Horror Vacui: Emptiness Might Distinguish between Major Suicide Repeaters and Nonmajor Suicide Repeaters: A Pilot Study

Empty societies create empty people. No societies perhaps have ever been more empty than those that exist in our present time, on the frontiers of modernity.1Major repeaters (individuals with ≥5 lifetime suicide attempts) account for 10% of all suicide attempters and pose a challenge to clinicians [1]. Recently, we have proposed that major repeaters are a distinct phenotype within suicidal behaviors (SBs) and may share some common features with patients with addictions [2]. Moreover, major repeaters may attempt suicide for different reasons than suicide attempters less prone to repetition. Unfortunately, there is virtually no published information with regard to the functional processes (i.e. reasons) that produce and maintain SBs in major repeaters.Nock and Prinstein [3] proposed 4 primary functions of self-mutilating behavior that can also be applied to SBs [4]. The 4 functions differ along 2 dimensions: contingencies (automatic vs. social) and reinforcement (positive vs. negative). In automatic negative reinforcement (ANR), individuals engage in SBs to achieve a reduction of negative affective states (e.g. ‘to stop bad feelings'). Automatic positive reinforcement (APR) refers to an individual using SBs to create a desirable physiological state (e.g. ‘to feel something, because you felt numb or empty'). Social negative reinforcement refers to an individual using SBs to escape from interpersonal task demands (e.g. ‘to avoid punishment'), and social positive reinforcement refers to using SBs for gaining attention from others (e.g. ‘to let others know how unhappy I am'). The main aim of this study is to explore these 4 functions of suicide attempts in major repeaters. Details on the procedures of this study have been reported elsewhere [5]. Basically, 82 individuals who had attempted suicide at least once during their lifetime were recruited from a psychiatric short-stay unit in 2012. All participants were administered the Spanish version of the Self-Injurious Thoughts and Behaviors Interview (SITBI) [5]. The characteristics of suicide attempts included the reported functions using a Likert scale (from 0 to 4) and referred to the most lethal suicide attempt recalled by the participant, as stated in the SITBI. Significant variables (p < 0.05) in univariate analyses were introduced in multivariate logistic regression models (table 1). Most of the 82 individuals were Caucasian, single and had high school education. 49% were women. The mean age was 43.3 years (SD = 10.3). Among these 82 individuals there were 11 (13%) major repeaters (≥5 attempts) [2] and 71 (87%) nonmajor repeaters, respectively, including 35 (42%) with a single attempt and 36 (45%) with 2-4 lifetime suicide attempts. The univariate analyses of clinical variables indicated that there were no significant differences in clinical variables between repeaters and nonmajor repeaters, with the exception of borderline personality disorder (BPD; 45 vs. 14%; Fisher's exact test, p = 0.027; OR = 5.0; 95% CI = 1.3-19.5). All major repeaters and 93% of the remaining suicide attempters had at least one axis I diagnosis. Major repeaters were statistically more likely to report APR than nonmajor repeaters (OR = 4.9; 95% CI = 1.3-18.3). ANR and social negative and social positive reinforcement were not significantly more frequent in major repeaters (table 1). A logistic regression model with ‘major attempter' as the dependent variable verified that the association between major repeater status and APR was not completely explained by the association between major attempter status and BPD (table 1, footnotes b and c). The present pilot study confirms that ANR (‘to stop bad feelings, psychological pain') is reported most frequently as the reason for SB. In our sample, these reports were present in almost all attempters (86% of nonmajor repeaters and 91% of major repeaters). This finding supports the concept that people may attempt suicide to relieve a painful or unbearable internal state [6] and places psychological pain at the core of SB [7]. Shneidman [7] and, more recently, Tossani [8] stressed the strong link between psychological pain and SB. However, ANR did not differentiate between major and nonmajor repeaters in our pilot study. On the other hand, major repeaters were nearly 5 times more likely than nonmajor repeaters to endorse APR (‘to feel something, because you felt numb or empty') as a reason for attempting suicide. SBs may also function as a means of generating feelings. Emptiness, which is one of the factors of the Orbach and Mikulincer Mental Pain questionnaire [6], is considered a relevant factor influencing the occurrence of SBs [9,10]. This study extends our previous findings by suggesting that emptiness appears to be particularly relevant as a reason for SB for major repeaters. Although speculative, it is possible that major repeaters are more likely to have been victimized during childhood or adolescence. In a previous work, we found that major repeaters were more likely to be diagnosed with any type of childhood maltreatment and that childhood and adolescent victimization were related to the repetition of SB [2].Finally, the relationship between APR and major repeater status was more relevant than the relationship between BPD and major repeater status. In other words, individuals who attempt suicide because they feel empty or numb or just want to feel something, even if pain, are more likely to be major repeaters. This occurs in patients with BPD and in other patients. We acknowledge that there are probably other pathways leading to major repetition of SBs, but our pilot study strongly suggests that one of the major ones may be relieving emptiness. Future studies should consider some of the limitations of the present study. As in all retrospective studies, the current study provides statistical associations that cannot be interpreted as providing etiological links. As explained elsewhere [2], we collapsed single attempters and ‘minor repeaters' into 1 category to gain statistical power [2]. Furthermore, we ‘equated' APR to emptiness in our discussion, and APR as a motivation for suicide attempts may have served to elicit other sensations, such as pain or satisfaction. In any case, the different sensations usually included in APR tend to load onto the same factor [3].In conclusion, the primary purpose of most suicide attempts is the regulation of emotions. APR and ANR are frequent among major repeaters, but only APR significantly distinguished major repeaters from nonmajor repeaters. Therapeutic approaches focused on enhancing emotion regulation would be most effective [3].The authors thank Lorraine Maw, MA, for her editorial assistance.This article received no support from any funding agency, commercial business or not-for-profit institution. In the past 3 years, Dr. Hilario Blasco-Fontecilla has received lecture fees from Eli Lilly, AB-Biotics, Janssen and Shire. In the past 3 years, Dr. Philippe Courtet received research grants from Janssen, Otsuka and Servier and honoraria for presentations in congresses from AstraZeneca, Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Pfizer and Servier. The remaining authors declare no commercial conflicts of interest in the past 3 years.In visual art, the Latin expression ‘horror vacui' means the filling of the entire surface of an artwork or space with detail.