Impulse control disorders (ICD), as the name suggests, are a series of psychiatric conditions characterized by difficulty controlling impulses and desires, which can lead to inappropriate and harmful behaviors. A study carried out at the Institute of Psychiatry of the Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo (HC-FM-USP) showed that people with the disorder are more likely to exhibit suicidal behavior.
THE search involved 2,788 volunteers treated at the institution's Integrated Impulse Disorders Outpatient Clinic (Amiti) between 1998 and 2019. Data were collected through structured (which follow a previously established question guide, applied to all interviewees equally) and semi-structured ( model that allows more flexibility in the interview).
Next, statistical methods were used to identify risk and protective factors associated with overt (suicide attempts) and covert (where there is no explicit suicide intention, but the individual puts themselves at risk) suicidal behaviors in this population. Furthermore, the association between these two behaviors linked to suicide was analyzed to understand how they coexist and whether they share risk factors.
“We decided to research this topic because of the need to better understand suicidal behaviors in patients with impulse control disorders, a group that has been little studied but has high rates of suicidality. [termo clínico que engloba tanto a ideação suicida quanto a tentativa efetiva de causar a própria morte]”, says psychiatrist Rodolfo Furlan Damiano, who participated in the study. “Furthermore, existing literature focuses on overt suicidal behaviors, but covert ones are understudied.”
Specific risk factors
The results of the work, which was supported by FAPESP and were published in International Journal of Mental Health and Addiction revealed that those with ICD are more prone to overt and covert suicidal behavior and that there are relationships between the two types of suicidal behavior. It was also possible to identify both shared and specific risk factors for each type of behavior.
“Patients who exhibited covert behaviors were 3.5 times more likely to also report suicide attempts compared to people without ICD,” says Damiano. The common factors for the two suicidal profiles were depressive symptoms, indirect hostility [agressão passiva] and low self-direction, a condition that reflects a lack of autonomy and control over one's actions, leading to more difficulty in dealing with challenges and regulating emotions.
The specific factors of open suicidal behavior were female gender (data compatible with the literature, as it suggests that women attempt suicide more frequently, although men tend to have more completed suicides), self-transcendence (patients who tend to see themselves as part of something larger and have spiritual or philosophical inclinations), non-suicidal self-harm (such as cuts and burns) and a history of psychiatric hospitalizations to treat illnesses such as depression or bipolar disorder.
The specific factors for concealed suicidal behavior, in turn, were younger age (which may be related to a lower ability to adequately assess risks and the impulsive characteristics that predominate in this age group), a greater number of children (which may reflect the stress and burden of parenting responsibilities in individuals with impulse control disorders), tobacco use or treatment history for tobacco dependence (suggesting that substance use may be linked to self-destructive behaviors), and intermittent explosive disorder ( a condition characterized by disproportionate outbursts of anger, which reflects the link between impulsivity and the risk of self-destructive behaviors).
Finally, the protective factors were the greater frequency of religious participation, which was important against covert suicidal behavior, a finding in line with other studies that show the positive role of religiosity in reducing suicidal risk, and diagnosis of excoriation disorder, a type specific form of TCI that leads the person to injure their own skin.
“Interestingly, patients with excoriation disorder were less likely to engage in covert suicidal behavior, suggesting that this condition may function as a less lethal route of expression of impulsivity compared to others,” says Damiano.
According to the researchers, these findings reinforce the importance of addressing overt and covert suicidal behaviors and considering individual, social and clinical factors when assessing suicidal risk in impulsive patients. They believe that the conclusions obtained in the study can be immediately applied to clinical practice.
“Mental health professionals must evaluate not only overt suicide attempts, but also covert behaviors that increase the risk of death, such as dangerous driving or exposure to risky situations”, says Damiano. He points out that these behaviors are often underestimated and, by identifying them, healthcare professionals can intervene more effectively to prevent suicide attempts. “In addition, the risk factors identified above should be investigated in all cases of suicide risk in patients with high impulsivity.”
The psychiatrist also highlights the importance of evaluating both clinical and personality factors in impulsive patients. This is because the study showed that traits such as high indirect hostility and low self-directedness are strongly linked to suicidal behaviors. Furthermore, data suggest that factors linked to social vulnerability, such as low education and lack of family support, also play a significant role in suicidal risk, indicating that interventions focused on social support may be equally crucial.
Suicide is recognized by the World Health Organization (WHO) as a global public health problem. It is estimated that 700,000 people worldwide die annually from this cause, 80% in low- and middle-income countries. In Brazil, in 2021, there were 15 thousand deaths by suicide (one every 34 minutes), the third highest cause of death among young people aged 15 to 29.
The article Unveiling Overt and Covert Suicidal Behavior in a Sample of Brazilian Impulsive Outpatients can be read at:
This content was originally published in Study maps risk and protective factors for suicidal behavior on the CNN Brasil website.
Source: CNN Brasil