no 2018/82/70 0950200/0 ‘Tae Jounas or Nexyoue an Marea. Drease Copy ©8s2by The Willams & Wars Co Vol 179,No.2 Family History of Suicidal Behavior Among Suicide Attempters GEORGE E. MURPHY, MD., ano RICHARD D. WETZEL, Pu.D! Efforts to predict suicide and attempted suicide are hampered by their relative rarity on the one hand and the inadequate specificity of clinical characteriates and relevant anteced- ent events on the other; that is, these features are found widely among the nonsuicidal as Well. In an effort to further understand these phenomena, the authors studied family history ‘of suicidal behaviors (suicide, attempted suicide, and suicide threats) in 127 patients hospitalized following a suicide attempt. Patients with personality disorders (antisocial personality disorder, alecholism, somatization disorder, and narcotic addiction), comprising 45 per cent of the sample, frequently reported a family history of these behaviors, most notably attempted suicide, Patients with primary affective disorder reported a family history of suicidal behaviors somewhat less often. The diagnoses grouped here as personality Aisorders (excepting alcoholism) contribute little to the suicide rate, while primary affective disorder contributes substantially. Although further data are needed, itis suggested that family history of suicidal behavior in primary affective disorder should alert the clinician to Iheightened suicide risk, while a similar history i diagnoses ia not particularly significant. nonaleoholies with other psychiatric Because of the steady increase in suicides and at- tempted suicides in the United States and elsewhere, physicians may lose sight of the fact that these are, statistically speaking, infrequent if not rare events, Efforts to understand, and therefore to predict, rare events may begin, as has been done in this subject with a study of immediate antecedents. These may include living circumstances, interpersonal conflict, personal distress, and psychiatric diagnosis, to men- tion the more striking findings. However, such events and conditions have a far wider distribution in the population than simply among suicide attempters and suicides. Thus, while they may correlate strongly, they are not adequately specific; that is, a population se- lected by the presence of these variables will contain a great many false positives. ‘The same is true of remote events. Parental bereave- ment, parental divorce, and other family disruptions during the presumably formative years have received much attention, Less notice has been taken of familial behavior patterns. Dahlgren (4) found a farnily history of suicide in 7 per cent of 237 suicide attempters. Several studies have reported similar frequencies, ‘Stengel (17) found 8 per cent, while Paerregaard (12) and Retterstél (13) each found a family history of suicide in 6 per cent of patients they studied after suicide attempt. Perhaps the clearest evidence of a difference between suicide attempters and other psy- "Department of Paychatry, Washington University School of ‘Medicine, 4940 Andubon Avenue, St. Louis, Miseourt 69110, Send reprint requests to Dr, Murphy. "This study was supported in part by National Institute of Mental alth Grants MIE. O8038 and MEL-1S011, chiatric patients was published by Woodruff et al (19) who discovered a family history of suicide attempt in 18 per cent of 71 patients who themselves gave a history of suicide attempt. These patients were iden- tified in a larger psychiatric clinic population not selected for suicide attempt. A similar family history was obtained in only 9 per cent of the remaining 429 Psychiatric outpatients without a history of suicide attempt. The difference is statistically significant (p <.05), Few family history data are available with respect to broader range of suicidal behaviors, including suicide attempt and suicide threats. Robins et al, (15) reported that 11 per cent of 109 suicide attempters gave a family history of either suicide or attempted suicide. Murphy et al. (11) found that one third of 55 callers to a suicide prevention center gave a family history of either suicide or suicide attempt. This was very significantly more likely (p< ,005) to be the case if the caller gave a personal history of suicide attempt (60 per cent us. 9 per cent). Flinn and Leonard (6) found that 13 per cent of 480 young nonpsychiatric subjects reported “suicidal behavior” among persons ‘known to them. They further noted that subjects who reported suicidal behavior in the self also reported more experience with suicidal behavior in others (pp ‘<.001) (raw data not given). Finally, Tishler et al. (18) reported recently that 22 per cent of a series of 108 adolescent suicide attempters treated at a children’ hospital emergency service gave a history that “at least one family member had exhibited suicidal behav- ior in the past” (p. 88). We know of no other studies bearing on this topic. However, these few suggest anFAMILY HISTORY IN SUICIDE ATTEMPT 87 association between suicide attempt and family his- tory of suicidal behavior. As with other phenomena associated with suicidal behavior, this, too, is a weal predictor. Further data may show how it may best be regarded. Methods ‘A random sample of all persons seen in a I-year period at the St. Louis County Hospital and admitted there or referred to another hospital for what was judged to be a suicide attempt were systematically interviewed. Our definition of a suicide attempt was any intentional act carried out by the subject that resulted in tissue injury or that included ingestion of any substance in excess of normal medicinal use and that was thought to be a suicide attempt. This defi tion is virtually the same as that of Kreitman (8) for parasuicide. The emergency room log was examined daily and admission for any reason suggestive of a suicide attempt by our definition led to examination fof the record. Cases of drug experimentation “for kicks” were excluded. Patients meeting the stated criteria were included, whether or not the patient agreed with our judgment that the act was a suicide attempt. Patients were not interviewed until they were sufficiently clear mentally to give an account of them- selves and their behavior. ‘The interview followed a printed schedule containing over 500 questions to en- sare that each question was asked of each subject. Verbatim answers were recorded on the schedule. The systematically collected data were coded and punched on IBM cards for data processing. Results One hundred twenty-seven patients were inter- ‘viewed, 84 women and 43 men (Table 1). This included 11 persons who denied making a suicide attempt. All were white. (As St. Louis County contained a very small percentage of nonwhites at the time this study was conducted, we excluded them.) Mean age of the patients was 30.9 years (SD, 12.1; range, 12 to 75 years), Distribution by religion was approximately that of the population of St. Louis County except for a not unexpected under-representation of the Jewish faith. The mean education was below the high school graduate level, with fewer than 12 per cent still in school. This rather low educational level is probably ‘a function of the study site, a public, rather than a private, hospital. A family history of suicide was given by 14 per cent of the patients (Table 2), attempted suicide by 24 per cent, and suicide threats by 6 per cent, The proportion of families in whom one or more of these suicidal behaviors was reported was 36 per cent. The fact that TABLE 1 Demographic Characteristics of Sample of Suicide Attempter Charatan F ‘Sex (N= 127) ‘Male “8 5 Fermale % 0% Age ‘Mean 09 (212) years Range 12-75 years Religion ‘Roman Catholic od Protestant ook Sewish| (Other non-Christian Agnoctic % ‘None 108 ‘Béucation (N= 112) ‘Mean 105 (42.62) years Stil in school 6 Has ‘TABLE 2 amily History of Suicidal Behavior Among Suicide Attempters aly History | = ‘Completed suicide 6 1 ‘Parents 2 2 Siblings 2 2 Chidzen 1 1 Other relatives 8 10 Attempted suicide st Py Parents wo 8 Siblings 10 8 Children 2 2 Other relatives 0 8 ‘Suicide threats 5 6 Parents ° ° Siblings 2 2 Childzen ° ° Other relatives 5 ‘ ‘Any form of suicidal behavior 6 38 Parente 16 13 Siblings 4 a Childzen 3 a Other relatives 2 ra fewer first-degree relatives were involved is doubtless a reflection of the greater number of non-first-degree relatives that a person is likely to have (grandparents, uncles, aunts, and cousins). All of these are known to participate to a greater than chance degree in psychi- atric illnesses related to that of the patient. ‘As psychiatric diagnosis has been shown to correlate differentially with suicidal behaviors (14, 16), sys- tematic attention was given in the interview to obtain- ing relevant diagnostic information. Diagnoses were made according to published criteria (5). What was88 GEORGE 8. MURPHY AND RICHARD D, WETZEL found is a substantially different distribution by diag- nosis from what has been found among actual suicides, where affective disorder comprises roughly one half and alcoholism one fourth of the cases (14) (Table 3) ‘This difference between suicides and attempters has been noted previously (10, 17). Not surprisingly, 37 pper cent of the suicide attempters suffered from a secondary depression—a depressive syndrome occur- ring in the course of another pre-existing psychiatric illness (20), ‘The most frequent primary diagnosis was that of antisocial personality disorder (ASPD), comprising 28 per cent of the sample. Nearly one fourth of the patients (23 per cent) suffered from primary affective disorder. Sixteen per cent had undiagnosed psychiatric illness. This is not a single diagnosis but a category for patients with unquestionable psychiatric symptoms who do not clearly fit any established diagnosis, ‘Smaller contributions, 10 per cent or less, were made by patients with variously diagnosed conditions. These represent first diagnoses only. Of those with a first diagnosis of ASPD, six received a second diagnosis of somatization disorder (Briquet's syndrome, hysteria), 12a second diagnosis of alcoholism, and three a second diagnosis of narcotic addiction. These are not exclusive diagnoses. One patient was diagnosed as exhibiting ASPD, somatization disorder, alcoholism, narcotic ad- diction, and non-narcotic substance abuse! Patients enumerated in Table 3, other than those listed as ASPD, were not additionally diagnosed as having ASPD. As just described, however, there were about as many patients with diagnoses of alcoholism, nar- cotic addition, or somatization disorder who had a first diagnosis of ASPD as who did not. Both because of TABLE 3 Leading Clinical Diagnosis of Suicide Attempters ‘Personality disorder group Aatisocial personality disorder a8 ‘Alcoholism Bo Narcotic addiction A Somatization dorder (Brique syndrome, hy 8 teria) Affective disorders Primary affective disorder “Miscellaneous group 8 8 Anxiety neurosis Mental retardation Organi brain syndrome Schizoatfective disorders Schizophrenia Sabstance abuse (non-narcotic) Undiagnosed Not peyeiatriclly il” lo Blecsoesc. TABLE 4 Family History of Suicidal Behavior by Broad Diagnostic Groupe oh Ply Rito of Diagnostic Group 7 eee ‘Sica Aten Any” Personality disorders re Primary affective order = «297,78 Other diagnoses andnone’ = 2B Ta” All patients ra 4% “Any suicidal behavior indudes suicide and attompted and threatened suicide, "Personality disorders include antisocial personality disorder, somatization disorder (Briquel's syndrome, hysteria), alcoholism, ‘nd narcotic addition. * Differs significantly from the remainder, p < 05. “Other diagnoses include anxiety neurosis (one patient), mental retardation (our), organie Brain syndrome (one), schizoaffective Alsorder (one), schizophrenia (four), cubstance abuso (four), und agnosed (20), and not psychiatrically (i), this great overlap and for natural history considera- tions, patients with these four diagnoses are consid- ‘ered together as the personality disorder group: This group reported a family history of suicide in 20 per cent, suicide attempt in 34 per cent, and suicide threat in 4 per cent (Table 4). The frequency of a family history of suicide attempt was significantly greater (p <_.05) than among the balance of subjects. Among suicide attempters with a diagnosis of pri- mary affective disorder, 17 per cent gave a family history of suicide, 17 per cent a family history of suicide attempt, and 4 per cent a family history of ‘suicide threat. The proportion with a family history of any suicidal behavior was 38 per cent, which indicates, very little duplication of these phenomena. Patients with all remaining diagnoses together reported a fam- ily history of suicide in 5 per cent, suicide attempt in 17 per cent, and suicide threat in'11 per cent. When any family history of suicidal behavior was considered, patients in the personality disorders group reported significantly more (46 per cent; p < .05), and the all other diagnoses group significantly less (21 per cent; p <.02) than the remainder. Discussion Kreitman eal. (9) found in a retrospective study of. contacts of suicide attempters (relatives by blood or marriage and close friends) that a significant excess (p < .001) had been admitted for suicide attempt in the 4 years preceding the admission of the proband attempter. Distribution of this phenomenon between 2 This isnot the grouping given in DSM-IIL (). However, sub stance we disorder ae noted to complicate ASPD (1) and, wil ‘be desribed, afr relationship hasbeen shown to exist between somtization diorder and ASP.FAMILY HISTORY IN SUICIDE. ATTEMPT 89 blood relatives and others (each proband was asked to identify two close friends) was not significantly skewed, meaning that blood relatives were neither ‘more nor less likely than named friends to have ex- hibited this behavior. An excess of positive contacts ‘was found for female patients, those under 35 years of age, and those ingesting drugs in their suicide attempt. Kreitman et al. concluded that their findings are com- patible with the hypothesis that suicide attempt is “a ‘language’ employed within such a group where other groups would use less pathological forms of commu- nication’ (p. 116). ‘The concept of suicide attempt as language or as-a ‘mode of communication derives from Stengel's state- ment (17), “In most attempted suicides we can dis- cover an appeal to other human beings” (p. 22). What wwe can discover concerning an appeal often requires some inputation of purposiveness, although a minority of attempters may report it unequivocally. Bancroft et cal, (2), for example, found that 19 per cent of 128 suicide attempters admitted “trying to influence some- fone” by their act. One third endorsed the idea that they wanted to “seek help from someone”; 42 per cent ‘acknowledged desire to “escape ... from an impossible situation”; 52 per cent agreed they sought “relief from aterrible state of mind”; and 18 per cent acknowledged none of these motivations. There is obvious overlap, as the percentages endorsing various reasons sum to 165 per cent. However, only one half (52 per cent), ‘assuming the unlikely nonduplication of seeking help and seeking to influence someone, acknowledged a communication motive. Other studies reporting rea- sons for suicide attempts are no more supportive of the language hypothesis than is Bancroft’s, although it is difficult to see how one could clearly refute it. ‘The fact that both blood relatives and those related. by marriage or not at all contributed to the excess of attempters among contacts named by the probands in Kreitman’s study gives no support to an hereditary hypothesis. One alternative to Kreitman’s communi- cation hypothesis is a contagion hypothesis which nothing about interpersonal motivation, but allows for imitative behavior. Another alternative is that of shared values or shared deviance. ‘The size of the personality disorder group in relation, to the whole (44 per cent) reflects the propensity of this group to suicide attempt and threat. It is strikingly similar to the proportion of suicide attempters with ‘equivalent diagnoses (41 per cent) found by Robins et al, (15) in an earlier public hospital study. There is a substantial clinical literature attesting to strong famil- ial trends in these disorders. For example, when one studies the families of antisocial personality probands, there is an increased likelihood of finding antisocial personality in their brothers and fathers and Briquet's syndrome (somatization disorder) in their sisters and mothers (3). By the same token, the brothers and fathers of women with Briquet’s syndrome (somati zation disorder) are likely to exhibit antisocial person- ality, while the sisters and mothers have a greater than chance probability of exhibiting Briquet’s eyn- drome. Similarly, alcoholism exhibits a strong familial tendency. Narcotic addiction, if familial, is found in siblings much more than in parents, possibly owing to the relatively recent development of the widespread recreational use of drugs. Substance abuse is a fre- ‘quent feature of ASPD, however. ‘Our study did not attempt to evaluate family history for clinical diagnosis. But if we consider what is known of familiality, the excess of suicide attempts in the family history of the personality disorder group can be accounted for by the likelihood of other family mem- bers being afflicted by the same disorders, Thus, the behavior seems to be a part of the package identified by the clinical diagnosis. Since ASPD, somatization disorder, and narcotic addiction have not been found to have a strong association with suicide, it is remark. able that the personality disorder group reports 8 high a family history of suicide as does the affective disorder group. The inclusion of alcoholism in this ‘grouping might be expected to contribute dispropor- tionately to a history of suicide but it does not. Tn suggesting that suicidal behavior is part of the package in the personality disorders, we are not bound to a genetic, or even to a familial, hypothesis. Assor- tative mating is known to occur in these disorders, and if this is the case, it can hardly be otherwise than that there would be assortative association as well, a form of shared deviance. Birds of a feather do flock together. ‘The situation is somewhat different with respect to primary affective disorder, in that the familial associ- ation of suicide with this disorder is known. Neverthe- less, the lifetime risk of suicide in primary affective disorder is “only” 15 per cent (7); that is, 85 per cent of other causes. We may appropriately ask, not why so many commit suicide, but why so few do. ‘There are no ready answers with respect to those who do not; but those who do so have an increased personal history of suicide attempt (14) and perhaps a family history, of suicidal behaviors as well. The patient's knowledge of this family history may have a significant releasing effect on suicidal behavior (shared devi- ‘Attention has been drawn by Stengel (17) to the separate but overlapping populations of suicides and suicide attempters. Follow-up studies of suicide at- ‘tempters show that about 1 per cent will commit suicide within the year and 1 per cent per year there- after to an asymptote around 10 to 12 per cent. On the other hand, up to one third of suicides have a past90 GEORGE E. MURPHY AND RICHARD D, WRTZEL history of suicide attempt (10). The relationship is therefore a significant one, with clinical diagnosis being an important intervening variable, Data on his- tory of suicidal behaviors in the families of suicides are mostly anecdotal. Available informants after the fact usually are spouses and offspring having little knowledge of the darker side of the deceased's family history. As can be seen from the literature review, data on suicidal behaviors in the families of suicide ‘attempters are limited, Robins et al, (15) were the first (and only investigators prior to the present ones) to consider this history in relation to the psychiatric diagnosis of the attempter probands. Either suicide or suicide attempt was found in the family history of 6 Per cent of attempters with affective disorder (manic-~ depressive psychoses) and in 16 per cent of patients we grouped here as personality disorders (chronic alcoholism, conversion reaction, and sociopathic per- sonality). While these are lower frequencies than in the present study, the relationship is in the same direction. From the repeated observation that affective disor- ders comprise a large proportion of suicides and per- sonality disorders (excepting alcoholism) a small one (14), it is safe to predict that few of the personality disorder patients in this series (and of these, mostly the alcoholics) but more of those with primary affec- tive disorder can be expected to present significant suicide risk in the future. A systematic family history of such behavior coupled with modern clinical nosis should prove useful in identifying those attemp- ters at increased risk of suicide, References 1. American Paychlatie Assocation, Diagnostic and Statistical ‘Manvel of Mental Disorders, 3rd Ba, pp. 908-230, Conant tee on Nomenclature and Siatisties,” American Paychistic Associntion, Washington, D.C, 1960, 2. Bancroft, J.J, Skrimshiv, A.M and Simkin S, The reasons eople give fr taking overdoses. J. Prychiatr, 12 8 is) 1076, 3. Cloinger,C. R, Reich, T., and Gu, 8. B, The multifactorial ‘model of disease transmission: IL. Fania relationship be: {teen sociopathy and hysteria. Br. J. Paythiatry, 127: 23-9, 195, 4. Dahlgren, K. G. On Suicide and Attempted Suicide. A Poy ‘hiatrcal and Statistical Investigation, p. 2. Ay PHL Lindstedte, Unis -Bokhandel Lunds 146, 5 Felner, J.B, Robins, E, Guz, SB. tal, Diagnostic criteria ‘for we in peyhlatic research, Arch Gen. Peyehatr, 28°57 3, 1972, 6 Flinn, D.E, and Leonard, C. V; Prevalence of suicidal destion ‘and behavior among basi trainees and college student, Mii Med, 197: 317-320, 1972 7. Guwe, §. B., and Robins, B, Suicide and primary affective Aicordes Br. J. Payehiaty, 117: 497-898, 170 8, Kreitman, N, Ed. Parasuiide, p. 3. John Wiley & Sons, Now York, 1077 8. Kreitman, N, Smith, P, and Tan, E-S. Attempted suicide in social networks. Br. J. Prev. Soe: Med, 29: 116-12, 1968 10. Murphy, G.E. Suicide and attempted mice, Hoop, Pract 12 738, 197, 1, Murphy, G. E, Wetzel, RD, Swallow, C. 8, and MeClure, J 'N, Jr. Who cls the suicide prevention center: A study ofS persons calling on their own behalf. Am J. Paychlaey, 126: 14-294, 1968 12, Paomregaatdl G, Selomordsforseg og Selomord I Kabenhavn, I. Up 208. Univesity of Copenhagen, Copenhagen, 1963, 18, Retinol, N. Long-term Prognosis After Attempted Suicide, . 36. Charles © Thomas, Springfield I, 1970, 14 Robins, E, Murphy, G. I, Wilkinson, RH, dr, ef al. Some ‘linical Considerations in the prevention of suicide based on 4 study of 134 succesful sulcides Am. J. Publie Health, 20: 38-99, 1950. 15, Robins, E, Schmidt, B, H., and O'Neal, P. Some interrelations of social factors and clinical diagnosis in attempted sulede- A uty of 109 patonta. Am J. Prvchiatny. 174-201-201, 1967, 16. Schmidt, EH, O'Neal, P, and Robins valuation of euiide tempts as guide to therapy: Clinieal and follow-up study of lone hundred nine patients, AMLA,, 155: 549-657, 1954, 17, Stengel, Band Cook, N. G, Altompted Suicide: ls Social ‘Significance and Bifeet. Maudsley Monographs No. & pp. 22-48-49, €9, Chapman and Hall. Lt, London, 2858, 18 Tshier,C. i, MeKenry, P. C:, and Morgan, KC. Adolescent sulcide tempts: Some significant factors Suiede. Life ‘Threat Behav. 1: 88-92, 196, 19, Woodrf, R.A, Jr, Clayton, P. J, and Gute, 8. B. Suicide tempts end paychiatric diggnosi: Dia. Nere: Syst 39 17 1, 197, 29, Woodrutl, R. A. Jr, Murphy, G. E. and Herjani, M. The natural history of affective'disordars. I. Symptoms of 72 patients atthe time of index hospital admission, J. Prychats Fr, 5: 255-269, 1967,