (negative correlation) (39).

The main advantage of this instrument is itssimplicity and its clarity, which make it a viable screeningtool. This is also its greatest disadvantage, because it isvery easy to conceal suicidality should the patient decideto do so.2.10 Life Orientation Inventory (LOI)

This instrument was developed by Kowalchukand King in 1988 and has two variants: one for screeningwhich consists of 30 questions and one for profiling whichconsists of 113 questions (grouped in six subscales: self-

esteem vulnerability, overinvestment, overdeterminedmisery, affective domination, alienation and suicidetenability). All items have answers ranging from 0 (I amsure I disagree) to 4 (I am sure I agree) (14).

The Cronbach alpha is high (0.90), showing ahigh internal consistency (14).

Validity has been shown by the instrument'sability to discriminate between controls, depressed

persons, possibly suicidal patients and high risk suicidal patients (14).

There is no proven predictive value.This instrument has a unique advantage in that its

long version has three validity indices: positive bias,column responses indicative of inattentiveness to thecontent of the items and spoiled or missing (14).

3.COMBINED RATING SCALES3.1 Inventory of Potential Suicide (IPS)

It is a checklist type instrument that was published by Zung in 1974 (40). It contains 69 items ofwhich 50 are clinical and its main advantage is the fact thatit has 3 different versions: one clinical report (physicianrated), one self-report and one reported by significantother (40).

It has little to none published research on validityand reliability, but the different versions make it worthmentioning.

3.2 Suicide Status Form (SSF)This instrument measures psychological pain,

external stressors, emotional upset, hopelessness, lowself-regard and overall risk of suicide, using 12 items – 6self-report and 6 clinician-administered. Each item isscored 1 (low) to 5 (high) (41).

It was reported that there is a high level ofagreement between clinician-administered and self-reportitems (42). But there was only a moderately inversecorrelation with the Reasons for Living Scale.

Nevertheless, the SSF was able to differentiatesignificantly suicidal ideation that had resolved fromchronic one (41).

There is no data regarding the predictive abilityof the instrument. Its main advantage is the combination ofclinician-rated and safe-report in the assessment of suiciderisk.

4 . M E A S U R E S O F S U I C I D E AT T E M P TLETHALITY

We include in this review some examples ofmeasures used for suicide attempt lethality because of theimportance of this element has been proven in theevaluation of suicide risk (43).

Risk-Rescue Rating (44, 45) – a clinician-

administered 10 item scale that measures the lethality andthe suicidal intent of a suicide attempt.

Self-Inflicted Injury Severity Form (46) – aclinician-administered 7 item interview designed for usein emergency departments in order to identify self-inflicted injuries that are life-threatening.

Lethality of Suicide Attempt Rating Scale (47) –a clinician-administered scale designed to measure thelethality of a suicide attempt. It has 11 items. The totalscore ranges from 0 (death is impossible as a result of thesuicidal behaviour) to 10 (death is almost certainregardless of the intervention of an outside agent; most

people will die quickly after such an attempt). It is

generally considered that a score above 3 signifies that theattempt is a medically serious one (14).

5.BRIEF SCREENING MEASURES5.1 Sad Persons

It was published by Patterson et al in 1983 and itcomprises 10 items, several of which are knowndemographic risk factors (sex, age and not living withfamily or a partner). Other items are: depression, previoussuicide attempts, alcohol abuse, loss of rational thinking,lack of social support, organised plan of suicide andsomatic illness. Items are scored as 0 – absent or 1 –

present (48).A modified version of the scale was published in

1988 (MSPS – Modified SAD PERSONS score). It alsohas 10 items, some different from the original version. Themain difference is due to the assignment of scores 0-2 tosome items (depression or hopelessness, rational thinkingloss and stated future intent – determined to repeat orambivalent). The importance of this version is that it wasvalidated for use in screening of patients who require

psychiatric hospitalisation due to suicide risk. Thus a scoreof 6 or more suggests the need for hospital admission. Theauthors found that this cut-off score resulted in 94%sensibility and 71% specificity (49).5.2 Paykel Suicide Items

This is a 5-question interview. The questions

have increasing levels of suicidal intent: 1) “Have youever felt that life was not worth living?”; 2) “Have youever wished you were dead? – for instance, that you couldgo to sleep and not wake up?”; 3) “Have you ever thoughtof taking your life, even if you would not really do it?”; 4)“Have you ever reached the point where you seriouslyconsidered taking your life or perhaps made plans howyou would go about doing it?” and 5) “Have you evermade an attempt to take your life?”. The level of the lastquestion with a positive answer is the score of the scale(50).

Internal consistency, validity and predictivevalue have not been adequately assessed.5.3 Hamilton Depression Rating Scale (Suicide Item)

It is a clinician-reported item, scored from 0 to 4,as follows: “absent”, “feels life is not worth living or anythoughts of possible death to self”, “wishes he were dead”,



16/38

122

“suicidal ideas or gestures”, “attempts at suicide” (51).The validity was established by a significant

correlation with the SSI score and with the sore of thesuicide item on the BDI (14).

Brown et al found that patients with scores of 2 orhigher were almost 5 times more likely to commit suicide,

thus establishing predictive validity (12).5.4 Beck Depression Inventory (Suicide Item)

This is a self-report item with a 4 point rating: 1 –“I don't have any thoughts of killing myself”, 2 – “I havethoughts of killing myself, but I would not carry themout”, 3 – “I would like to kill myself” and 4 – “I would killmyself if I had the chance” (12).

Brown et al found that patients with scores of 2 orhigher were almost 7 times more likely to commit suicide(12).

6 .SCALES RELATING TO PROTECTIVEFACTORS

6.1 Reasons for Living Inventory (RLI)This is the most widely used instrumentassessing protective factors against suicide. It consists of48 items and is a self-report clinical tool. The items aregrouped in 6 subscales: survival and coping beliefs,responsibility to family, child-related concerns, fear ofsuicide, fear of social disapproval and moral objections tosuicide. Each item is scored from 1 (“not at all important”)to 6 (“extremely important”) (52).

The RLI has shown high internal reliability(Cronbach alpha 0.89 for the total score) (52).

The survival and coping subscale was comparedto BDI, BHS (53) and SSI (54) and it was found that therewas a significant negative correlation. Also it was found

that the RLI can distinguish between suicide attemptersand ideators and between suicide attempters and

psychiatric controls (11, 35).There are also available an extended 72-item

version and a brief 12-item version (55).

CONCLUSIONSThere are numerous clinical suicide assessment

instruments described in the literature. Many of them have been studied, some more extensively than others,regarding their psychometric properties.

The main difficulty encountered when usingclinical instruments is a low degree of specificity

(meaning many false positive cases). Anotherdisadvantage is the high reliance on the patient's sincerity.Also, many of the scales or questionnaires described donot differentiate between acute and chronic suicide risk.

Another conclusion that can be drawn from thiswork is that, although, many of the instruments presentedevaluate the suicidal process, meaning that, to some extentthey are complementary and not interchangeable. This iswhy it is important to make an informed choice whenapplying a certain clinical instrument to an individualsituation. This choice has to take into account the specificreason for the evaluation, the viability and reliability of theinstrument regarding this evaluation, whether or not it has

been applied to the population the patient pertains to etc.One instrument seems to stand out: the STS-3. It

is a newly developed interview, the only one that wascreated specifically for the evaluation of acute suiciderisk. Also, it tries to resolve another major problem

encountered by other clinical instruments: the reliance onthe patient's sincerity.

Further research is needed in the assessment ofsuicidal crises (acute suicide risk) since this

REFERENCES

1. Organizaţia Mondială a Sănătăţii. Preventing suicide a globali m p e r a t i v e – M y t h s , 2 0 1 4 . A v a i l a b l e a t :http://www.who.int/mental_health/suicide-prevention/myths.pdf?ua=12. Harris EC, Barraclough B. Suicide as an outcome for mental disorders.A meta-analysis. Arch Gen Psychiatry 2005;62(6): 617-27.3. Beautrais AL, Joyce PR, Mulder RT et al. Prevalence and comorbidityof mental disorders in persons making serious suicide attempts: a case-control study. Am J Psychiatry1996;153(8): 1009-14.4. Baldessarini RJ. Lithium: effects on depression and suicide. J Clin Psychiatry 2003;64: 7.5. Buglass D, Horton J. A scale for predicting subsequent suicidal behaviour. Br J Psychiatry 1974;124(0): 573-8.6. Cohen E, Motto JA, Seiden RH. An instrument for evaluating suicide potential: a preliminary study. Am J Psychiatry1966;122(8): 886-91.7. Tuckman J, Youngman WF. A scale for assessing suicide risk ofattempted suicides. J Clin Psychol1968;24(1): 17-9.8. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention:

the Scale for Suicide Ideation. J Consult Clin Psychol 1979;47(2): 343-52.9. Beck AT, Brown GK, Steer RA. Psychometric characteristics of theScale for Suicide Ideation with psychiatric outpatients. Behav Res Ther1997;35(11): 1039-46.10. Molock SD, Kimbrought R, Lacy MB et al. Suicidal behavior amongAfrican American college students: A preliminary study. J of Black Psychol 1994;20(2): 234-251.11. Mann JJ, Waternaux C, Haas GL, Malone KM. Toward a clinicalmodel of suicidal behavior in psychiatric patients. Am J Psychiatry1999;156(2): 181-9.12. Brown GK , Beck AT, Steer RA, Grisham JR. Risk factors for suicidein psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol2000;68(3): 371-7.13. Cochrane-Brink KA, Lofchy JS, Sakinofsky I. Clinical rating scalesin suicide risk assessment. Gen Hosp Psychiatry 2000;22(6): 445-51.14. Range LM, Knott EC. Twenty suicide assessment instruments:

evaluation and recommendations. Death Stud1997;21(1): 25-58.15. Beck AT, Brown GK, Steer RA et al. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav1999;29(1): 1-9.16. Beck AT, Weissman A, Lester D, Trexler L. Classification of suicidal behaviors. II. Dimensions of suicidal intent. Arch Gen Psychiatry 1976;33: 835-7.17. Mieczkowski TA, Sweeney JA, Haas GL et al. Factor composition ofthe Suicide Intent Scale. Suicide Life Threat Behav 1993;23(1): 37-45.18. Beck AT, Steer RA. Clinical predictors of eventual suicide: A five toten year prospective study of suicide attempters. J Affec Disord 1989;17:203-9.19. Tejedor MC, Diaz A, Castillon JJ, Pericay JM. Attempted suicide:Repetition and survival – findings of a follow-up study. Acta PsychiatrScand 1999;100(3): 205-11.20. Yaseen ZS, Gilmer E, Modi J et al. Emergency room validation of therevised Suicide Trigger Scale (STS-3): a measure of a hypothesized

suicide trigger state. PLoS One 2012;7(9): e45157.21. Yaseen ZS, Kopeykina I, Gutkovich Z et al. Predictive validity of theSuicide Trigger Scale (STS-3) for post-discharge suicide attempt in high-risk psychiatric inpatients. PLoS One 2014;9(1): e86768.22. Beck AT, Steer RA, Ranieri WF. Scale for Suicide Ideation: psychometric properties of a self-report version. J Clin Psychol1988;44(4): 499-505.23. Steer RA, Rissmiller DB, Ranieri WF, Beck AT. Dimensions ofsuicidal ideation in psychiatric inpatients. Behav Res Ther 1993;31(2):229-36.24. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: The hopelessness scale. J Consult Clin Psychol 1974;42:861-5.25. Aish AM, Wasserman D, Renberg ES. Does Beck's HopelessnessScale really measure several components? Psychol Med 2001;31(2):367-72.26. Rifai AH, George CJ, Stack JA et al. Hopelessness in suicide

attempters after acute treatment of major depression in late life. Am J Psychiatry 1994;151: 1687-90.27. Dyer JAT, Kreitman N. Hopelessness, depression, and suicidal intentin parasuicide. Br J Psychiatry1984;144: 127-33.28. Kovacs M, Beck AT, Weissman A. Hopelessness: An indicator ofsuicidal risk. Suicide 1975;5: 98-103.

Ana-maria Exergian: Clinical Instruments For The Evaluation Of Suicide Risk – An Overview


17/38

123

29. Fawcett J , Scheftner WA, Fogg L et al. Time-related predictors ofsuicide in major affective disorder. Am J Psychiatry 1990;147(9): 1189-94.30. Clum GA, Curtin L. Validity and reactivity of a system of self-monitoring suicide ideation. Journal of Psychopathology and Behavioral Assessment 1993;15(4): 375-85.31. Cull JG, Gill WS. Suicide Probability Scale Manual . Los Angeles:Western Psychological Services, 1988.32. D'Zurilla TJ, Chang EC, Nottingham EJ, Faccini L. Social problemsolving deficits and hopelessness, depression, and suicidal riskin college students and psychiatric inpatients. J Clin Psychol 1998;54:1091-107.33. Osman A, Gutierrez PM, Kopper BA et al. The Positive and NegativeSuicide Ideation Inventory: Development and validation. Psychol Rep 1998;82(3 Pt 1): 783-93.34. Reynolds WM. Psychometric characteristics of the Adult SuicidalIdeation Questionnaire in college students. J Pers Assess 1991;56(2):289-307.35. Osman A, Kopper BA, Linehan MM et al. Validation of the AdultSuicidal Ideation Questionnaire and the Reasons for Living Inventory inan adult psychiatric inpatient sample. Psychological Assessment 1999;11: 115-223.36. Rudd MD. The prevalence of suicidal ideation among collegestudents. Suicide Life Threat Behav 1989;19(2): 173-83.37. Firestone RW, Firestone LA. Firestone Assessment of Self-

Destructive Thoughts. San Antonio, Texas: Psychological Corporation,1996.38. Cole DA. Hopelessness, social desirability, depression, and parasuicide in two college student samples. J Consult Clin Psychol 1988;56: 131-6.39. Cotton CR, Peters DK, Range LM. Psychometric properties of theSuicidal Behaviors Questionnaire. Death Studies 1995;19:391-7.40. Zung WWK. Index of potential suicide (IPS): A rating scale forsuicide prevention. In: Beck AT, Resnik HLP, Lettieri DJ (eds). The prediction of suicide. Bowie: Charles Press, 1974, 221-249.41. Jobes DA, Jacoby AM, Cimbolic P, Hustead LAT. Assessment andtreatment of suicidal clients in a university counseling center. Journal ofCounseling Psychology 1997;44(4): 368-77.42. Eddins CL, Jobes DA. Do you see what I see? Patient and clinician perceptions of underlying dimensions of suicidality. Suicide Life Threat Behav 1994;24: 170-3.

43. Leadholm AK, Rothschild AJ, Nielsen J et al. Risk factors for suicide

among 34,671 patients with psychotic and non-psychotic severe

depression. J Affect Disord2014;156: 119-25.

44. Weissman AD, Worden JW. Risk-Rescue Rating in suicideassessment. Arch Gen Psychiatry 1972;26: 553-60.45. Weissman AD, Worden JW. Risk-Rescue Rating in suicideassessment. In: Beck AT, Resnik HLP, Lettieri DJ (eds). The prediction of

suicide. Philadelphia: Charles Press, 1974.46. Potter LB, Kresnow M, Powell KE et al. Identification of nearly fatalsuicide attempts: Self-inflicted injury severity form. Suicide Life Threat Behav 1998;28: 174-86.47. Smith K, Conroy RW, Ehler BD. Lethality of suicide attempt ratingscale. Suicide Life Threat Behav 1984;14(4): 215-42.48. Patterson WM, Dohn HH, Bird J, Patterson GA. Evaluation ofsuicidal patients: the SAD PERSONS scale. Psychosomatics1983;24(4): 343-5, 348-9.49. Hockberger RS, Rothstein RJ. Assessment of suicide potential bynonpsychiatrists using the SAD PERSONS score. J Emerg Med1988;6(2): 99-107.50. Paykel ES, Myers JK, Lindenthal JJ, Tanner J. Suicidal feelings in thegeneral population: A prevalence study. Br J Psychiatry, 1974;124: 460-9.51. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960;23: 56-62.

52. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons forstaying alive when you are thinking of killing yourself: The Reasons forLiving Inventory. J Consult Clin Psychol 1983;51(2): 276-86.53. Strosahl K, Chiles JA, Linehan M. Prediction of suicide intent inhospitalized parasuicides: Reasons for living, hopelessness, anddepression. Compr Psychiatry 1992;33(6): 366-73.54. Dean PJ, Range LM, Goggin WC. The escape theory of suicide incollege students: Testing a model that includes perfectionism. Suicide Life Threat Behav 1996;26: 181-6.55. Ivanoff A, Jang SJ, Smyth NF, Linehan MM. Fewer reasons forstaying alive when you are thinking of killing yourself: The BriefReasons for Living Inventory. J Consult Clin Psychol 1983;51(2): 276-86.

***



18/38

ORIGINAL ARTICLES

COMPARATIVE DIMENSIONAL APPROACH OFPERSONALITY DISORDERS THROUGH THEMODELS OF BIG FIVE AND BIG SEVEN

INTRODUCTIONPersonality disorders (PD) have always constituted amajor problem in psychiatry, because of the impact theyhave on our society. Understanding personality and itsdisorders helps us to develop much more sophisticatedtreatment guidelines and prophylactic measures. TheDSM-IV diagnostic criteria for PD uses a categoricalapproach and this way is not much of a help in anindividualized treatment strategy. This latter assumptionled researchers adopt an opening towards dimensionalapproaches. Phenotypic trait personality models have a

better precision in clinical settings then developmental personality models but are not useful to describe

underlying intrapsychic processes(1). The Big fivemodel is a phenotypic trait personality model which wasdeveloped to assess normal personality but being adimensional model it can be used to assess pathological

personality too. Although this model cannot be used todiagnose PD, low scores on agreeabilness and emotionalstability can be a predictor of pathologic personality traits.A developmental personality model is the Big sevenwhich was developed for normal and pathologic

personality, thus it is useful in the diagnosis of PD.Deficiencies of the character, namely low scores on self-direction and cooperativeness prove the presence of aPD.(2)

1 MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures. Correspondence: [email protected]

2 MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.

3 MD Psychiatry resident, PhD Candidate at Psychiatry Clinic II, Targu Mures.

4 Medical Student, University of Medicine and Pharmacy, Targu Mures

Received July 09, 2014, Revised September 01, 2014, Accepted October 03, 2014

Abstract: Introduction: The dimensional models of personality have gained ground in the area of trait psychology, fact provenby the introduction of the alternative DSM-5 model.Objectives: The aim of the study was to find correlationsbetween the dimensions of Big five and Big seven.

Method: A group of patients (N= 44) from our Personality Disorders Register were included in this study. They filledout two self-administered, paper-and-pencil tests: the

Temperament and Character Inventory(TCI) and the D i s p o s i t i o n ( O p e n n e s s ) - E x t r a v e r s i o n -Consc ien t iousness -Agreeabi lnes s -Emot ionalStability(DECAS) Inventory.

Results: We have found moderate positive correlationbetween Disposition and Self-Transcendence (r=0.51; p=0.0004) respective Disposition and Persistence (r=56; p=0.0001) and a strong negative correlation between Disposition and Harm Avoidance (r=-0.64; p=0.0001). Extroversion was correlated with Self-Transcendence(r=0.4; p=0.0044), Novelty Seeking (r=0.43; p=0.0031), Harm Avoidance (r=-0.72; p=0.0001) and Persistence(r=0.45; p=0.0021). Conscientiousness is correlated withSelf-Transcendence (r=0.49; p=0.0006), Harm avoidance(r=-0.5; p=0.0005) and Persistence (r=0.43; p=0.0031).We have found a moderate positive correlation between Agreeabilness and Harm Avoidance (r=0.45; p=0.0019).Conclusions: The comparative comments of thedimensional evaluation places a premium on the diagnosisof personality disorders. Self-transcendence has a majorrole in understanding personality disorders in any socio-culture.

Key words: Personality disorder, alternative DSM-5model, dimensional models of personality, TCI, DECAS.

processes, DSM-5, neuropsychology

124


19/38

125

OBJECTIVEOur aim was to compare the dimensions of the big fivetheory with the dimensions of the seven factor model, inthe hope of finding correlations between them, and thisway strengthening the link between different dimensionalmodels.

MATERIAL AND METHODSA group of patients(N= 44) from our PersonalityDisorders Register were included in this study. Thisregister contains recorded data from patients diagnosedwith PD between 2011 and 2014 at the Psychiatric ClinicII in Tirgu Mures.In our study we used the data of two self-administered,

paper-and-pencil tests: the Temperament and CharacterInventory(TCI) and the Disposition (Openess)-Extraversion-Conscientiousness-Agreeabilness-Emotional Stability(DECAS) Inventory.Ethical rules regarding informed consent andconfidentiality were applied. Data where processed using

Microsoft Excel(Microsoft Corp., Redmond, WA, USA)and GraphPad InStat. Linear(Pearson) correlation test wasused calculate the correlation between differentdimensions.

RESULTSDescriptive statisticsSummed scores of the item pools where examined foreach dimension (Table 1, Table 2)

Table 1. The mean, standard deviation(SD) and normality test forthe summed scores of the DECAS dimensions.

Table 2. The mean, standard deviation(SD) and normality test for

the summed scores of the TCI factors. Sd- self-directed; Co-cooperative; St- self-transcendent; Ns- Novelty seeking; Ha-Harm avoidance; Rd- rewa

revista romana de psihiatrie

Documents