suicidality as a psychotic disorder ‘suicidal drive’ · 2 f hears a girl’s voice speaking to...

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Suicidality as a Psychotic Disorder

Ian Kelleher MB BCh, MSc, PhD

Royal College of Surgeons in Ireland

No disclosures

Suicide and psychosis?

‘Suicidal drive’ – ‘the most serious of

schizophrenic symptoms’

Eugen Bleuler, 1911

Up to half of patients with schizophrenia

make at least one suicide attempt

However, most cases of suicidal behaviour

not psychosis

“‘The number of latent and potential

psychoses is astoundingly large in

comparison with the manifest cases.

Without being able to give exact

statistics, I reckon it at 10:1”

Carl Jung, 1958

Psychosis as a continuum

Attenuated psychotic symptoms

E.g., auditory hallucinations

Voices are

definitely not my

own thoughts

Possible voices are

my own thoughts

(but unlikely)

Voices sound outside my

head but are probably my

own thoughts

Clinical utility?

Supported by research on UHR for psychosis

Voices sound outside my

head but are definitely

my own thoughts

Psychotic experiences

Hallucinations Delusions

Common in the population

Systematic review and meta-analysis: 19 studies

ages 9 to 12: 17%

ages 13 to 18: 7.5%

Adults: 5-7%

SOCRATES Assessment of Perceptual

Abnormalities and Unusual Thought Content

Source (inside or outside head)

Onset, frequency and duration

Character and content

Reality testing and Attribution

Timing

Effects on functioning

Severity of distress (out of 10)

How to assess psychotic experiences?

2

F hears a girl’s voice speaking to her. Sounds outside head.

Onset: 2 years ago. Frequency: 1 per month. Duration: a

few seconds to about 1 minute.

Hears several different voices, all girls. Usually hears voices

when alone, 1 voice at a time only. Never conversing voices

Examples: “Why are you doing it that way’?

“She is wearing a red coat”.

Does not sound the same as my voice talking to her -

different quality, raspy, less clear.

Attribution and reality testing: Thinks it's a ghost - a little

girl with black hair, gothic looking (but has not actually seen

her). Accepts it could be her imagination when I challenge

her but thinks most likely a ghost.

Finds experiences frightening – 7/10 distress severity.

Example

Questionnaire

Poor PPV and NPV for clinician-verified sx

But: ‘Have you ever heard voices or sounds no

one else can hear?’

PPV 100%, NPV 88%

How to assess psychotic experiences?

Psychotic sx as predictors of psychotic dx

Meta-analysis: 3.5 X population risk (Kaymaz et al.,

2012)

Vast majority do not develop psychotic disorder

Any implications for those who do not develop

psychotic disorder?

80% of teens with PEs – at least 1 Axis-1 disorder

Clinical Utility?

Any disorder in particular?

Major depressive

disorder

Social phobia

Obsessive compulsive

disorder

Attention deficit

hyperactivity disorder

Generalised anxiety

disorder

Oppositional defiant

disorder

Conduct Disorder

No

Wide range of mental disorders assoc with psychotic sx

But...

Pre

vale

nce o

f p

sych

oti

c s

x %

0%

10%

20%

30%

40%

50%

60%

No disorder 1 disorder 2 disorders 3 or more disorders

Dose response relationship between # Axis-1 dx and odds

of reporting psychotic experiences

Multimorbidity

3

ABD study and CT study

423 adolescents, aged 11 to 16 years

School based, Dublin, Ireland

Diagnostic interview: K-SADS

Suicidal Ideation and Behaviour

0

2

4

6

8

10

12

No psychotic sx ABD psychotic sx CT psychotic sx

Od

ds

Rati

o

Kelleher et al, 2012, Arch General Psychiatry

...stratified by psychopathology

CT sample with

behavioural dx (n=18) 0% 75% ∞

Prevalence of

suicide plans or

attempts –

no psychotic sx

Prevalence of

suicide plans or

attempts –

psychotic sx

OR (CI95)

CT sample with

depressive dx (n=37) 16% 67% 13.7 (2.1 – 89.6)

CT sample with suicidal

ideation (n=28) 24% 86% 19.6 (1.8 – 216.1)

Majority of adolescents with suicide plans or attempts

reported psychotic sx when directly questioned

ABD: 60% CT: 55%

What about in the clinic?

Clinical sample: Mater CAMHS

Catchment area: 73,000 < 16 years

108 adolescents aged 12-16 with at least one

DSM-IV disorder, newly referred to the service

between 2008 and 2009

‘Clinical case – clinical control’ study:

patients with psychotic experiences compared to

patients who did not have psychotic experiences

Suicidal Behaviour

1. Affective dx with vs without PEs

2. Anxiety dx with vs without PEs

3. Behavioural dx with vs without PEs

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Major Depressive Disorder

Kelleher et al, 2013, Psychological Medicine

Anxiety Disorder


Behavioural Disorder


What about predicting suicidal

behaviour over time?

TCHAD

Cohort study 2,263 followed to adulthood

All twins born in Sweden May 1985 to

December 1986

Assessed:

13 to 14 years - Youth Self Report and Child

Behavior Checklist

16 to 17 years - Youth Self Report and Child

Behavior Checklist

19 to 20 years - Adult Self Report and Adult

Behavior Checklist

TCHAD

Psychotic experiences: “I hear sounds or voices

other people think aren’t there”

Suicidal ideation: “I think about killing myself”

Internalizing psychopathology: YSR/ASR

Externalizing psychopathology: CBCL/ABCL

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TCHAD

Suicidal ideation

13 to 14 years old: 5% (n=116)

16 to 17 years old: 8% (n=191)

19 to 20 years old: 8% (n=138)

Psychotic experiences

13 to 14 years old: 7.3% (n=162)

16 to 17 years old: 3.9% (n=89)

19 to 20 years old: 2.6% (n=44)

TCHAD

Most suicidal ideation transient

35% persisted from 13-14 to 16-17 years

29% persisted from 16-17 to 19-20 years

PEs at 13-14 years did not predict persistence of

SI at 16-17 years

PEs at 16-17 years predicted a 6-fold increased

odds of persistence of SI to 19-20 years

More than half of SI with PEs persisted (54%)

SEYLE

RCT to assess prevention strategies for suicidal

behaviour in 11 countries

17 second level schools in Cork and Kerry

1602 consent forms – 1112 took part (~70%)

Follow up at 3/12 (90%) and 12/12 (88%)

Psychopathology

Strengths and Difficulties Questionnaire – top 20%

Psychotic sx

7% (n=77)

22% of psychopathology sample

Suicide attempts:

3.1% (n=96) had at least one lifetime suicide attempt

0.5% (n=14) had made a suicide attempt within the

2 weeks preceding a study assessment point (acute

suicide attempts)

Suicide attempts Psychopathology but no psychotic sx

0%

5%

10%

15%

20%

25%

30%

35%

40%

3 months 12 months

Kelleher et al, 2013, JAMA Psychiatry

Suicide attempts

0%

5%

10%

15%

20%

25%

30%

35%

40%

3 months 12 months


6

Suicide attempts

0%

5%

10%

15%

20%

25%

30%

35%

40%

3 months 12 months


Suicide attempts

0%

5%

10%

15%

20%

25%

30%

35%

40%

3 months 12 months

OR=5.7

N.S.

OR=13.5

OR=18.4


12 Month Risk

0%

5%

10%

15%

20%

25%

30%

35%

40%

Pre-diabetes - Diabetes

MCI - Dementia ARMS - Psychosis SRMS - Suicide attempt

12 Month Risk

0%

5%

10%

15%

20%

25%

30%

35%

40%



12 Month Risk

0%

5%

10%

15%

20%

25%

30%

35%

40%



12 Month Risk

0%

5%

10%

15%

20%

25%

30%

35%

40%



7

12 Month Risk

10%

15%

22%

34%

0%

5%

10%

15%

20%

25%

30%

35%

40%



Long term follow up – Dunedin birth cohort

50% who reported psychotic experiences age 11

attempted or completed suicide by age 38

DeVylder et al (In Press)

JAMA Psychiatry

US Collaborative Psychiatric Epidemiological

Surveys

Large general population sample USA

20,013 adults, aged 18+

Pts with PEs

5x odds suicidal ideation , 9x odds suicide attempts.

Pts with suicidal ideation

PEs >3x odds to make an attempt over the

concurrent 12-month period (adjusted for disorders)

Severity of suicide attempts

“My attempt was a cry for help, I did not want to

die”

“I tried to kill myself, but I knew the method was

not fool-proof,” or

“A serious attempt to kill myself and it was only

luck that I did not succeed,”

77% of suicide attempts in those with PEs were with

intent to die

19% with a mental disorder and SI without PEs

attempted suicide

Nearly 50% with a mental disorder plus PEs

attempted suicide

Why do PEs index risk for

suicidal behaviour? Clinical factors

Psychopathology severity, multimorbidity

0%

10%

20%

30%

40%

50%

60%

No disorder 1 disorder 2 disorders 3 or more

disorders

Neurocognitive dysfunction

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Processing speed

‘Systems’ based process

Reflects speeded integration and coordination between

distributed brain networks (Dickinson et al., 2008)

Related to structural integrity of major white matter

tracts (Turken et al., 2008)

Superior longitudinal fasciculus

Occipito-frontal fasciculus

Inferior longitudinal fasciculus

Disconnection hypothesis extended psychosis

phenotype

Tracts in proximity to

ROI 4 Tracts in proximity to

ROI 1


ROI 5


ROI 3

Tract visualization using CSD tractography

Volumetric diffs – cingulate cortex &

orbitofrontal cortex (Jacobson et al., 2010)

Stress regulation (Koolschijn et al, 2009)

MRI studies of suicidal patients (Monkul et al, 2007)

rs-fMRI

Reduced intrinsic functional connectivity (iFC)

between regions supporting inhibitory control

(Jacobson et al, 2013)

MRI Weaker iFC between:

Right inferior frontal

gyrus (IFG) and

cingulum

IFG and striatum

Anterior cingulate cx and

claustrum

Precuneus and

supramarginal gyrus

Jacobson et al, 2013, Acta Psychiatrica Scand

Psychological factors

Poorer coping skills:

Lin et al, 2011: community sample adolescents –

more non-adaptive coping

Wigman et al, 2013: clinic sample of adolescents –

more non-adaptive coping

Stress sensitivity (Lataster et al, 2009)

Strong affective reactions to stress

Not just down to stress tolerance

DeVylder et al (In Press) – stress intolerance does

not explain high rate of suicidal behaviour

Childhood Trauma

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Trauma measures

Physical assault

Have you, during the past 12 months, been

physically attacked?

Baseline: n=111 (10%)

3 months: n=78 (8%)

12 months: n=78 (8%)

Bullying

In the past 12 months, have others...

often spread rumours about you?

teased you?

deliberately left you out of activities?

taken money, property or food from you?

called you names?

made fun of how you look or talk?

Baseline: n=409 (39%)

3 months: n=281 (30%)

12 months: n=322 (33%)

Principles of causation

Biologic/psychologic plausibility √

Temporal relationship √

Incident psychotic sx on exposure to trauma

Strong association √

Physical assault: 5 to 6↑ odds

Bullying 3 to 4↑ odds

Dose-response relationship √

Alternative explanations – reverse causality √

Cessation of exposure – cessation of effect √

Cessation of exposure

Conclusion

Clinical Implications

Importance of renewed focus on assessing

(attenuated) psychotic symptoms in all patients

Systematic approach

Are some psychotic experiences more predictive

than others?

Completed suicides

Larger datasets...

Conclusions

PEs should alert clinicians that:

Multiple disorders are likely

Average of 3 mental disorders

SI is unlikely to be transient

Among 16-17 year olds, 54% persistent 3 years later

Individuals with psychopathology who report PEs–

‘clinical high risk’ for suicide attempt

34% suicide attempt within 12/12

50% attempt or complete suicide over long term

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Mary Cannon

Martin Cederlöf

Mary Clarke

Paul Corcoran

Irene Daly

Carol Fitzpatrick

Padraig Flannery

Michelle Harley

Jennifer Murphy

Síle Murphy

Aileen Murtagh

Erik O’Hanlon

Hugh Ramsay

Caroline Rawdon

Sarah Roddy

Hanneke Wigman

Sarah Jacobson

Helen Keeley

Paul Lichtenstein

Aoife Lonergan

Fionnuala Lynch

Carla Mills

Charlene Molloy

Derek Morris

Acknowledgments

suicidality as a psychotic disorder ‘suicidal drive’ · 2 f hears a girl’s voice speaking to...

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