Alcoholics who live alone are also at high risk

Compared to the general population, individuals with alcohol-use disorders (AUDs) have a significantly greater risk of suicide attempts. New research examines the impact of all personality disorders (PDs) on the risk of a suicide attempt among individuals with AUDs. Alcoholics with a borderline personality disorder and those who live alone are at highest risk.

Compared to the general population, individuals with alcohol-use disorders (AUDs) have a significantly greater risk of suicide attempts. Up to 40 percent of treatment-seeking patients with AUDs report having attempted suicide, which is six to 10 times greater than suicide attempts among the general population. In the May issue of Alcoholism: Clinical & Experimental Research, researchers examine the impact of the full range of personality disorders (PDs) on the risk of a suicide attempt among individuals with AUDs, finding that those with co-occurring alcoholism and borderline PD have the highest risk.

"We knew from previous research that both alcohol dependence and personality disorders are significant risk factors for suicidal behavior," said Ulrich W. Preuss, assistant professor of psychiatry at Martin-Luther-University of Halle, Germany. "However, how each affects the other or interact together, this was not researched."

Kenneth R. Conner, associate professor of psychiatry at the University of Rochester Medical Center, concurs. "There are meager data on the contribution of most personality disorders to attempted suicide among individuals treated intensively for alcohol dependence, a high-risk population," he said. "This study is highly unusual in that all of the current personality disorders were assessed using a credible research interview in a large alcohol-dependent sample."

Researchers recruited 376 (303 males, 73 females) inpatients from an alcohol-dependence treatment ward in Germany. All patients were 18 years of age or older. Study participants were assessed by several instruments, including the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), the Semi-Structured Assessment on Genetics in Alcoholism, and the Structured Clinical Interview for DSM-IV Axis II Disorders. Personality-disorder diagnoses were divided into three clusters: A (paranoid, schizoid, schizotypal); B (histrionic, narcissistic, borderline, antisocial); and C (avoidant, dependent, obsessive-compulsive, depressive, negativistic).

Results indicate that 55 percent of the patients had a PD, and approximately 25 percent had a history of at least one suicide attempt.

"All personality disorders, from all the clusters, increase the risk for suicidal behavior among alcoholics," said Preuss. "Subjects who have cluster B PDs - which include narcissistic, histrionic, borderline and antisocial PDs - are at particular risk. Furthermore, taking into account several known risk factors - such as depression, marital status, aggression and impulsive traits - statistically speaking, subjects with borderline PD and those who live alone are at highest risk."

Preuss and Conner described a borderline PD as a pervasive or enduring pattern of self-destructive behavior characterized by an instability of interpersonal relationships, a propensity to experience negative emotions such as sadness or anger - both acutely and intensively, poor self-image, marked impulsivity beginning by early adulthood and presenting in a variety of contexts, and an uncertainty of one's values and goals.

"Alcohol-dependent individuals who live alone often are separated or divorced from their spouses due to their alcoholism," noted Preuss. "Furthermore, they are significantly more often unemployed and have a poor perspective in life. This might lead to an even higher intake of alcohol and subsequently to more hopelessness, depression and social isolation. Together with their difficult socio-economic situation, often a minor event - such as trouble with the authorities or neighbors - is enough to precipitate suicidal behavior. Very often these subjects get drunk before the suicide attempt."

"Among individuals with a history of one or more suicide attempts," added Conner, "analysis of the characteristics of the most serious attempt suggests that alcohol-dependent individuals with borderline personality disorder had high intent to die, indicating that suicide attempts in this population can not be taken lightly. In other words, alcohol-dependent individuals with a borderline personality disorder are likely to be at high risk for completed suicide, in addition to the well-known fact that they are at high risk for attempted suicide."

"I hope these findings might provide some insights for clinicians on how to assess suicide risk in these double-diagnoses subjects," said Preuss. "Clinicians and personnel who have frequent contacts with these patients in outpatient clinics or community clinics should be able to offer long-term suicide prevention strategies to subjects with known risk factors. I also hope that members of the public will realize that alcohol dependence is a psychiatric disease and not a habit, that personality disorders in alcoholic subjects occur very often, and that alcoholics with comorbid conditions are at high risk for suicidal behavior."

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