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ORIGINAL ARTICLE
Year : 2015  |  Volume : 36  |  Issue : 2  |  Page : 106-111

A study of the personality traits and the level of anxiety in suicidal polydrug users


1 Department of Neuropsychiatry, Suez Canal University, Ismailia, Egypt
2 Al-Baha Psychiatric Hospital, Al-Baha, Egypt

Date of Submission06-Apr-2015
Date of Acceptance03-May-2015
Date of Web Publication4-Jun-2015

Correspondence Address:
Amany A Baalash
Al-Baha Psychiatric Hospital, Al-Baha 22888
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.158119

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  Abstract 

Background
Suicidal behavior among substance abusers is common. Despite increasing knowledge about substance abuse and suicidal behavior, we lack sufficient knowledge about the characteristic features of suicidal substance abusers.
Objective
This study aimed to examine the associative characteristics of suicidal thoughts among polysubstance abusers.
Materials and methods
This was a case-control comparative study on 239 individuals between 18 and 45 years of age. We reviewed 122 individuals who fulfilled the DSM-IV-TR criteria of substance abuse for two or more substances, and their data were compared with that collected from 117 control persons. Detailed demographic, clinical, and laboratory data of the participants were collected. They were administered a semistructured psychiatric interview and examination, the Eysenck Personality Questionnaire (EPQ), and the Hamilton Anxiety Scale (Ham-A) on almost the 10th day after admission (after detoxification).
Results
Suicidal cases formed 64.75% of the polysubstance abusers in our study. The mean score of Ham-A was 13.71 ± 6.31 for suicidal polydrug abusers, which was significantly the highest among the groups; 24.1 and 6.3% of the suicidal cases experienced mild to moderate and moderate to severe anxiety, respectively, whereas the remaining experienced mild symptoms. Suicidal cases attained significantly higher scores on the psychoticism and lie scale of EPQ in this study.
Conclusion
A statistically significant relation was found between the suicidality in polysubstance abusers and a high level of anxiety as assessed by the Ham-A scale and personality traits related to psychoticism and the lie scale on EPQ.

Keywords: Eysenck Personality Questionnaire, Hamilton Anxiety Scale, polysubstance abuser


How to cite this article:
Fahmy MT, Haggag WL, Mohamed KA, Baalash AA. A study of the personality traits and the level of anxiety in suicidal polydrug users. Egypt J Psychiatr 2015;36:106-11

How to cite this URL:
Fahmy MT, Haggag WL, Mohamed KA, Baalash AA. A study of the personality traits and the level of anxiety in suicidal polydrug users. Egypt J Psychiatr [serial online] 2015 [cited 2020 Aug 11];36:106-11. Available from: http://new.ejpsy.eg.net/text.asp?2015/36/2/106/158119


  Introduction Top


The prevalence of actual substance abuse among youths has nearly doubled over the past decade (Kempner and Bukstein, 2009). Substance abuse is associated with suicidal ideation and suicide. This may be attributed to the intoxicating and disinhibiting effects of many psychoactive substances (Richard and Rosenthal, 2008).

The term 'Suicide' stems from the Latin ward 'Sui', which means the one-self, and 'cida' from caedera that means to kill. Suicide is a significant social problem and, theoretically, a preventable cause of death (Anti and Kongable, 1995).

Suicide accounts for nearly 1% of all deaths (Salah, 2001). Suicide rates are increasing every year in Saudi Arabia. The main reasons, according to social workers in Jeddah, that lead to suicide are weak faith and a sense of overwhelming pressure, wherein a person cannot cope and thus sinks into a deep depression that leads to suicide or attempted suicide. Suicide also stems from social, psychological, and economic reasons, and many drug addicts commit suicide (Andijani, 2008).

Generalized anxiety disorder is when a person has persistent recurring feelings of stress and anxiety. It is found to be associated with increased risk of suicide (Vijayakumar et al., 2004).

Personality characteristics that have been associated with a higher risk of suicide are identified by a heightened sense of hopelessness, a high score on neuroticism, an external locus of control, low self-esteem, aggression, novelty-seeking behavior, impulsiveness, etc. (Apter et al., 1997).

Prevention of suicide depends on the timely assessment of suicide risk. Shea (2000) says that timely assessment depends on clinicians' overcoming their own fixed ideas and basing their assessment on three pillars: analyzing the risk factors and predictors, uncovering and understanding suicidal ideation, and developing prevention strategies.

The main objective of this study was to investigate the personality and emotional characteristics of suicidal substance abusers. Assessment of these links is important to identify predictors of suicide in substance abusers to develop specific interventions for persons in substance abuse treatment.


  Materials and methods Top


Study design

A case-control comparative study was carried out to assess the personality traits and the level of anxiety in the participants.

Setting of the study

This study was conducted during the period from May 2011 to June 2012 in Al-Baha Psychiatric Hospital in the south area in Saudi Arabia.

Study population

Cases in this study were male inpatients, aged 18-45 years, who met the criteria of Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th ed. (DSM-IV-TR), for the psychiatric diagnosis of substance abuse, and who were abusing two or more substances.

Controls included men who never had the experience of taking illicit substances and were not suffering from any current or past psychiatric disorders or any serious medical disease.

Controls were matched for age, residential environment, and were chosen from employees, workers in the hospital, and their relatives and friends.

Ethical considerations

Written informed consents were obtained from the patients after explaining to them the aim of the study, the importance of data they are going to offer, and that these data are confidential.

The sampling technique and data collection

The presumptive prevalence of substance abuse among this study population was 7.8%, similar to the study by Taha (2001). The calculated sample size per group was around 122 according to the following equation:

n = (z/e) 2 (p) (1-p)

where, n is the sample size per group; p (the expected prevalence) is 7.8%; z (the critical value that determines the area underlying 95% of the population on the normal distribution curve) is 1.96; and e (the margin of sample error tolerated) is 0.05.

n = (1.96/0.05) 2 × (0.078) × (1-0.078) = 111

The expected dropout was 10%, and so the total sample size will be 122.

This study included 122 cases in addition to 117 controls. Five participants from the control group were considered as dropouts because they did not fulfill the criteria.

The sample was selected by systematic random sampling. There were about 225-273 cases suffering from polysubstance abuse admitted to the hospital yearly, whereas our sample size was 122, and so our interval was 273/122 = 2. This was calculated as follows:

K = N/n

where 'K' is the interval, 'n' is the sample size, and 'N' is the population size.

The first case was chosen randomly, and then, every second case was selected to fulfill the sample size required, which was 122 cases.

Participants were organized into two major groups: the cases (polysubstance abusers) group (n = 122) and the control group (n = 117). Then, patients were classified into the suicidal and the nonsuicidal groups according to the presence of a lifetime history of suicidal ideation or attempt (Grohol, 2012). The study was carried out for both groups.

Information from family members was gathered in some cases.

Participants were subjected to the following:

(1) Psychiatric history and mental state examination were performed. Patients were diagnosed according to DSM-IV-TR.

(2) Full physical and neurological examination, routine laboratory tests (complete blood count, blood chemistry, thyroid function, liver function and urine analysis), and ECG were performed in order to exclude serious organic pathology. A urine and blood toxicology screen for substance abuse was performed to detect benzodiazepine, alcohol, amphetamine and amphetamine derivatives, opioids, cocaine, phencyclidine (PCP), barbiturate, and cannabis.

(3) The Hamilton Anxiety Scale (Ham-A): It was designed by Hamilton M., 1959, to quantify anxiety. The Arabic version was prepared and standardized by Lotfy Fateem, 1998 (Lotfy Fateem, 1998). It is 14-item clinician-rated instrument designed to assess and quantify the severity of anxiety. Each item is rated on a five-point Likert-type scale ranging from 0 (not present) to 4 (severe), with higher scores indicating more severe anxiety. Regarding symptoms (the other 13 items), the assessment must be based on the condition during the last week; for item 4 (insomnia), only the last 3 days were assessed (Hamilton, 1981).

(4) The Eysenck Personality Questionnaire (EPQ): This questionnaire was developed in1975 by Eysenck, and then translated into Arabic and standardized by Abdel-khalek, 1991 (Abdel-Khalek, 1991). The EPQ measures the personality traits, usually called temperament, in four scales: P, psychoticism or tough-mindedness (assessed by 25 questions); E, extraversion (assessed by 20 questions); N, neuroticism or emotionality (assessed by 23 questions); and L, lie (assessed by 23 questions). Hans Eysenck's theory is based primarily on physiology and genetics. Extraversion-introversion dimensions are supposed to be located in the activating reticular formation. Neuroticism, according to Eysenck's theory, is based on activation thresholds in the sympathetic nervous system or the visceral brain, whereas psychoticism is based on testosterone, with higher levels of psychoticism associated with higher levels of testosterone (Okasha, 1987). The EPQ is a questionnaire with 91 questions to be answered by putting (x) in the space for 'Yes' or 'No' after the question.

Statistical analysis

The collected data were organized, tabulated, and statistically analyzed using the software statistical computer package (SPSS, version 16, USA). For quantitative data, the mean and SD were calculated. For qualitative data, comparison between two groups and more was performed using the c2 -test. For comparison between means of two groups of parametric data, the Student t-test was used. For comparison between more than two means, the F value of analysis of variance was calculated, where Tamhane's T2 test (for unequal groups) was performed to compare each of the two means if the F value was significant.

P-value indicates the level of significance:

P > 0.05 = nonsignificant; P < 0.05 = significant; P < 0.01 = highly significant; P < 0.001 = very highly significant.


  Results Top


The sample consisted of 122 cases (79 suicidal cases and 43 nonsuicidal cases) and 117 controls. Amphetamine and cannabis dominated the list of substances abused by the cases in the present study (not tabulated).

[Table 1] shows that suicidal cases were highly present among polysubstance abusers (64.75%), and 22.13% of the cases had a history of at least one suicide attempt.
Table 1 The prevalence of suicidal thoughts and behavior among participants

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[Table 2] shows the Ham-A for the control, the nonsuicidal, and the suicidal groups. Suicidal cases attained statistically significantly higher scores compared with the other two groups (P < 0.0001), and the control group attained statistically significantly lower scores compared with the other two groups (P < 0.0001).
Table 2 The Hamilton Anxiety Scale for control, nonsuicidal, and suicidal cases

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[Table 3] shows the level of anxiety as measured by the Ham-A for the controls, the nonsuicidal, and the suicidal cases. Suicidal cases were more common than the other two groups among those who were suffering from mild to moderate and moderate to severe levels of anxiety. All controls and most of the nonsuicidal group showed mild anxiety; the difference between the three groups was statistically significant (P < 0.0001).
Table 3 The depth of anxiety as assessed by Hamilton Anxiety Scale for control, nonsuicidal, and suicidal cases

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[Table 4] shows the EPQ for control, nonsuicidal, and suicidal cases. Suicidal cases attained significantly higher scores compared with the control group regarding all domains on the EPQ, and attained significantly higher scores compared with nonsuicidal cases regarding psychoticism and lie scales.
Table 4 Personality traits assessed by Eysenck Personality Questionnaire for control, nonsuicidal, and suicidal cases

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  Discussion Top


Suicide cases in Saudi Arabia are increasing according to reports of the Ministry of Health. The ministry pointed out that at least 266 persons took their own lives in 2006. However, the problem is seemingly underestimated. According to Dr Abdul Razak Al-Hamad, a consultant in mental medicine at King Saud University, the exact figures for suicides in Saudi Arabia are not available (Abdul Ghafour, 2007). This can be attributed to the strict religious doctrine in Saudi Arabia that forbids suicide, providing a significant cultural deterrent. Nevertheless, suicide attempts leading to hospital admissions occur occasionally. For a society that abhors and forbids suicide, this subject has not been studied adequately (Al-Jahdali et al., 2004).

The present study shows that among polysubstance abusers, 64.75% of the patients were suicidal, and had experienced at least one suicidal thought, as compared with the control group, which contained none, and 22.13% of the substance abusers had a history of at least one suicide attempt. The results of this study agree with the findings of previous researchers linking substance abuse to suicide (Felts et al., 1992).

However, this seems to be higher than that in a research by Al-Sharqi et al. (2012) that was conducted at Al-Amal mental health hospitals in three major nonmountainous cities in Saudi Arabia on a group of patients with alcohol and drug abuse to study suicidal behavior among them; the clinical profile revealed that 50.7% of the respondents reported any suicidal ideation. This may suggest the possibility of the effect of a mountainous geographical characteristic of Al-Baha (i.e. high altitude) on suicidality among substance abusers, as mentioned in a previous study by Haws et al. (2009) who reported increased suicide rates among high-altitude residents compared with residents in lower altitudes.

In the present study, the Ham-A showed a highly significant relation to suicidality when the three groups were compared. Mild to moderate and moderate to severe anxiety were found to be more prevalent among suicidal cases than in the other two groups.

Anxiety was one of the most common psychiatric symptoms reported among methamphetamine (MA) users, who were largely presented in our study. It was clarified by Suzette (Glasner-Edwards et al., 2010) that anxiety symptoms commonly emerge both during MA intoxication and during withdrawal, although the extent to which such symptoms persist after the cessation of MA use remains largely unknown. The observation of anxiety symptomatology in this population may be explained, in part, by the activation of the sympathetic nervous system through a receptor stimulation (Glasner-Edwards et al., 2010). Moreover, Suttajit et al. (2012) recorded that compared with the general population, individuals with alcohol use disorders alone had significantly increased risks of anxiety disorders. The risks became higher among individuals with polydrug use (Suttajit et al., 2012).

In a previous research, Nepon et al. (2010) examined the relationship between anxiety disorders and suicide attempts; results were comparable to ours', and showed that among individuals reporting a lifetime history of suicide attempt, over 70% had anxiety disorder. Even after adjusting for sociodemographic factors, Axis I, and Axis II disorders, the presence of an anxiety disorder was significantly associated with having attempted suicide (Nepon et al., 2010).

Suicidal cases in our study attained significantly higher scores compared with the control group regarding all domains on the EPQ: psychoticism (tough-mindedness), neuroticism (emotionality), extraversion (sociability), and lie scale (social desirability). It was noticed that suicidal cases attained significantly higher scores compared with nonsuicidal cases regarding psychoticism and lie scales.

A previous study on the usefulness of the EPQ-R for suicide evaluation and prevention on a sample of 63 female suicide attempters showed that EPQ-R psychoticism appeared as the most relevant dimension related to hopelessness, suicidal ideation, and the number of previous attempts (Lolas et al., 1991), which is consistent with our study. This elevated psychoticism explains their tough-mindedness, nonconformity, inconsideration, recklessness, hostility, anger, impulsiveness, and manipulative and attention seeking behavior.

A higher neuroticism score was recorded in our study in the suicidal group. This indicates a greater likelihood than the average of experiencing feelings of anxiety, anger, envy, guilt, and depressed mood. They respond more poorly to environmental stress, and are more likely to interpret ordinary situations as threatening and minor frustrations as hopelessly difficult. This was approved by O'Boyle and Brandon (1998), who studied the prevalence and the relevance of a positive suicide attempt history among 103 individuals who had entered a substance abuse program and participated in a study of personality. Suicide attempters had significantly higher neuroticism (O'Boyle and Brandon, 1998).

The mean score of the extraversion scale was found to be higher in the suicidal group than in other groups, which indicates irresponsibility, impulsiveness, and risk-taking. This fact was approved by Coid et al. (2006), who stated that personality traits that are related to psychopathy or impulsive behaviors are also linked to violence and suicide (Coid et al., 2006).

Consistent with our study, the EPQ study of drug users who had attempted suicide had significantly higher scores for psychoticism, neuroticism, and extraversion in a research conducted by Roy (2003).

The lie scale in our study was found to be significantly higher among suicidal cases compared with other groups. Lie scales are constructed from items listing issues and behaviors that are either socially desirable or infrequently practiced or frequently practiced but socially undesirable. It attempts to measure a tendency of some individuals to 'fake good' (Alujaa et al., 2003).


  Conclusion Top


This study demonstrated that suicidal thoughts and behaviors are highly present among polysubstance abusers and are associated with a higher level of anxiety as assessed by Ham-A scale. Furthermore, suicidality in polysubstance abusers is associated with certain personality traits on the EPQ, specifically those that result in high scores on the psychoticism and lie scale on EPQ.


  Acknowledgements Top


The authors thank and express their gratitude to psychologist Azhar El-Marhoom and Ghada Abdel-Rahman for their significant help and valued suggestion.

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all participants for being included in the study.

Conflicts of interest

There are no conflicts of interest.[30]

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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