An Empirical Study of the Psychodynamics of Suicide: a Preliminary Report

DEPRESSION 4:89-91 (1996)

AN EMPIRICAL STUDY OF THE PSYCHODYNAMICS OF SUICIDE: A PRELIMINARY REPORT

Susan E. Chance, M.A.,! Susan L. Reviere, M.A.,! James H. Rogers, Ph.D.,z Mark E. James, M.D., Salley Jessee, M.D.,3 Lisseth Rojas, M.A.,4 Carrie A. Hatcher, B.A.,s and Nadine]. Kaslow, Ph.D.6*

Preliminary results from a study ofpsychodynamic constructs are presented based on data from inpatientsfollowing a suicide attempt. The study examines the association between four psychodynamic constructs, severity ofsuicidal in tent, and severity of depressive symptomatology in a sample of hospitalized suicide attempters. Higher levels of suicidal intent were associated with less differentiated selfand object representations and less emotional investment in relationships. More severe depressive symptoms in suicide attempters were cor related with more self-targeted anger, less eternally directed anger, higher lev els ofshame and guilt, more affectively negative views ofrelationships, greater use of maladaptive and self-sacrificing defenses, and more impaired reality testing. These findings offer some preliminary empirical supportfor the valid ity of psychodynamic theories of suicidal behavior. Depression 4:89-91 (1996). © 1997 Wiley-Liss, Inc.

INTRODUCTION cissistic injuries, they are unable to self-soothe or turn Psychodynamic theorists posit that suicidal behavior to others for comfort. is associated with: (1) self-directed anger, (2) patho Ego theorists assert that the primary defenses used logical responses to object loss, (3) poorly integrated by suicidal people include denial, splitting, idealiza hostile introjects and few soothing introjects (patho tion, introjection, regression, and repression (Apter et logical internal object relations), and (4) ego function al., 1989). They also note that suicidal persons mani ing disturbances in the form of borderline level fest impaired reality testing in response to abandon defenses and impaired reality testing in response to ment or self-esteem loss. loss. These constructs lack empirical testing and vali This paper presents initial results from an empirical dation (Hendin, 1991). study examining the association between these four psy In terms of self-directed anger, it has been sug chodynamic constructs, severity of suicidal intent, and gested that suicidal people turn against themselves severity of depressive symptoms in suicide attempters. the destructive wishes felt toward a lost or disap pointing object (Freud, 1917). Parts of the ego 10epartment of Psychiatry and Behavioral Sciences, Geor identified with the lost object become the target of gia State University, Atlanta, GA; 2PROMINA Windy Hill sadistic wishes. Hospital, Atlanta, Georgia; 3Emory University School of With regard to object loss, theorists posit that sui Medicine and Emory University Psychoanalytic Institute, At cide may involve a fantasy ofnarcissistic reunion, serv lanta, Georgia; 40erner Institute at Adelphi University, Gar ing to undo this separation (Hendin, 1991). Research den City, New York; SOepartment of Psychology, University reveals that people who experience early losses and of Michigan; 6Emory University School of Medicine, Atlanta, painful separations are at increased risk for suicide Georgia. (Cross and Hirschfield, 1986). Object relations theory views suicide as an attempt Contract grant sponsor: American Psychoanalytic Association to destroy bad internal objects. According to Kern Research Fund. berg (1975), suicide represents the superego's attempt to eliminate the bad self that results from the internal 'Correspondence to: Nadine Kaslow, Ph.D., Emory University Department of Psychiatry and Behavioral Sciences, Grady ization of pathological interpersonal interactions. Health System, 80 Butler Street SE, Atlanta, GA 30335. Maltsberger and Buie (1980) assert that suicidal people evidence poorly integrated hostile introjects Received for publication 24 June 1996; Revised 6 August 1996; and few soothing introjects. Thus, in response to nar- Accepted 9 September 1996.

METHOD their TAT responses (r = -.25, P < .05), more mal adaptive (1' = .52, P < .01) and self-sacrificing (r = .33, The sample was 46 females (n = 32) and males (n = P < .05) defenses on the BDSQ, and more impaired 14), Mean age = 30.5 (SD = 10.7), hospitalized at Grady reality testing according to their schizophrenia index Health System, a teaching affiliate of Emory Univer on the Rorschach (r = -.28, P < .05). sity School of Medicine, that serves an urban, low in come population. Most participants were African American (62%). Patients with schizophrenia, bipolar DISCUSSION disorder, organicity, or serious medical illnesses were Preliminary findings support three psychodynamic excluded. constructs, particularly for those suicide attempters Participants, recruited within 1 week of hospitaliza with either elevated levels of suicide intent or depressive tion, provided written informed consent. Severity of symptoms. Attempters with greater intent endorsed suicidal intent was measured by the Suicide intent more narcissistic and less mutual object relationships, Scale (SIS) (Beck et a1., 1979). Diagnoses were ob and demonstrated less differentiated self and object tained from the Structured Clinical Interview for Di representations. This finding is consistent with the agnosis (SCID) (Spitzer et a1., 1990). Other symptom hypothesis that suicidal behavior is associated with measures were the Beck Depression Inventory (BDI) pathological internal object relations. (Beck et a1., 1961) and the Depression and Suicide The self-directed aggression theory appears perti Constellations of the Rorschach (Exner, 1993). To nent to depressed attempters, as they exhibit increased evaluate the self-directed anger hypothesis, the Self self-targeted anger and higher levels of shame and Targeted Anger (STA) (Knopf et a1., 1990, unpub guilt. It is of note, however, that higher levels of sui lished data), and Shame-Guilt (Gioella, unpublished cide intent and depressive symptoms were associated manuscript) scales were used. To examine the loss hy with lower levels of externally directed anger in the pothesis, demographic data were obtained about present study, a finding contradictory to the research losses. Object representations were measured by the revealing that suicidal behavior is correlated with ag Hypervigilance Index of the Rorschach, the Object gression and violence (e.g., van Praag et a1., 1990), but Relations Inventory (ORI) scored using the self-other consistent with early psychodynamic theories postu differentiation scale (Diamond et a1., 1990), and The lating that the rage and anger experienced by suicidal matic Apperception Test (TAT) with responses coded individuals is directed toward the self rather than to for complexity of human representations, affect-tone ward others. of relationships, capacity for emotional investment in Depressed attempters used maladaptive action pat relationships, and understanding of social causality tern and self-sacrificing defenses, which might make (Westen et a1., 1990). The Bond Defense Style Ques them prone to deflect aggression away from others tionnaire (BDSQ) (Bond, 1984) and Rorschach ego and turn to self-destruction. They also have problems structure measures (coping deficit index, schizophre perceiving reality in a manner similar to that of most nia index) assessed ego functioning. people. These findings offer support for dynamic theories indicating that depressed, suicidal people use primarily borderline level defenses and evidence real RESULTS ity testing problems, both of which are suggestive of Patients' primary Axis I disorders were depression ego functioning deficits. (n = 27, 59%), substance use (n = 8, 17%), adjustment Attempters with higher levels of suicide intent andl (n = 9, 20%), and other (n = 3, 7%). Axis II diagnoses or depressive symptoms did not report greater levels were: Cluster A, 7% (n = 3); Cluster B, 33% (n = 15); of object loss, raising questions about the utility of the Cluster C, 9% (n = 4); Personality Disorder NOS, object loss hypothesis. This finding should be exam 20% (n = 9). Patients reported high levels of depres ined more given the lack of a thorough measure of sion on the BDI (M = 23.5, SD = 12.9). loss, and the discrepancy between these data and those Correlational analyses revealed that those suicide at from other researchers (Cross & Hirschfield, 1986). tempters with higher levels of intent on the SIS reported Findings must be interpreted cautiously given the more depressive symptoms on the BDI (r = .27, P < .05), small sample size, dearth of statistically significant more prior attempts (r = .29, P < .05), less differentiated findings in the predictive analyses, lack of cultural sen self and object representations on the ORI (r = -.29, P < sitivity of the measures, the broad and heterogeneous .05), and less emotional investment in relationships ac nature of the participants' Axis I and II diagnoses, and cording to their TAT responses (1' =-.31, P < .05). the lack of a control group. Future research needs to Attempters reporting high levels of depressive include more narrowly defined samples in terms of symptoms (BDI), endorsed more self-targeted anger (r psychiatric diagnoses, and focus on comparisons of = .32, P < .05) and less externally directed anger (r = suicide and nonsuicide attempters in terms of self-di -.32, P < .05) on the STA, more shame and guilt on rected aggression, object loss, internal object rela the Shame-Guilt Scale (1' = .50, P < .001), more tions, and ego functioning. While data on the affectively negative representations of relationships in association between suicidal intent, severity of de- BriefReport: Psychodynamics ofSuicide 91

pressive symptoms, and the psychodynamic con Cross CK, Hirschfield RMA (1986) Psychosocial factors and sui structs hypothesized to be associated with suicidal cidal behavior: Life events, early loss, and personaliry. Ann NY behavior provide some empirical support regarding Acad Sci 487:77-89. the utility of these hypotheses, a comparison of at Diamond D, Kaslow N, Coonerry S, Blatt S (1990) Changes in separation individuation and intersubjectiviry in long-term treat tempters and nonattempters is needed to substanti ment. Psychoanal Psychol 7:363-397. ate or disprove these constructs. Exner JE (1993) The Rorschach: A Comprehensive System. New Acknowledgments. The authors thank Lawrence York: John Wiley Inderbitzin, M.D., for his comments on an earlier ver Freud S (1917/1957) Mourning and melancholia. In Complete Psy sion of this manuscript. This study was funded by a chological Works, Standard Edition Volume 14. London: Ho grant from the American Psychoanalytic Association garth Press. Research Fund. Hendin H (1991) Psychodynamics of suicide, with particular refer ence to the young. AmJ Psychiatry 148:1150-1158. Kernberg 0 (1975) Borderline Conditions and Pathological Nar REFERENCES cissism. New York: Jason Aronson. Maltsberger JT, Buie DH (1980) The devices of suicide: Revenge, Apter A, Plutchik R, Sevy S, Korn M, Brown S, van Praag H (1989) riddance, and rebirth. Int Rev Psycho anal 7:61-72. Defense mechanisms in risk of suicide and risk of violence. Am J Spitzer RL, Williams JBW, GIbbon M, First MB (1990) Structured Psychiatry 146:1027-1031. Clinical Interview for DSM-III-R Patient Edition (SCID-P) and Beck AT, Ward CH, Mendelson M, MockJE, Erbaugh J (1961) Structured Clinical Interview for DSM-III-R-Personality Disorders An inventory for measuring depression. Arch Gen Psychiatry (SCID-II). Washington, DC: American Psychiatric Press. 4:561-571. van Praag HM, Plutchik R, Apter A (Eds) (1990) Violence and Sui Beck AT, Kovacs M, Weissman A (1979) Assessment of suicidal cidaliry: Perspectives in Clinical and Psychobiological Research. intention: The scale for suicide ideation. J Consult Clin Psychol New York: Brunner/Maze!. 47:343-352. Western D, Lohr N, Silk KR, Gold L, Kerber K (1990) Object Bond M (1984/1986) Defense Sryle Questionnaire. In Valiant GE relations and social cognition in borderline, major depressives, (ed): Empirical Studies of Ego Mechanisms of Defense. Wash and normals: A thematic apperception test analysis. Psychol As ington DC: American Psychiatric Press. sess 2:355-264.