...where“treatment-resistant”pa1entsbecomepeopletakingchargeoftheirlives. www.austenriggs.org

StatesofMindPrecedingaNearLethalSuicideA7empt:AMixedMethodsStudy

JaneG.Tillman,PhD,ABPPJenniferL.Stevens,PhD,ABPP

TheEriksonIns=tuteoftheAustenRiggsCenter

1

ResearchTeam• PrincipalInvesAgator:JaneG.Tillman,PhD

• Co-InvesAgators:A.JillClemence,PhD;JenniferL.Stevens,PhD;Ka=eC.Lewis,PhD

• Consultants:DavidE.Reiss,MD;ChristopherJ.Hopwood,PhD;RobynA.Cree,PhD;JohnT.Maltsberger,MD;HerbertHendin,MD

2

Funding• Interna=onalPsychoanaly=cAssocia=on

• AmericanPsychoanaly=cAssocia=on

• JeffreyGu=nFundoftheNewHampshireCharitableFounda=on

3

SuicideintheUSA• SuicideintheUSAincreasedby24%between1999-2014.

• Bostwicketal.,(2016)foundthat59.3%ofpeopledyingbysuicidediedonthefirsta_empt.

• Over60%offirstsuicidea_emptsoccurwithinthefirstyearoftheonsetofsuicidalidea=on(Kessleretal.,1999).

• Followingasuicidea_empt,thelife=meriskofcompletedsuicideiselevatedforaslongas37yearsfollowingtheindexa_empt(Suominen,2004).

4

5

Suicidevs.BreastCancer:IncidenceandFunding

6

494169

231840

43298 40290

0

100000

200000

300000

400000

500000

600000

Suicide BreastCancer

SuicidevsBreastCancerOccurrence/DeathsChart(2015)

Occurrence Deaths

$46,000,000

$674,000,000

0

100000000

200000000

300000000

400000000

500000000

600000000

700000000

800000000

Suicide BreastCancer

NIHFunding(2015)

SuicideResearch• Popula=onbasedepidemiologicalstudiestoiden=fygroupsatelevatedriskforsuicide

• Clinicalstudiesbydiagnosis(depression,PTSD,etc..)

• Lessisknownaboutprotec=vefactors

• Li_lea_en=ontotheinterac=onofriskandprotec=vefactorsinvulnerablepopula=ons

• Beyondriskandprotec=vefactors:Needtounderstandthepsychologyofthepersonwhoa_emptsorcompletessuicideandthestatesofmindprecedingasuicidea_empt

7

TheoreAcalModelsofSuicideOveradozenpsychologicalmodelsofsuicidewithempiricalsupportbutli_leintegra=on

• Stress-DiathesisModel(Mannetal.,1999)

• InterpersonalTheoryofSuicide(Joiner,2005)

• Cogni=veTheory(WenzelandBeck,2008)

• 3STTheory;“idea=on-to-ac=on”(KlonskyandMay,2014)

• Psychodynamictheoryofsuicide(Maltsberger,2004)

8

CommonFindingsAcrossTheories• Suicideisacomplexbehaviorwithmul=factorialcauses

• Thereareproximalfactorsanddistalfactorsinvolved(state-trait)

• Stressisinvolvedincrea=ngthecondi=onsforsuicide,withacutestressasaprecipitantforsuicidalbehavior

• Cannotexplainwhyextremestressisassociatedwithsuicidebehaviorinsomebutnotallexposedindividuals

9

RiskFactors• DemographicRisk:age,gender,raceandethnicity,familyhistoryofsuicide

• NeuropsychiatricRisk:diagnoses,neurosignaturesofrisk

• PsychologicalRisk:impulsiveness,hos=lity,aggression,“psychache.”

• DevelopmentalRisk:earlyadversity,sexualabuse,physicalabuse

• Nega=velifeevents:trauma,violence,loss,betrayal,bullying,poverty

10

ProtecAveFactorsWhattheyare:

• Psychologicalprotec=vefactors:reasonsforliving,resilience,hardiness,meaninginlife,hope,self-efficacy

• Accesstoadequatetreatment

• Socialsupport

Whytheyareimportant:

Inthecontextofanincreasingnumberofriskfactors,someofwhicharefixed,protec=vefactorsbecomeextremelyimportant.

11

AimsofStudy• Understandthe“career”ofsuicideinAustenRiggspa=ents:psychiatrichistory,suicidehistory,psychologicalcharacteris=cs

• Howdoriskandprotec=vefactorsinteractinthisgroupofhigh-riskpa=entswithsuicidestatus(i.e.non-a_empters,ideators,a_empters,near-lethala_empters,numberoflife=mea_empts)?

• Whatcanpa=entstellusabouttheirstateofmindimmediatelyprecedinganear-lethalsuicidea_empt?

• Canweheara“deepstory”abouttheprocessofsuicidethatimprovesourcapacitytorecognizethetransi=onfromchronictoacuterisk?

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MixedMethodsApproach• Researchques=oncallsforbothquan=ta=veandqualita=vedata

• Onriskandprotec=vefactorsmeasures,whatdoestheRiggspa=entpopula=onlooklikeincomparisontoothersamples?Howdoriskandprotec=vemeasuresinteract?(quanAtaAve)

• Whatisthe“deepstory”thatsurvivorsofnear-lethalsuicidea_emptstellabouttheirstateofmindpriortothesuicidea_empt?(qualitaAve)

13

ResearchContext• AustenRiggsCenter:Approximately45%ofpa=entsadmi_edduringtheperiodofthestudyhadahistoryofapriorsuicidea_empt

• Fromthefollow-alongstudyweknowourpa=entshavecomplexpsychiatricdifficul=es

• Extensiveco-morbidity;difficultyengaginginoutpa=entpsychotherapy;mul=plemedica=ontrialsorotherbiologicalapproachesthathavenotbeeneffec=ve

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HumanSubjectsResearchatRiggs

• Anxietyandconcerninclinicalstaffaboutaskingpar=cipantstoreconstructtheirstateofmindpriortothesuicidea_empt

• Concernabouthowtalkingsoexplicitlyanddirectlyaboutsuicideinaresearchcontextmightaffectclinicalcareandmilieu

• Almostyear-longdiscussionandnego=a=onwithclinicalleadershipaboutethicsanddesignofresearchproject

• Substrate:Trauma=zedorganiza=onbasedonpa=entsuicides

15

16

Study#1

ObjecAve

• Todeterminetheincrementalassocia=onofreasonsforlivingtothelifeAmenumberofsuicidea7emptsinrela=ontootherknownriskandprotec=vefactors

17

Hypotheses1.ResilienceandReasonsForLivingwillbeposi=velycorrelated,demonstra=ngconvergentvalidity

2.Higherscoresonprotec=vefactorsmeasures(CDRISCandRFLI)willbeassociatedwithfewerlife=mesuicidea_empts,eveninthepresenceofriskfactorsofimpulsiveness,generalpsychiatricseverity(GAFscores),andnega=velifeeventsofsexualand/orphysicalabuse

18

MeasuresProtec=veFactorMeasures

• ReasonsforLivingInventory(RFLI)

• A48-itemself-reportmeasureasking“whataresomereasonsyouwouldNOTkillyourself?”InLinehan’sfactoranalysistherearesixfactors.

• Connor-DavidsonResilienceScale(CDRISC)

• 25-itemself-reportmeasure,developedforuseinpopula=onswithPTSD

RiskFactorMeasures

• Barra7ImpulsivenessScale-11(BIS)

• 30-itemself-reportmeasure.Threesubscales:cogni=ve,behavioral,motoricimpulsiveness

19

ParAcipants298 patients admitted during study period (38 months)

131 (53%) participated

119 questionnaires only 12 questionnaires + psychodynamic research interviews

1 excluded from analysis

50 met exclusion criteria

248 eligible participants

117 (47%) refused or did not respond

20

ParAcipantCharacterisAcsTable 1

Demographic, Suicide, and Psychiatric History Descriptive Variables

Demographics N Overall Min/Max Gender 131

Male

49 (37.4%) Female

82 (62.6%)

Age (years), mean ± SD 131 33.06 ± 12.74 18-71 Psychiatric and suicide history Suicide Attempters

71 (54.2 %)

Lifetime number of attempts, mean ± SD

2.65 ± 2.02 1-12 Non-Attempters

60 (45.8%)

History of physical abuse 128 40 (30.5%) History of sexual abuse 130 43 (32.8%) Age of first psychiatric contact, mean ± SD 131 15.53 ± 9.94 2-70

Age of first onset of suicidal ideation, mean ± SD 107 19.97 ± 13.44 5-70 Age of first suicide attempt, mean ± SD 71 24.52 ±13.70 8-70 Prior Psychiatric Hospital Admissions, mean ± SD 129 3.75 ± 5.27 0-35 Presence of Axis I Diagnosis 131 131 (100%)

Presence of Axis II Diagnosis 131 122 (93.0%) Current Severity (GAF score), mean ± SD 131 45.85 ± 6.92 25-70

21

FactoranalysisofRFLI

• Weiden=fied5andnot6factorsontheRFLI

• Linehangroupiden=fiedfearofconsequencesofsuicideandfearofsuicideactasseparatefactors.

• Wefoundasingle“fearfactor”

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CorrelaAonsbetweenReasonsforLivingCompositesandCriterionVariables

RFLI Composite CDRISC LSA BIS-11 GAF SA PA

Survival and Coping Beliefs .60* -.29* .02 .07 -.01 -.07

Responsibility to Family .08 -.08 .08 -.03 -.12 -.22

Child-Related Concerns .33* .04 -.12 -.11 .05 .11

Fear -.13 -.33* .14 .18 -.14 -.20

Moral Objections .17 -.23 .07 .09 .11 -.04

CDRISC = Connor Davidson Resilience Scale; LSA = Lifetime number of suicide attempts; BIS-11 = Barratt Impulsiveness Scale; GAF = Global Assessment of Functioning; SA = History of sexual abuse; PA = History of physical abuse

* p< .01

23

BetacoefficientsfromamodelwithriskfactorsandselectedReasonsforLivingcompositespredicAng

lifeAmesuicidea7empts

Variable 𝛽 p

History of Sexual Abuse .34 .001*

History of Physical Abuse -.06 .53

Impulsiveness -.01 .94

Current Severity (GAF) -.09 .26

Survival and Coping Beliefs -.23 .007*

Fear -.22 .01*p<.01

24

Conclusion

25

•Theprotec=vefactorofSurvivalandCopingBeliefsmaybeanimportantbarriertorepeatedsuicidea_empts

•RFLImaybeasuicidespecificresiliencemeasure

•Weneedabe_erunderstandingofhowprotec=vefactorsaredevelopedinearlylifeandwhatsupportsorerodesprotec=vefactors

26

Study#2

ObjecAvePa=entswithahistoryofsuicidalidea=onora_empts,especiallyiftheyhaveseriouspsychopathologywithrepeatedhospitaliza=ons,areburdenedbyongoingriskforsuicide.Westudiedthishigh-riskgrouptoassesstheirpsychologicalstatusfollowingtheirmostrecentsuicidea_empt,incontrasttoequallyillpa=entswithoutasuicidehistory.Further,amongsuicidalpa=ents,wecomparedthosewithonlyidea=on,withanon-medicallyserioussuicidea_emptandwithmedicallyserioussuicidea_empts.Wealsoreportonthedevelopmentofanewmeasureofpsychicpain.

27

Hypotheses• Groupsofpar=cipantswithdifferentsuicidehistorieswillbesignificantlydifferentfromoneanotheronriskandprotec=vefactormeasures

• non-a_empters<ideators<a_empters<medicallyseriousa_emptersonriskfactormeasures

• non-a_empters>ideators>a_empters>medicallyseriousa_emptersonprotec=vefactormeasures

28

MeasuresProtec=veFactorMeasures

• ReasonsforLivingInventory(RFLI)

• A48-itemself-reportmeasureasking“whataresomereasonsyouwouldNOTkillyourself?”InLinehan’sfactoranalysistherearesixfactors.

• Connor-DavidsonResilienceScale(CDRISC)

• 25-itemself-reportmeasure,developedforuseinpopula=onswithPTSD

RiskFactorMeasures

• Barra7ImpulsivenessScale-11(BIS)

• 30-itemself-reportmeasure.Threesubscales:cogni=ve,behavioral,motoricimpulsiveness

• PsychicPainScale(PPS)

• Newlydevelopedaspartofthisstudy,20-itemself-reportmeasurewithitemsconstructedbasedonMaltsberger’stheoryofthesuicideprocessinvolving“affec=vedeluge”andasubjec=vefeelingofa“lossofcontrol.”

29

30

Variable N Overall Non-suicidality (N = 24)

Suicidal Ideation(N=36)

Non-Severe Suicide

Attempts (N = 30)

Medically Serious Suicide

Attempts (N = 41)

p†

RFLI, mean ± SD 127 3.24 ± 0.90 4.28 ± 0.85 3.26 ± 0.79 2.72 ± 0.83 2.99 ± 0.56 <0.001

CDRISC, mean ± SD 131 49.95 ± 18.5 59.81 ± 18.23 49.61 ± 17.45 48.01 ± 20.58 45.90 ± 16.43 0.026

PPS, mean ± SD 129 61.31 ± 17.21 45.21 ± 12.73 60.49 ± 15.99 66.12 ± 18.02 67.65 ± 14.14 <0.001

BIS-11, mean ± SD 130 69.40 ± 12.31 69.85 ± 10.64 68.38 ± 14.84 67.15 ± 11.07 71.69 ± 11.59 0.444

Prior Admissions, mean ± SD

129 3.75 ± 5.27 1.69 ± 4.20 2.14 ± 2.28 4.0 ± 4.15 6.14 ± 7.20 <0.001

DescripAonofsamplebysuicidality

† P-value for ANOVA (continuous variables); 𝛘2 or Fisher’s exact test (categorical variables)RFLI, Reasons for Living Inventory; CDRISC, Connor Davidson Resilience Scale; PPS, Psychic Pain Scale, BIS-11, Barratt Impulsiveness Scale-11

31

4.35 4.28 4.23 4.18

3.623.26

2.992.72

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

PsychiatricControlGroup

NonAttempters UniversityStudents

AfricanAm.WomenwithSuicideHistory

Suicideattempters

Ideators Near-LethalAttempters

Attempters

Osman,Kopperetal(1999)

Tillman,Clemenceetal.

(2017)

Grewwal-Sandhu(2009)

Street,J.C. Osman,Kopperetal(1999)

Tillman,Clemenceetal.

(2017)

Tillman,Clemenceetal.

(2017)

Tillman,Clemenceetal.

(2017)

ReasonsforLivingInventoryMeanItemScore

32

80.4076.70

68.0059.81 59.50

49.80 49.61 48.01 45.90

GeneralPopulation

USVeteransofIraqand

Afghanistan

PsychiatricOutpatients

NonAttempters OEFVeteranswithPTSD

AbstinentSubstance

Abuserswithahistoryofsuicide

attempts

Ideators Attempters Near-LethalAttempters

Connor,Davidson(2003)

Youssef, Greenetal.(2013)

Connor,Davidson(2003)

Tillman,Clemenceetal.

(2017)

Pietzak,Johnsonetal.(2010)

Royetal.(2007) Tillman,Clemenceetal.

(2017)

Tillman,Clemenceetal.

(2017)

Tillman,Clemenceetal.

(2017)

ConnorDavidsonResilienceScale

33

59.40 61.21

67.15 68.38 69.85 71.47 71.6975.10

82.10

0

10

20

30

40

50

60

70

80

90

AdultHealthy

Control

Undergraduate

students

Attempters Ideators NonAttempters Femaleswith

BulimiaNervosa

Near-Lethal

Attempters

ManicAdolescents BipolarPatients

withMedically

SevereSuicide

Attempts

Malloy-Diniz,

Fuentes,etal.

(2007)

Snorrason,Smariet

al.(2011)

Tillman,Clemence

etal.(2017)

Tillman,Clemence

etal.(2017)

Tillman,Clemence

etal.(2017)

Merlotti,Mucciet

al.(2013)

Tillman,Clemence

etal.(2017)

Nandagopal,Fleck

etal.(2011)

Swann,Dougherty,

Pazzaglia,etal.

(2005)

BarrattImpulsivenessScale-11

34

38.5445.21

60.4966.12 67.65

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

Undergraduatestudents NonAttempters Ideators Attempters Near-LethalAttempters

Hopwood&Good(2016)

PsychicPainScale

35

1 2 3 4 5 6 7 8 9

1. PPS

2. RFLI -0.5***

3. CDRISC -0.73*** 0.46***

4. BIS-11 0.21* 0.07 -0.25**

5. Psychiatric admissions 0.27** -0.17 -0.13 0.05

6. Child abuse 0.21* -0.18* -0.06 -0.04 0.20*

7. Adolescent abuse 0.13 -0.13 0.05 -0.02 0.26** 0.51***

8. Adult abuse 0.13 -0.08 0.11 0.00 0.35** 0.23* 0.40***

9. Age 0.02 -0.13 -0.07 -0.20* 0.11 0.09 0.06 0.12

10. Gender -0.24** 0.13 0.11 0.01 -0.27** -0.21* -0.37*** -0.31*** -0.01

CorrelaAonsofStudyVariables

* p <0.05, ** p < 0.01, *** p <0.001

36

Variable Unadjusted OR (95% CI)

Unadjusted p-value

Adjusted OR (95% CI)

Adjusted p-value

PPS 1.06 (1.03,1.09) <0.001 1.05 (1.01,1.10) 0.009

RFLI 0.24 (0.15,0.40 <0.001 0.28 (0.15,0.52) <0.001

CDRISC 0.97 (0.95,0.99) 0.009 1.03 (0.99,1.07) 0.157

Admissions 1.24 (1.08,1.42) 0.002 1.08 (0.95,1.23) 0.247

Childhood abuse 2.14 (1.08,1.42) 0.048 0.71 (0.25,1.99) 0.514

Adolescent abuse 3.53 (1.63,7.66) 0.001 2.40 (0.79,7.30) 0.122

Adult abuse 3.92 (1.47, 10.44) 0.006 2.27 (0.65,7.95) 0.202

Age 1.03 (1.00,1.06) 0.068 1.03 (0.99,1.07) 0.087

Male 0.44 (0.21,0.91) 0.026 1.14 (0.45, 2.87) 0.782

Results

Ahistoryofsuicidalidea=onorsuicidea_emptsisassociatedwithpropor=onallymorepsychicpainandfewercurrentreasonsforliving.Priorhistoryofabuse,impulsiveness,andgeneralresiliencewerenotsignificantlyassociatedwithsuicidalseverity.

37

Conclusions•Itisconceivablethatpsychicpainandotherriskfactorswalka

persontotheedgeofaproverbialcliff,butreasonsforlivingmaystopapersonfromjumping.

•Forpa=entswhohavesuicidalidea=on,orhavea_emptedsuicide,andalsohaveaddi=onalriskfactorsincludingpasthospitaliza=on,treatmentsshouldincludebothunderstandingthesourcesofpsychicpainandpromo=ngindividualdiscoveryofreasonsforliving.

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39

PTSD and a foreshortened sense of the future and/or hopelessness about the future

Increased Psychic Pain

Childhood Abuse

Suicidal Ideation and Number of Lifetime Attempts

Decreased Reasons for Living

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QualitaAveResearchInterviews:Amorecomplex

story

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Semi-StructuredDynamicInterview

Semi-structuredpsychodynamicinterviewforpar=cipantswhohavesurvivedanear-lethala_emptinthetwoyearspriortoadmission.

InterviewStructure:

• Generalthoughtsandfeelingsatthe=meofthea_empt

• Acutecontextfora_emptwitha_en=ontointernalandexternalcircumstances(fantasies,dreams,stress)

• Interpersonalcontext

• Detailsofmethod

• Rescue,damage,lethalityinforma=on

• Survival

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InterpretaAvePhenomenologicalAnalysis(Smith,Flowers,&Larkin,2009)

• IPAisatheore=callybasedqualita=veapproachtoanalyzinginterviewdataattheleveloftheindividualinordertounderstandhowpeoplemakesenseofadefinedlifeexperience.

• Helpsresearchersgainanunderstandingofthepsychologicalprocessesandthemeslinkedtoaspecificsitua=on.

• “movingfromthepar=culartotheshared,andfromthedescrip=vetotheinterpreta=ve”(p.79).

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IPAProcedure1. Interviewdigitallyrecordedandtranscribed

2. Eachtranscriptreadforini=alfamiliarityandtocorrecterrorsintranscrip=on

3. Transcriptsreadasecond=meandini=althemesanddetailswerenotedalongwithdescrip=vesummarycommentsabouteachtranscript

4. Transcriptsandnotesfromstep3usedinathirdreadingtoconstructalistofemergingthemes

5. Eachresearcheddevelopsalistofthemesforeachpar=cipant’sinterviewandlooksforrecurringthemesacrossinterviews

6. Researcherscomparedalistofallthemesthateachhadindependentlyiden=fiedineachinterview.Placeofdiscordancediscussedandfurtherelaborated.Elabora=onandconsolida=onofthemeswithineachinterviewoccurred.

7. Researchersworktogethertoreconcile61thema=cunitsiden=fiedacrossalleleveninterviews,sor=ngtheunitsintocategories.Finalsortyieldedseventhema=ccontentandprocessunitsassociatedwiththestateofmindleadinguptoanearlethalsuicidea_empt.

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DevelopingtheDeepStoriesofSuicide

45

46

Theme DescriptionDevelopmental

conflictsDevelopmental crises, difficulty tolerating separation and loss, conflicts with authority played out in separation struggles, childhood trauma

Character traits and vulnerabilities

Perfectionism, grandiosity, rigid character and cognition, nihilistic philosophy of life, sensitivity and reactivity to betrayal and rejection, malignant narcissism, fixed ideas, perverse relationship to death and others

Interpersonal and object relations

paradigms

Misuse of persons, self and other seen as in perverse engagement, fixed ideas about the interpersonal world, spitting with the self as particularly bad in relation to good other or other as particularly bad in relation to victimized and misunderstood good self.

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Theme Description

Thinking and affect Unbearable, difficult to symbolize pain that is believed will never end; nihilistic philosophy used as a defense against painful feelings; thinking problems such as subtle thought disorder, poverty of understanding, and strained logic or reality testing about the finality of death; shame and humiliation; unconscious and/or denied rage; feelings of helplessness and of being trapped.

Fantasies of death Death as a means to peaceful relief from suffering; relational fantasies of death as a means of reunion with a dead parent, death as a means of revenge or a way of evoking guilt or longed for recognition in others.

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Theme Description

Paradoxical nature of the immediate moment of the

suicide attempt

Dissociation, attempt paradoxically both planned and impulsive, ineffable quality of the immediate moment, paradoxical focused attention and confused thinking, internal world simultaneously numb while unbearable pain imposes the scene

Reactions to survival Loss of a fear of death, regret, relief, ambivalence about surviving; effect on relationships with family members.

Conclusions• Mixedmethodsresearchishardtowriteup!

• Thereappearstobeagapbetweenwhatwediscoverwithourquan=ta=vemeasuresandtherichtextureofourinterviews

• Iseachsuicideasingularity,withidiosyncra=canddeeplyheldpersonalmeaningsthatmustbediscoveredandaddressed?Ifso,whataretheimplica=onsforquan=ta=veresearch?

49

NextSteps• Preparingtodoafollow-upwithourpar=cipantstofindoutaboutsuicidalidea=onora_emptssincedischargeandtorepeattheReasonsforLivingandPsychicPainScale

• Weknowthat6ofour131par=cipantshavedied,5bysuicide(3.8-4.6%)

• Inaddi=on5ofournon-par=cipantshavediedbysuicide

50