Suicidal behavior among alcohol dependents: Relationship with anger and personality dimensions.

BACKGROUND: Alcohol dependents have high percentage of nonfatal suicidal behaviors. There is no substantial data on anger and personality correlates of suicidal behaviors among alcohol users. The present work explored the relationship of anger and personality with suicidal behaviors among alcohol-dependent individuals.
MATERIALS AND METHODS: Sociodemographic data sheet, State Trait Anger Expression Inventory (STAXI), and Neo Five-Factor Inventory (NFFI) were administered on 30 subjects who had lifetime history of suicidal attempt.
RESULTS: A total of 80% attempted suicide in the intoxicated states, 56.7% were high on trait anger, and 60% were high on anger expression outward. A significant negative correlation was found between expressing feelings (verbally/physically) openness, conscientiousness, and agreeableness. A significant positive correlation was found between anger expression inward and neuroticism.
CONCLUSIONS: It helped in understanding the psychological variables associated with suicidal behavior among alcohol-dependent individuals and has implications for addressing neuroticism openness, conscientiousness, and agreeableness for bringing change in anger expression.

Substance use often coexists with anger, aggressive behavior, and person-directed violence. Alcohol intoxication increases suicide risk up to 90 times in comparison with subjects maintaining abstinence.[1] The disinhibition produced by intoxication facilitates suicidal ideas and increases the likelihood of suicide-related cognition being put into action, often impulsively. Aggression and impulsivity increases risk for suicidal behavior among persons with alcohol dependence. Individuals with high levels of trait anger and alcohol consumption had the lowest levels of anger control in self-reported alcohol intoxicated states.[2] Alcohol intoxication is also associated with the use of more lethal means (e.g. a firearm) for the suicidal attempts and it also leads to lethal choice of methods of suicide.[3] The theoretical model proposed to understand the present relationship includes predisposing factors (aggression/impulsivity and alcoholism severity) that increase (moderate) risk for suicide among individuals with alcohol along with the presence of precipitating factors in form of major depressive episodes and stressful life events, particularly interpersonal difficulties.[4] Clinical and community research also suggested the relationship between suicide attempts and psychological traits of aggression, anger, and impulsivity. Impulsivity and harm avoidance (HA) have association with self-aggressive tendencies, borderline personality disorder, and substance use.[567] Temperament and character dimensions have been associated with suicidal behaviors in patients with mood disorders, eating disorders, and substance use disorders as well as in subjects with mixed psychiatric diagnoses. Elevation in the temperament dimensions of “novelty seeking” (NS) and “HA” and decrease in the character dimensions of “self-directedness” (SD) and “cooperativeness” (CO) are seen in suicide attempters compared to nonsuicidal controls. Behavioral disinhibition, aggression, and impulsivity, also predispose the individuals to the use of violent methods in suicide attempts in alcoholics.[8] In Indian context, high percentage of alcoholics had nonfatal suicidal behaviors along with axis 1 diagnosis, especially dysthymia and depressive symptoms.[9]

Alcohol dependents have high psychological distress, trait anger, and low anger control.[10] Quality of life has negative correlation with trait anger expression among the alcohol group.[11]

The available work in the Indian context documents relationship of trait anger with psychological distress, low anger control, and poor quality of life as well as the relationship suicidal behaviors with axis 1 diagnosis. The present work is going to extend our understanding regarding the role of anger and personality with suicidal behaviors among alcohol users. It will have implication in understanding the personality variables as well as for anger management and prevention suicidal behaviors.

MATERIALS AND METHODS

Aim

To study the relationship of personality variables with suicidal behavior among alcohol-dependent individuals.

Objectives

To assess the relationship of alcohol dependence with the following:

Anger

Suicidal behavior

Dimensions of personality: Neuroticism, extraversion, openness, agreeableness, conscientiousness.

To assess the relationship among the above mentioned variables.

Sample: A total of 30 users in the age group of 18-60 years seeking treatment for alcohol dependence at inpatient and outpatient treatment setting of (National Institute of Mental Health and Neuroscience (NIMHANS), Bangalore, Karnataka, India were selected. The inclusion criteria includes those with diagnosis of alcohol dependence and lifetime indulgence in suicidal behaviors in nontoxicated/intoxicated state; whereas, participants with dependence on any other substance except nicotine use, psychiatric illness like schizophrenia, personality disorder (antisocial and borderline personality) and refusal to participate were excluded from the study. Socio-demographic data prepared by the investigators to elicit information age, gender, education, family type, locality, income per month in rupees, details about family members, and history of suicide in family is taken. State Trait Anger Expression Inventory-2 (STAXI-2):[12] It measures the experience and expression of anger and is a 57-item self-report questionnaire. It consists of six scales and an anger expression index. It is the widely used scale in the Western context for assessment of the following dimensions: State Anger (S-Ang), the intensity of angry feelings at the time of completion; Trait anger (T-Ang), a disposition to experience anger; Anger Expression-Out (AX-O), the expression of angry feelings out; Anger Expression-In (AX-I), the suppression of angry feelings; Anger Control-Out (AC-O), the prevention of anger expression towards other people or objects; Anger Control-In (AC-I), the control of suppressed anger; and Anger Expression Index (AX-index) an overall index of the frequency of anger expression, regardless of direction. Understanding of these dimensions also has therapeutic implications. Internal consistency reliability has a value of α ranging from 0.73 to 0.95 for the total scale and from 0.73 to 0.93 for the subscales. Neo Five-Factor Inventory (NFFI):[13] It is a measure of the five major dimensions of personality and has implication for theoretical/management of aggression. It consists of 60 items. It is derived from the form S of NEO–Personality Inventory (PI)–Revised. It is brief and comprehensive. It consists of five 12-item scales that measure each domain of a normal adult personality. The NFFI scales show correlations from 0.75 to 0.89 with the NEO–PI validimax factors. Internal consistency values range from 0.74 to 0.89 (Costa and McCrae, 1992). Approval from the Institute Ethics Committee had been obtained.

Procedure

A total of 350 subjects with alcohol dependence syndrome were screened for 6 months for the presence of suicidal behavior at inpatient and outpatient settings of NIMHANS, Bangalore, Karnataka, India. Out of which 30 subjects who satisfied the inclusion and exclusion criteria were taken for the main study. Informed consent was taken from the subjects prior to administration of STAXI-2 and NFFI.

Data analysis

Data was analyzed using descriptive statistics such as frequencies, means and standards deviation, and correlation and t-test. Qualitative analysis of information obtained in clinical interview was carried out.

RESULTS

The subjects were in the age range from 18 to 60 years with a mean age of 34.5. Majority of the subjects were literate (n = 29, 97%), from urban background (n = 26, 86.7%), belonged to nuclear family (n = 25, 83.3%). Seventeen (56.6%) were employed and 13 (43.3%) were found to be currently unemployed. 46.7% had family history of alcohol use and 17.7% had family history of suicide. Seventy percent of the people had self-injurious behaviors in home context, whereas 30% had outside home. Forty percent of them got hospitalized due to self-injurious behavior. Eighty percent of the cases attempted suicide during intoxicated state. Sixty percent reported inability to control suicidal idea/cognition. 56.7% perceived relationship of alcohol use with the self-injurious behavior. 63.3% reported guilt feeling secondary to the suicidal behavior [Tables 1-3].

Table 1

Distribution of subjects according to mode of self-injurious behavior

Table 3

Correlation of state trait anger dimensions with dimensions of Neo-Five Factors

A significant negative correlation was found between expressing feelings (verbally/physically) and openness; anger expression index and conscientiousness/agreeableness; and a significant positive correlation was found between anger expression inward and neuroticism.

DISCUSSION AND CONCLUSIONS

The study documented the relationship of attempted suicidal behavior and intoxicated state [Figure 1] and its relationship with psychosocial variables like inability to exercise control; guilt feeling; family history of suicide, and history of hospitalization. Most of them were higher on trait anger and in anger expression outward (AX-O) [Table 2 and 2a]. A significant negative correlation was found between expressing feelings (verbally/physically) and openness. A significant positive correlation was found between anger expression inward and neuroticism and negative for agreeableness. Significant negative correlation was found between anger expression index and conscientiousness [Table 3]. The findings were corroborated by other studies. A state of intoxication triggers self-inflicted injuries; by increasing impulsivity and by promoting depressive thoughts and feelings of hopelessness, while simultaneously removing the inhibiting barriers to hurting oneself.[14]

Figure 1

Percentage of subjects who have used alcohol during the time of indulgence in self-injurious behavior

Table 2

Percentage scores for state and trait anger

Table 2a

Percentage score for anger expression and anger control

It has also been found that individuals who have attempted more lethal suicide attempts are higher in trait anger, feeling being treated unfairly, and frustration than those who have attempted less lethal ones. The dependent group has high trait anger.[1015] Trait anger significantly associated with aggression, among men who were intoxicated and who have reported low levels of anger control.[16] A person with high trait anger is also more likely to exhibit physical aggression and violence, problems with substance abuse, and poorer health.[17] Alcoholic patients who attempted suicide had higher scores for neuroticism and low for conscientiousness. They are also at risk for drinking problem owing to their low self-discipline and the tendency to make hasty and irresponsible decisions.[1819] Low conscientiousness is also related to indulgence in sensation seeking behavior.[20] Individuals low in agreeableness has also been found to drink for enhancement reasons. Agreeableness was also found to be negatively correlated with drinking quantity and alcohol-related problems. It also implied that individuals with agreeableness and conscientiousness are more capable of self-regulating their tendencies toward anger and aggression.[21] The present work helped in identification of psychological variables/personality variables related to suicide among alcohol dependent and integration of addressing neuroticism openness, conscientiousness, and agreeableness for bringing change in anger expression. It has limitation in term of representative adequate sample size; role of family dynamics in acting as a resilience or risk factors (personality disorders for suicidal behavior were not explored and exploration of relationship of early onset and late onset of alcohol use with suicidal).