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Desperation--a clinical dimension in the personality of suicidal patients/Disperarea--o dimensiune clinica prezenta in personalitatea suicidarului.

INTRODUCTION

The last decade research has shown that personality disorders represent a major risk in suicidal behavior (suicidal ideation, suicide attempt, accomplished suicide), as severe as the risk of suicidal behavior manifested in bipolar disorders and schizophrenia (Marsha M. Linehan, 2002). Although the non-fatal suicidal behavior including the suicide attempt is one of the criteria for diagnosis in borderline personality disorders and the incidence of the suicide attempts among the persons who meet BP diagnostic criteria is well recognized, the association between the personality disorders or personality traits and suicide hasn't been fully documented. In spite of medicine great progress in studying normal or pathological personality, the role of personality traits or dimensions in determining suicidal behavior hasn't been completely established during the last decades. I would mention that Chapter III of the present DSM-V manual introduces modifications in diagnosing personality disorders, namely the dimensional approach in determining a personality disorder as specific trait.

Hopelessness is not considered to be a personality trait still it is a clinical dimension that manifests at high levels with the emergence of suicidal behavior. More than fifty years ago, Allport (1961) stated that "personality is something and personality does something" (1). Personality systems serve an adaptive purpose. In order to understand a personality disorder, we should focus on the functional aspects of the personality and on how those functions get disrupted. (2) Based on Allport's statement, Cantor said that the phrase "personality makes" refers to how major tasks are solved in life (3). Major tasks are tasks or coping problems that the individual must solve to adapt effectively. There are three distinct interrelated areas of functioning where people with personality disorders are facing difficulties: the self, the relationships with close family and relatives and the social or group relationships.

These disorders may be formulated as follows:

--failure in establishing stable and integrated representations of self and others;

--dysfunctions in interpersonal relationships manifested by failure in developing necessary abilities for intimacy, in functioning as an attachment figure and/or involving in a relationship lineage;

--failure in adaptive social functioning, manifested by failure in developing a pro-social and /or cooperation behavior.

We need to mention that those disorders have to be persistent, documented since adolescence or, at least, since the young adult period and should not be the result of Axis I pervasive and chronic disorders (Mircea Lazarescu, 2005) (4).

In order to translate our definition into diagnostic criteria, we need a more detailed description of self and interpersonal pathology (2).

Failure in adaptation

An alternative approach is the possibility to extract a definition of personality disorder from understanding normal personality functions. Such an approach would anchor the concept of personality disorder in a general concept of personality structure and functions. Such a theory would bring consistency to current knowledge formulated in various theoretical and descriptive concepts. The approach could be achieved only by developing a systematic theory of personality which could articulate a universal conception of personality functions. Although that seems an unattainable goal considering the current knowledge, we can still turn to it by developing a theory to incorporate our present knowledge about the functions of personality.

Perhaps the most suitable pattern that could be used for this purpose is the evolutionary theory (Millon, T., 1990 and 1996) (5, 6, 7). Millon and Davis have suggested that "personality could be seen as representing the more or less distinct style of adaptive functioning that an organism manifests in relation to the typical environment". In this conception, personality disorder could be defined as the "particular types of maladaptive functioning, which may be related to deficiencies, imbalances and conflicts of the individual's capacity to relate to the environment in which he lives" (7). Millon's contributions have set the stage for a systematic approach that anchors the concept of personality disorder in understanding how adaptive functions of personality become disturbed. Evolutionary processes refer to the selection of mechanisms that allow the individual to adapt to his environment and reproduce. Although evolutionary theories about human behavior and personality are in an early stage of development, some fundamental principles about the nature of personality can be identified and used in defining personality disorders (2).

General hypothesis of the research

Highlighting some predisposing factors for suicidal behavior in patients with personality disorders

Specific hypothesis of the research

Highlighting the particular dimensions of personality in PD patients with suicidal behavior as compared to PD patients without suicidal behavior

Evaluating the relation between personality dimensions scores, hopelessness and suicide risk in PD patients

MATERIAL AND METHOD

Targeted population

Personality disorder patients with any PD type formed the targeted population of the present research. A special interest was given to patients with active suicidality, i.e. patients who had made a suicide attempt a little while before the hospitalization and would manifest an intense suicidal ideation and who were diagnosed with personality disorder, since those patients formed one of our research groups. The available population for the present study were the PD patients who addressed the medical center from Cluj (Transylvania central region).

The sample consisted of 131 patients diagnosed with personality disorder of any type who addressed for medical evaluation and treatment to The Psychiatric Hospital III from Cluj-Napoca between 2004 and 2009 and signed an acknowledged consent.

The selection criteria of the population for this study comply with international adopted methodology, taking into account the type of clinical manifestation (i.e., the personality disorder) and the type of event (i.e., the suicidal behavior).

Comparison groups

1. Patients with personality disorders and suicidal behavior (N = 46).

The suicidal behavior refers to the index episode, i.e. the episode that generates the target symptoms:

--recent suicidal attempt (cause of hospitalization or presentation of the patient to a clinical consult);

--present intense suicidal ideation with or without a suicidal plan;

--present fluctuating suicidal ideation.

2. Patients with personality disorders without suicidal behavior (N = 85).

Work instruments

The Mini-International Neuropsychiatric Interview (MINI) including Module 3--Suicide ideas

Structured Clinical Interview for Axis II Personality Disorders (SCID II)

Temperament and Character Inventory--TCI

The categorial tests for evaluating psychopathology and personality disorders

The Mini-International Neuropsychiatric Interview (MINI) was used in the present study for identifying the comorbide disorders on Axis I and for assessing the suicidal risk: low, moderate, high, as in the MINI Module C--Suicide ideas.

Structured Clinical Interview for Axis II--Personality Disorders (SCID II) was applied for the categorial diagnoses of PD on Axis II--Diagnosis level.

Dimensional tests for personality evaluation--Temperament and Character Inventory (TCI)

The Temperament and Character Inventory (TCI) is a battery of tests under the form of an auto evaluation questionnaire with 240 items of right/wrong possible answers which evaluates 7 high descriptors of personality or behavior, including four temperament descriptors and three character descriptors. Each of those descriptors has multiple facets and is composed of several inferior level components. The TCI describes a total of 25 features (12 temperament and 13 character facets).

The four dimensions of human temperament:

--Novelty seeking;

--Harm avoidance;

--Reward dependence;

--Persistence/perseverance.

The three character dimensions:

--Self-directedness;

--Cooperativeness;

--Self-transcendence.

Assessment tools used in the analysis of suicidal behavior

Hopelessness scale--Hopelessness Beck Scale (BHS). Hopelessness scale is one of the most commonly used self-assessment questionnaire for predicting suicide. We used this scale because the subjects with suicidal behavior were assessed immediately after a suicide attempt or in a period of their life when they were seriously thinking about suicide or even making plans of suicide. The scale consists of 20 items, each rated True or False. The total score falls theoretically from 0 to 20 and the individuals who score 9 or more have a high risk of suicide.

External validity (concurrent) shows a high correlation with the Beck Depression Inventory (8). Hopelessness symptom is included among the items of depressed mood in HAM-D.

However hopelessness is an individual psychological experience that can be assessed more adequately using a questionnaire such as BHS rather than the HAM-D.

Brown et al. (2004) carried out a prospective study on 1,891 psychiatric outpatients to identify the risk factors associated with suicide (9).

The patients were administrated a structural diagnostic interview and a battery of psychological tests including Beck Hopelessness Scale. 49 cases of suicide were identified, the average age was of 41 years and the vast majority (96 %) had a diagnosis of mood disorder. Covariance models--proportional hazard indicated that high levels of suicidal ideation, depression, unemployment and hopelessness were significant risk factors for suicide. Patients who scored 9 or higher on Beck Hopelessness Scale were four times more likely to commit suicide within a year from the evaluation. If hopelessness does not change under treatment, it can predict suicide attempts and suicide. Fawcett et al. (1990) also found that hopelessness, loss of interest and loss of pleasure make the difference between a group of suicidal patients and a control group (10). Meta-analysis of various questionnaires on the quality of life showed that the factor or overall dimension is a negative psychological welfare versus a positive one. BHS consists of items which cover both positive and negative coping. Nine BHS items quantify coping or negative welfare ("false"). The other 11 BHS items assess coping or positive welfare ("true") (e.g. "My future seems dark") (see Annex III). We evaluated the suicide risk for the patients in our group by applying Module C "suicide ideation" of MINI Scale and Suicidal Item Scale Paykel, as listed below.

RESULTS AND DISCUSSION

We noted statistically significant differences on hopelessness scale between the two study groups (Hopelessness Beck Scale).

Patients with personality disorder and suicidal behavior showed significantly higher scores of hopelessness than patients with personality disorder without suicidal behavior (p < 0.001--Welch test)--see Figure 1.

[FIGURE 1 OMITTED]

The correlation between personality dimensions and hopelessness

--The analyze of scores obtained by our subjects on personality dimensions and those obtained on hopelessness scale BHS (see Table 6) highlights significant correlations between:

--Avoiding trauma scores and hopelessness scale scores (p < 0.001--Spearman);

--Reward dependence scores and hopelessness scale scores (p = 0.005--Spearman);

--Self-directedness scores and hopelessness scale scores (p < 0.001--Spearman);

--Cooperativeness scores and hopelessness scale scores (p = 0.001--Spearman).

Thus, as revealed by our research, significant variations of hopelessness scores are explained by score variations of two temperamental dimensions (avoidance of trauma and reward dependence) and by score variations of two character dimensions (self-directedness and cooperativeness). High scores of hopelessness with high statistical significance are intensively positive correlated with high scores of Avoiding trauma temperament dimension.

When self-directedness scores are low, the hopelessness scores are high.

High hopelessness scores are also influenced by low scores on another dimension of character, Cooperativeness.

Regression model

The regression model reveals the only independent variables that significantly influence the possibility of developing suicidal: age, education, marital status and intensity of hopelessness, according to the variance--2 Log Likelihood which prevails Wald test results (see Table 2).

The above regression model validated age, low education, lack of spouse and intense hopelessness as independent variables of risk for suicidal behavior.

Age as unchangeable variable and the impact of aging on suicidality are counteracted by potentially changeable independent variables, such as education, marital status, hopelessness intensity that may become potentially protective factors with a role in preventing the onset of active suicidality.

CONCLUSION

Personality dimensions decide the hopelessness intensity in human psyche and soul. They are the secret weapon of the individual in relation to everyday stress.

Minodora Marinela Manea--M. D., Ph. D., Assistant Professor, Department of Medical Psychology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca; Senior Psychiatrist, Clinic of Psychiatry, Clinical Emergency Hospital, Cluj-Napoca, Romania

Mircea Doru Lazarescu--M. D., Ph. D., Academician, Professor, Department of Psychiatry, "Victor Babes" University of Medicine and Pharmacy, Timisoara; Senior Psychiatrist, "Eduard Pamfil" Department of Psychiatry, Timisoara, Romania

ACKNOWLEDGMENTS AND DISCLOSURE

The authors declare that they have no potential conflicts of interest to disclose.

REFERENCES

(1.) Allport, G. W. Pattern and growth in personality: A psychological interpretation. Ed. Holt, Rinehart & Winston, New York, 1961

(2.) Livesley, W. J. Handbook of Personality Disorders: Theory, Research, and Treatment. Ed. The Guilford Press, New York, 2001

(3.) Cantor, N. From Thought to behavior: "Having" and "doingg" in the study of personality and cognition. American Psychologist. 45: 735-750; 1990

(4.) Lazarescu, Mircea. Probleme ale circumscrierii tulburarilor de personalitate. Personalitatea intre anormalitati biologice si interpretari culturale, Editura University Press, Targu-Mures. 29-42; 2005

(5.) Livesley, W. J., Schroeder, M. L., Jackson, D. N., Yang, K. N. Categorical distinctions in the study of personality disorder: Implication for classification. Journal of Abnormal Psychology. 103: 6-17; 1994

(6.) Millon, T. Toward a newpersonology: An evolutionary model. Ed. Wiley, New York, 1990

(7.) Millon, T., Davis, R. Disorders of personality DSM-IV beyond. Ed. Wiley, New York, 1996

(8.) Beck, A. T., Weissman, A., Lester, D. et al. The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology. 42:861-865; 1974

(9.) Brown, G. K. A review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults. Bethedsa, NIMH, 2004

(10.) Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C., Young, M. A. et al. Time-relatedpredictors of suicide in major affective disorder. Am J Psychiatry. 147:1189-1194; 1990

Correspondence:

MINODORA MARINELA MANEA

Department of Medical Psychology--"Iuliu Hatieganu" University of Medicine and Pharmacy

No. 43 Str. V. Babes, code 400012, Cluj-Napoca, Romania

Phone: +40 721 913 014

Fax: +40 264 590 576

E-mail: mmanea@umfcluj.ro

Date of Submission: December, 18, 2013

Acceptance: January, 24, 2014

INTRODUCERE

Cercetarile din ultimul deceniu arata ca tulburarile de personalitate reprezinta un factor de risc major in aparitia comportamentului suicidar (ideatie suicidara, tentativa de suicid, suicid realizat), cu un grad de severitate comparabil cu cel al comportamentului suicidar intalnit in tulburarile afective si schizofrenie (Marsha M. Linehan, 2002). Desi comportamentul suicidar non-fatal, inclusiv tentativa de suicid, este un criteriu pentru TP Borderline, iar incidenta tentativelor de suicid in randul persoanelor care indeplinesc criteriile pentru TP Borderline este recunoscuta de toata lumea, asocierea dintre tulburarile de personalitate sau trasaturile de personalitate si suicid nu este suficient documentata. Astfel, in ciuda unor mari progrese in plan mondial in problematica personalitatii normale sau patologice, rolul trasaturilor sau al dimensiunilor de personalitate in determinismul comportamentului suicidar a fost insuficient studiat in ultimele decenii.

Doresc sa mentionez faptul ca, in actualul manual DSM-V, se introduc modificari in diagnosticarea tulburarilor de personalitate, in sensul ca, in capitolul al III-lea al actualului manual, se ia in considerare abordarea dimensionala in aprecierea unui diagnostic de tulburare de personalitate cu trasatura specifica. Disperarea nu este considerata a fi trasatura de personalitate, dar este o dimensiune clinica ce se exprima la cote inalte odata cu aparitia comportamentului suicidar.

In urma cu mai bine de cincizeci de ani, Allport (1961) a afirmat ca "personalitatea este ceva si personalitatea face ceva" (1). Sistemele personalitatii deservesc un scop adaptativ. Pentru a intelege tulburarea de personalitate, trebuie sa ne concentram atentia asupra aspectelor functionale ale personalitatii, precum si asupra modului in care aceste functii sunt perturbate (2).

Pornind de la afirmatia lui Allport, Cantor a afirmat ca expresia "personalitatea face" se refera la solutiile sarcinilor majore de viata (3). Acestea sunt sarcinile sau problemele adaptative pe care individul trebuie sa le rezolve pentru a se adapta efectiv.

Trei domenii de functionare distincte, dar interconectate, in care persoanele cu tulburare de personalitate prezinta probleme, ar putea fi precizate aici: sistemul sinelui, relatiile cu familia apropiata si rudele si relatiile sociale sau de grup. Aceste disfunctii ar putea fi formulate astfel:

--esec in stabilirea unor reprezentari stabile si integrate ale sinelui si ale celorlalti;

--disfunctii in relatiile interpersonale, manifestate prin esecul de a-si dezvolta capacitatile necesare intimitatii, de a functiona ca o figura de atasament si/sau de a se implica in relatii de filiatie;

--esec in functionarea sociala adaptativa, manifestat prin esecul in dezvoltarea unui comportament pro-social si/sau a relatiilor de cooperare.

Pentru a completa aceasta definitie, este necesar sa se precizeze ca aceste deficiente trebuie sa fie persistente, sa poata fi obiectivate inca din adolescenta sau, cel putin, din perioada de tanar adult, si nu trebuie sa fie rezultatul unei tulburari pervazive si cronice de Axa I (Lazarescu, Mircea, 2005) (4).

Pentru a transpune aceasta definitie in criterii diagnostice, este necesara o descriere mai amanuntita a patologiei sinelui si a patologiei relatiilor interpersonale (2).

Esecul adaptativ

O abordare alternativa este reprezentata de posibilitatea de a extrage o definitie a tulburarii de personalitate din intelegerea functiilor personalitatii normale. O astfel de abordare ar ancora conceptul tulburarii de personalitate intr-un concept general despre structura si functiile personalitatii. O teorie de acest fel ar aduce coerenta cunostintelor actuale, formulate in diverse concepte teoretice si descriptive. O astfel de abordare ar putea fi realizata doar prin dezvoltarea unei teorii sistematice a personalitatii care sa articuleze o conceptie universala despre functiile personalitatii. Desi, in lumina cunostintelor actuale, acesta pare un obiectiv nerealizabil, neam putea, totusi, indrepta spre acesta prin dezvoltarea unei teorii care sa inglobeze cunostintele noastre actuale despre functiile personalitatii.

Probabil cel mai potrivit model care ar putea fi folosit in acest scop este reprezentat de teoria evolutionista (Millon, T., 1990 si 1996) (5, 6, 7). Millon si Davis au sugerat ca "personalitatea ar putea fi conceputa ca reprezentand stilul mai mult sau mai putin distinctiv de functionare adaptativa pe care un organism ... il manifesta in relatia cu mediul inconjurator tipic" (7). In aceasta conceptie, tulburarea de personalitate ar fi definita de "tipuri particulare de functionare maladaptativa, ce poate fi legata de deficiente, dezechilibre sau conflicte ale capacitatii individului de a se relationa cu mediul in care traieste" (7).

Contributiile lui Millon au creat premisele unei abordari sistematice care ancoreaza conceptul de tulburare de personalitate in intelegerea modului in care functiile adaptative ale personalitatii sunt perturbate.

Procesele evolutioniste privesc selectia mecanismelor care ii permit individului sa se adapteze mediului in care traieste si, in consecinta, sa se reproduca.

Desi teoriile evolutioniste referitoare la comportamentul uman si personalitate se afla la un nivel incipient de dezvoltare, se pot, totusi, identifica cateva principii fundamentale despre natura personalitatii, care ar putea fi de folos in definirea tulburarii de personalitate (2).

IPOTEZA GENERALA A CERCETARII

Evidentierea unor factori de personalitate predispo%anti pentru comportamentul suicidar la pacientii cu tulburare de personalitate.

IPOTEZE SPECIFICE ALE CERCETARII

Evidentierea particularitatilor dimensionale ale personalitatii la pacientii cu TP si comportament suicidar comparativ cu pacientii cu TP fara comportament suicidar.

Evaluarea relatiei intre valorile obtinute la dimensiunile personalitatii, disperare si riscul suicidar, in ca%ul pacientilor cu TP.

MATERIAL SI METODA

Populatia studiata

Populatia vizata de prezentul studiu este cea a pacientilor cu tulburare de personalitate, indiferent de tip. Un interes deosebit a fost manifestat pentru pacientii cu suicidalitate activa, de exemplu, tentativa de sinucidere recenta, anterioara internarii si ideatie suicidara intensa, la care a fost validat diagnosticul de tulburare de personalitate, deoarece acesti pacienti au constituit unul dintre grupurile de cercetare.

Populatia accesibila pentru prezentul studiu a fost cea a pacientilor cu tulburare de personalitate din zona de influenta a centrului medical Cluj (zona centrala a Transilvaniei).

Au fost inclusi in studiu un numar total de 131 de pacienti diagnosticati cu tulburare de personalitate, indiferent de tip, care s-au adresat pentru consult si tratament Clinicii Psihiatrie III din Cluj-Napoca, in perioada 2004-2009 si care au semnat consimtamant informat.

Criteriile de selectare a populatiei de studiu respecta metodologia internationala in vigoare, luand in calcul criterii de selectie de tipul manifestarii clinice (in cazul studiului de fata, tulburarea de personalitate), dar si tipul de eveniment (in cazul studiului de fata, comportamentul suicidar).

Grupurile care se compara sunt urmatoarele:

1. Pacienti cu tulburare de personalitate si comportament suicidar (N = 46). Comportamentul suicidar se refera la episodul index, adica la episodul care genereaza simptomele-tinta:

--tentativa suicidara recenta (de multe ori, fiind cauza internarii sau a prezentarii la consult) sau

--ideatie suicidara intensa actuala cu sau fara plan suicidar sau

--ideatie suicidara fluctuanta actuala.

2. Pacienti cu tulburare de personalitate fara comportament suicidar (N = 85).

INSTRUMENTE DE LUCRU UTILIZATE

1. Interviul Structurat de Diagnostic Neuropsihiatric (MINI), inclusiv cu Modulul 3 "Idei de suicid

2. Interviul Clinic Structurat pentru Tulburarile de Personalitate de pe Axa II (SCID II);

3. Inventarul de Temperament si Caracter Temperament and Character Inventory--TCI);

4. Testele categoriale de apreciere a psihopatologiei si a tulburarilor de personalitate.

In prezentul studiu, Interviul Structurat de Diagnostic Neuropsihiatric (MINI) a fost utilizat pentru identificarea tulburarilor de pe Axa I comorbide tulburarilor de personalitate, dar si pentru incadrarea gradului de risc suicidar: scazut, moderat, crescut, cu ajutorul MINI-Modulului C "Idei de suicid". Interviul Clinic Structurat pentru Tulburarile de Personalitate (SCID II) a fost aplicat pentru diagnosticul categorial al tulburarilor de personalitate de la nivelul Axei II diagnostice.

Teste dimensionale de apreciere a personalitatii--INVENTARUL DE TEMPERAMENT SI CARACTER (TCI)

Inventarul de Temperament si Caracter (TCI) este o baterie de teste prezentata sub forma unui chestionar de autoevaluare cu 240 de itemi, cu variante de raspuns adevarat/fals si care evalueaza sapte descriptori de rang inalt ai personalitatii sau comportamentului, incluzand patru descriptori ai temperamentului si trei ai caracterului. Fiecare dintre acesti descriptori este multifatetat, fiind alcatuit din mai multe componente de rang inferior.

In TCI, sunt descrise, in total, 25 de trasaturi (12 fatete ale temperamentului si 13 ale caracterului).

Cele patru dimensiuni ale temperamentului uman:

--cautarea noului;

--evitarea traumei;

--dependenta de recompensa;

--persistenta/perseverenta.

Cele trei dimensiuni de caracter:

--auto-directionarea;

--cooperarea;

--auto-transcendenta.

Instrumentele de evaluare folosite in analiza comportamentului suicidar

Scala disperarii--Beck Hopelessness Scale (BHS)

Scala disperarii este unul dintre cele mai frecvent utilizate chestionare de autoevaluare pentru predictia suicidului. S-a folosit aceasta scala, intrucat subiectii care au prezentat comportament suicidar au fost evaluati imediat dupa o tentativa de suicid sau intr-o perioada a vietii in care se gandeau serios la sinucidere sau unii dintre ei faceau chiar planuri asupra modalitatii de infaptuire a sinuciderii.

Scala consta din 20 de itemi, fiecare cotat adevarat sau fals.

Astfel, scorul total se incadreaza teoretic de la 0 la 20, iar persoanele cu scoruri de noua sau mai mult prezinta un risc inalt al suicidului.

Validitatea externa (concurenta) releva o corelatie inalta cu Beck Depression Inventory (8). Simptomul de disperare este inclus intre itemii dispozitiei depresive din HAM-D.

Totusi, disperarea este o traire psihologica individuala, evaluata cel mai adecvat printr-un chestionar, ca de exemplu BHS, mai curand decat prin HAM-D.

Brown si colaboratorii (2004) au efectuat un studiu prospectiv de 20 de ani pe 6.891 de pacienti ambulatorii psihiatrici, pentru a identifica factorii de risc asociati cu suicidul (9).

Acestor pacienti li s-a administrat un interviu structural diagnostic si o baterie de teste psihologice, inclusiv Beck Hopelessness Scale. Au fost identificate 49 de cazuri de suicid, varsta medie era 41 ani, iar vasta majoritate (96 %) prezenta un diagnostic de tulburare de dispozitie. Modelele de covarianta--hazard proportional au indicat faptul ca nivelele ridicate de ideatie suicidara, depresie, somaj si disperare au fost factori de risc semnificativ pentru suicid. Pacientii cu scoruri de 9 sau peste la Beck Hopelessness Scale au avut probabilitatea de patru ori mai mare de a comite suicid in intervalul de un an de la evaluarea disperarii si a obtinerii unui scor de peste 9. Disperarea care nu se modifica sub tratament poate prezice tentativele suicidare si suicidul.

Fawcett si colaboratorii (1990) au gasit, de asemenea, ca disperarea, pierderea interesului si pierderea placerii fac diferenta dintre un grup de pacienti suicidari si un grup de control (10).

Meta-analiza diverselor chestionare de calitate a vietii a demonstrat ca factorul sau dimensiunea generala il constituie bunastarea psihologica pozitiva versus negativa.

BHS este alcatuita din itemi ce acopera atat copingul pozitiv, cat si pe cel negativ. Noua itemi BHS cuantifica copingul sau bunastarea negativa ("falsa"). Ceilalti 11 itemi BHS evalueaza copingul sau bunastarea pozitiva ("adevarata") (de exemplu: "Viitorul meu pare intunecat'') (vezi Anexa III).

In cadrul lotului luat in discutie, riscul suicidar si incadrarea acestuia in diferite grade de severitate s-a evaluat prin aplicarea Modulului C "Idei de suicid" din MINI si a Scalei itemilor suicidari "Paykel". Atat Modulul C MINI, cat si Scala itemilor suicidari "Paykel" am ales sa fie prezentate mai jos si nu in anexa, intrucat dimensiunea redusa a acestora a permis acest lucru.

REZULTATE SI DISCUTII

Intre cele doua loturi studiate, s-au inregistrat diferente semnificative din punct de vedere statistic la scala disperarii (Beck Hopelessness Scale).

[FIGURA 1 OMITIR]

Pacientii cu tulburare de personalitate si comportament suicidar prezinta cote semnificativ mai inalte ale disperarii decat pacientii cunoscuti cu tulburare de personalitate, dar fara comportament suicidar (p < 0,001--testul Welch)--vezi figura 1.

Relatia intre dimensiunile personalitatii si disperare

Analizand corelatiile intre valorile obtinute de subiecti la dimensiunile personalitatii si scorurile obtinute de acestia pe scala disperarii BHS (vezi tabelul 1), se evidentiaza corelatii semnificative intre:

--scorurile obtinute la dimensiunea Evitarea traumei si scorurile obtinute pe scala disperarii (p < 0,001--Spearman);

--scorurile obtinute la dimensiunea Dependenta de recompensa si scorurile obtinute pe scala disperarii (p = 0,005--Spearman);

--scorurile obtinute la dimensiunea Autodirectionare si scorurile obtinute pe scala disperarii (p < 0,001--Spearman);

--scorurile obtinute la dimensiunea Cooperativitate si scorurile obtinute pe scala disperarii (p = 0,001--Spearman).

Astfel, dupa cum cercetarea a evidentiat, variatii importante ale scorului pe scala disperarii sunt explicate de variatiile scorurilor la doua dimensiuni temperamentale (evitarea traumei si dependenta de recompensa), precum si de variatiile scorurilor la doua dimensiuni caracteriale (autodirectionarea si cooperativitatea).

Scorurile inalte ale disperarii au corelat intens pozitiv, cu inalta semnificatie statistica, cu scorurile crescute la dimensiunea de temperament evitarea traumei.

Daca scorul la autodirectionare variaza catre valori scazute, scorul la disperare variaza catre cote inalte. Scorul inalt la disperare este influentat si de scorurile reduse la o alta dimensiune de caracter, cooperativitatea.

Modelul de regresie

In urma construirii modelului de regresie, singurele variabile independente care influenteaza semnificativ probabilitatea dezvoltarii comportamentului suicidar au rezultat a fi: varsta, nivelul de studii, starea civila si intensitatea disperarii, conform modificarii -2 Log Likelihood, aceasta primand asupra rezultatului testului Wald (vezi tabelul 1 si tabelul 2).

Varsta inaintata, scolarizarea redusa, lipsa partenerului de viata si cotele inalte ale disperarii s-au validat ca variabile independente, care reprezinta factori de risc pentru comportamentul suicidar, conform acestui model de regresie.

Astfel, varsta ca variabila nemodificabila si impactul inaintarii in varsta pe suicidalitate sunt contracarate de variabilele independente cu potential de modificabilitate, precum nivelul de scolarizare, statutul marital, nivelul disperarii care devin posibili factori de protectie, cu rol in preventia si declansarea suicidalitatii active.

CONCLUZII

Dimensiunile personalitatii sunt cele care hotarasc nivelul disperarii in psihismul si sufletul uman, acestea fiind arma secreta a individului in relatia cu stresul cotidian.

Minodora Marinela Manea--M. D., Ph. D., Asistent universitar, Disciplina Psihologie Medicala, Universitatea de Medicina "Iuliu Hatieganu", Cluj-Napoca; Medic Primar Psihiatru, Clinica Psihiatrie, Spitalul Clinic Judetean de Urgenta, Cluj-Napoca, Romania

Mircea Doru Lazarescu--M. D., Ph. D., Academician, Profesor universitar, Catedra de Psihiatrie, Universitatea de Medicina si Farmacie "Victor Babes", Timisoara; Medic Primar Psihiatru, Clinica de Psihiatrie "Eduard Pamfil", Timisoara, Romania

MULTUMIRI SI DEVOALARI

Autorii declara ca nu au potentiale conflicte de interese de declarat in legatura cu acest articol.

BIBLIOGRAFIE

1. Allport, G. W. Pattern and growth in personality: A psychological interpretation. Ed. Holt, Rinehart & Winston, New York, 1961

2. Livesley, W. J. Handbook of Personality Disorders: Theory, Reasearch, and Treatment. Ed. The Guilford Press, New York, 2001

3. Cantor, N. From Thought to behavior: "Having" and "doing" in the study of personality and cognition. American Psychologist. 45: 735-750; 1990

4. Lazarescu, Mircea. Probleme ale circumscrierii tulburarilor de personalitate. Personalitatea intre anormalitati biologice si interpretari culturale, Editura University Press, Targu-Mures. 29-42; 2005

5. Livesley, W. J., Schroeder, M. L., Jackson, D. N., Yang, K. N. Categorical distinctions in the study of personality disorder: Implication for classification. Journal of Abnormal Psychology. 103: 6-17; 1994

6. Millon, T. Towards a newpersonology: An evolutionary model. Ed. Wiley, New York, 1990

7. Millon, T., Davis, R. Disorders of personality DSM-IV beyond. Ed. Wiley, New York, 1996

8. Beck, A. T., Weissman, A., Lester, D. et al. The measurement of pessimism: the hopelessness scale. Journal of Consulting and Clinical Psychology. 42:861-865; 1974

9. Brown, G. K A review of Suicide Assessment Measures for Intervention Research with Adults and Older Adults. Bethedsa, NIMH; 2004

10. Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C., Young, M. A. et al. Time-relatedpredictors of suicide in major affective disorder. Am J Psychiatry. 147:1189-1194; 1990

Corespondenta:

MINODORA MARIN ELA MANEA

Disciplina Psihologie Medicala--Universitatea de Medicina "Iuliu Hatieganu"

Str. V. Babes nr. 43, cod 400012, Cluj-Napoca, Romania

Tel.: +40 721 913 014

Fax: +40 264 590 576

E-mail: mmanea@umfcluj.ro

Primire: Decembrie, 18, 2013

Acceptare: ianuarie, 24, 2014
Table I. Correlations between personality
dimensions scores and BHS scores obtained
by patients

Novelty Seeking      0,063    0,477
Harm avoidance       0,499    < 0,001
Reward Dependence    -0,244   0,005
Persistence          -0,020   0,817
Self-directedness    -0,514   < 0,001
Cooperativeness      -0,281   0,001
Self-transcendence   -0,113   0,197

Table II. Modification -2 Log Likelihood

Variables                    Log         Change     df   P changes
                          Likelihood     -2 Log
                            Model      Likelihood

Step 1   BHS               -57,529       36,027     1     < 0,001
Step 2   Education         -39,516       42,799     4     < 0,001
         BHS               -30,690       25,148     1     < 0,001
Step 3   Age               -18,116       11,609     1      0,001
         Education         -36,237       47,851     4     < 0,001
         BHS               -27,576       30,529     1     < 0,001
Step 4   Age               -17,897       20,564     1     < 0,001
         Marital status    -12,312       9,394      2      0,009
         Education         -33,736       52,243     4     < 0,001
         BHS               -16,414       17,599     1     < 0,001

Tabelul I. Corelatii intre valorile obtinute de pacienti
la dimensiunile personalitatii si valorile obtinute pe
scala BHS

Dimensiunea                Coeficientul   P
                           de corelatie
                           Spearman (r)

Cautarea noutatii          0,063          0,477
Evitarea traumei           0,499          < 0,001
Dependenta de recompensa   -0,244         0,005
Persistenta                -0,020         0,817
Autodirectionarea          -0,514         < 0,001
Cooperativitatea           -0,281         0,001
Autotranscendenta          -0,113         0,197

Tabelul II. Modificarea -2 Log Likelihood

Variabile                  Log       Modificarea   df   P modificare
                        Likelihood     -2 Log
                          Model      Likelihood

Pas 1        BHS         -57,529       36,027      1      < 0,001
Pas 2      Studii        -39,516       42,799      4      < 0,001
             BHS         -30,690       25,148      1      < 0,001
Pas 3      Varsta        -18,116       11,609      1       0,001
           Studii        -36,237       47,851      4      < 0,001
             BHS         -27,576       30,529      1      < 0,001
Pas 4      Varsta        -17,897       20,564      1      < 0,001
        Starea civila    -12,312        9,394      2       0,009
           Studii        -33,736       52,243      4      < 0,001
             BHS         -16,414       17,599      1      < 0,001
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Author:Manea, Minodora M.; Lazarescu, Mircea D.
Publication:Bulletin of Integrative Psychiatry
Article Type:Report
Date:Mar 1, 2014
Words:5066
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